The URL can be used to link to this page

Home My WebLink AboutReel_0024C IT N., rMU - ,??1?,. T Q iLrGT? x.12? ,?,..... ..., MIDOLE ) AND BOX, NZ. :ODE ORIVERSOCCUPwTl011. ^ BIRTH AGE ? BOOYuSTYLE, j 12Yan:1 PLATE NO: ):, BTATfi?„ c S H[wcnl OOOMETEHINIIC"aK ,,,? :ORIV ERS LICENSE NO; ........i.... R ..F.. T., . ..?._... T^L"H"... _, NL-YES LJ NO cat ?,,; AGE,'. x.56% M-F. DNE THAT A?PL I? tom- IEB,'r'";:'. Il.iYC [.IT VfiNIf.LE.{L/.'OY.NUf/MOB 61t1 ''?ty r.' nvTSnn+r6D ur ?.,.? 'oP ....... 4- 1. TO H1O11 ALIT GOING fiTn+IGHT AHEAIT OVT.IIT,Ni Nf. ANO HAB.INO MAKINI: II.GIIr TURN MAKIYC. LI,r TARN MANING U.-IN Ii--NO fli OnHrO POH TnA-IC AT r:IGNAL I Nal N R n AY ? l f y4 f ?k/??i ?r ?TE OG COLLISION OaY O' COpILISION SA1 I T RI uS COUNT•. it NO cI BPRq u BP T E O O v Yn. .u r > B > OO ZO J Z A EwCLS PREFI% FOR STREET GOOF Rp CTIo S ? STATE ROUIE COUNTY ROwO ? CITY STREET Uu? ,Y ? - / ,s c y ,?P C15, ?O `? 0 HOTHER W.-Y) l 7 V T MI EPOST L IN /'n !!?? Q Lj PREFI%EO. L ?y1OF n / ? ? ®O C 171 • L.lMILES Ll F RE)T OR NI Nw Ee NO.O INTFM14ECTINO WITH:STREETORROA LL IA RA .. T ON y0a f Sr17NE ? , o NO R3ECTIN STREET OR x•RD NON INTIE0.5ERION .1 S'7a c1 R OLS . E ENC C 445 AEETEET OR ROAD E &l• •" ?` NO STREET N =r7j rJ M5 . BETWEE ISTAN< oOIRELTON FNOM REPENENCE C OS4S R T EEC nn? w pF SaVAIAn? CAu' Cam T uNOnm SPEC fA I r ?OTNER Iw 1 enuN COLLISION INVOlVEO: I.V VEHICLE-VEHICLE ?VEHICLC-6 CYCLE HIT ?VEHICLE -. - .. - STOLES VEHIC "`II NICLE-OBJECT AIN TOTAL NO 1[ seve Rli _-NO. KILLED LE .HO.INJURED . _ OF VEHICLES® ?yEMICLE-PEOESTPIwN ?NOn-<O L910N ?.-ARD0 ERIAL -.._ -- PROPERTY DAMAGE ONLY ES-AMAOE OE +ECTSTRUCK INwME OF OBJER STRUCK ANO OWNEPS NAMEI .. ... LOC TION Of OBJECT STRUCK ?AOADWAY FEET ? IN) RO. EOOE i FIRST MIODIE .NAME LAS! fl opLE II, vCLIYi ON PED FLxI ? Oi11v FJ1" HS M ctllC IAN CM" IvE RS NAME r OR R STREET ADDRESS STREETAOORE9 .. +• 5a & V R clTr Z oe } -. a NO. Z''?3w113e?? 'Zu?A • x8368 E R CITY ... IP<ODE -.... P O.E NO .... . RIV ERS LI<l NSE NO. STATE. p (? NI Ej? ( GATE U 2 l8 _ N U VlAS LICE sE NO. .:? STATE SEX DATE OFBIRTH 10. R DAY 0. NAME R OCCU-TIO E ORIVEi6000PATION ,..f I-NAME, ...... PHONE NO. ORIV RS M sa t-? 2 e t ?>C7.?V?._a CODES 1311NJM1V55r 1AI SE TBELi IsIEIE<TION CODE$ 1]I?LJr, Ix)SEwT BELT .- -- +sIE+ECTIOV . qE3 F of - -E. N TO KNE V1 O (DART-nOVwl STYLE 130 .-COn V.I fi G R B OO VEN. YEA MA s E VEH.YEAR KEIOODDE-CNEV. O ASTV LE 13 ....... V.I MOOELIO.RT-NOV E ? ? Z r?u E N C 0Z 0. PLATEN TA ! RAILERPLATENO . TATE 3 "E COLD LIC. PLwiE NO. vEN. STATE IRAILERPLATENO S ATE " . qtz. L ENICLE IDl NTIFICATION NUMBER IOK 148'7 8 l ODOMETER (off 148 ' ° VEHICLE IDENTIfI CATlO NUMBER, ODOMETER E 'N REOlsrcneD wneR-LwsT r'.-_..MIDDLE .. /• ..._.. P? x? •N c, IL E o REmsiEREO OWNER-,LASr ..... FIRST .. MIDDLE o. ' 3 ,..... ADDReestD YFNER 2 .,: _ • 2 ADDRESSOFOwNER. pR A.ENr RESB OF INSUR NCE CO N NAME ANO wDOR O URPNCQ C40RA E T 0.E I . EANO ADO A HAM O ? .... ....... :. C CHAROf .,; _ ITATION NO. ENFORCEMENT ACTION CNAROE - CITATION N . CO DES 1 _ > S NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ex AaE sTArDS N T [>ECT. C N v U ODne eo PnoM A-.. IS F nG HE BY TO P A AME: N w DRE.: oven fnoM T S ' r un[O S Ia 11. >y?x ^3 t? r I Ivf 9 'I e ?.h t 1 N T. o RFno M TD E 5 S' Y 'ISM" ' i1 NY TM • ro ? N IR 4 A ?rlal Ilan I31 IN1V R Y CLAYS ' , IFI SEAL IIEll IBI CYECTION [O !-c". G NO[R r NO INJURY NON RLINO INIUN >. PA-V I 2U NM1CEN1 3 B MO A 1 A Y UrIM4lwl1. OLIN USE > Or r EJECTED T y (C![n ' O F °P[El[ TRIAN - tun rsr. laTHFRP o ON AnmvAL .FV 1 unr n¢rc Cl CIlI OFO IN I104PIrwL ! OV S > N : v w > UNRH p IBUS-u0-OR POSrnDN UNKNOWN ?' e 7 B I INIS sAt MILT fA1LUN1 iGT .O E . 4 I 1 I r I ? AI`D ,'.w t -,r N NP 1V r I !y. Y y?+ iEIIICLE DAMAGE PI EACH 30X. CIRCLE THE. l--JaER OF EACH 34-C L'1 AR_:., SHADE ARFAO SEVEREST M1I ] l 1. I, ? J ( ( (j r . lMSTF?UCTIONS: , oaa:/ ARHO:I SI TO SHOIV S:fG.v PRINCIPAL DIRECTION OF E-cE rJ /. nn. • D HALED VEHICLEE N O.1 I..E THS VALE •o.._-c.-U-1-e TO: E. K'O*u lcrcL:: Er... OAMAEED VEHICLE N O. 2 ! i I . Ro-W 'T • ! I 0 GE. VEH CLE NO.I L!I I B G AGE ]QOT-M.v DIFIG`i Ai, MAGE [J TIG-LG4 AGE 1 0 N A tv OF OA•.IAGe' •UTHE. EC E lE LbwOSABLY00A-E ]C ..-DE ? FUN CTOVAL OAMa4E 'A'? G SE RITV OF DAMAGE, VEHICLENO ] ?C?OSaBt NO GAMAGE ]C1 THE. M."DAMAGE a ruN A1,4GE •I [] h AG NAL E CTI MAGE uAE ,II C '1?•y? •JE?/ T. A tCW EO BV Si. DX.•.IA4E L EST.O+uA4E TOVlEO tlY i0 't {r t:,?E111 (1 ,. 3 ??^L.. L? TO E TO S DIAGRAM OF COLLISION - DRAW ARROW SHOWING NORTH IN CIRCLE I. Ls L I T F«ATe..D..FLL.DINTGF _ ]. r«°,.. t« iLE .FDE:*XIAN OR ArMr DF LKT,GE , GNS AR i 11 a -.>.. HOFT,h.NrAMSFtrOat ?. ?-?_? ?_.?• r - I, JLC DESCRIPTION OF ON IOT ONOAGRAM,EG 0 IVER - AFTER HNOICATEI AT PA09ABLY E EO BEFORE. DURING O TIE C SK INCLUDE T COLLISION C, BILITY, PFWCEO V SIB LITY ECESTIIAN CLOTIIIG COLOR. CONSTR CT10r. OR RE A R WORK, E ., r?>r?s ICE?'ro'."-!'c. +t' _.._ I Ja=,<°.'t`r e `-/ !1a,C-n <'2di/,tJLI G;eJ isr/i:?C'GlJ<T-rJc ;C1J_- . C-R .. ?G# J? iJ?" fJL?? (/?1 .CIE?L?/! •TAcJ ['Ti{iG.C J JYAu ? .. _. 'J'='?/ ? ?._. _ ci4E1[. 4-.E- !)f1.2? /1?J%11.?iiL l??!G r%/CL G =..(J c/?J i.. . n w ^` r. FIGS1TIO { VCH. HEA.I. N BEFORE COLL SI- .11, POST DIR. ` ON y RECT OR X G-WF1 NASIE OR NO /' IN ONEGO nEC?ION , tC r LEGALLY ARKEO PARK IOCAftXGO NO. (.. `? S INCEEEAE- OE[RE-HG _ IA VU?/'.?[P CT•i.LJS??.CJ???L.•?1 . • 1" IV vE5- YES N_O ] X I IV / - . PED. , nr. I... D Lw ° ALONG C-SING - FR- ...... O.__...--. '11-ICVCLISE-S-1- 6 OSYCLE ROUTE 1 OTHER i SIDE-. ] ALK SHOULDER! CR04RVn LK S• CRUNMARKED O S_X C HOAOSURfACE ILI-0 WEATHER CECK ONE( CONTRIBU TING CIRCUMSTANCES HECK ONE OA MORE D-v=CLEACTIONS .1,5MF CR VER :r0.] .-ER INO.t - DRIVER NO.] RIVEH // DOING !j STRAIGHT ANEAD?" ?,X CRY ] WET ' I LEAR. CLOUDY XA OVERCAST... ] RAINING OE I KE OG .. COO UGS IYF LUEUtf Or O E C£FOI NG ETATEO 1 fOL LOw NG TOUCLOSELY B ER <CNTfn TD•. EG ED ARE, •. f SIG, AELEEP r v MvwOPE 11"K III . T Y'OµVpR1AKING J?? ASSINr. 3 G NO RN MAKING ] SNOW CE ] WOWING t /OG S ] SPEEOLIMIi l Et IVG REAS EED GRANTHVV No, S TO E ICL[ y EGNaI IMPUOPEH '0 TURN it ErHREwnD ETOPA GOLCHr IS S LOCATION OPERATING . 'S OEFFCTIVFE rUrrr''IP 1/ ^ I X R !-U ? LEFT TURN KIN. 7 TURN E UI.A OWING X IS -GTHEN SPlCIIYI OTNfR IYECIF VI OIIF B PASSING ISREGAHUSTOP IT SIG N E fiNAL XUTH rTECIFYI IB In V IEILAIION r - STOPPED 10. T ... TRAFFIC ICt1T CONDITIONS -1K -I RAFFICCONTRO INO.TVEHICLE VT NNICLe TYPE OF ROAD O.] (CH ECK ON E OR MORE( VEHICLE CONDITION VE LE b €K J9??'CffJJS 4f t 1 SOBRIETY HIC ICHECK ONE( 1 VI NO ] B 'STOPPED Ar SIGNAL .- OR STOP SIGN .. • E GIGNALS ONE WAY IIBU FDI ) ON C(? yF ? G POa0W0AY I OAr LIGHT OAw ] S4N ] LO YT V/_ TIM WAV wFV ] FPSIELE I nI PfCNVE SHAKES Fr FCTIVF T I HED ABILITY I-AIIILD T A ILITV M STARTINGIN 0 1R111IC LANE II lARTINGFROM ] V I OUSK • _ SON t I ASXINO REO _ 0 0 lFCHaN4E OOP RAMP „ lAD LI41I TS 'S EI'l-TVE III -LIGHTS PAIHEO. NOT I S HBO SOWEIY LINK. PARKED POSITION I] '' MFNOINO ENTER... .,_ TNAFFICI e ifo.Rien E INq A eER y ALLEY RFE /uwN off suO.Nf X HAEDNNOTIN K IN O OR eF IS O?CKING -_ S L...ISORI [T -_ ... A iI°f.nAL 6 TWO wAV- ?rT TUANLANEI 4 H oSI « t n vW CHEM, TEST Cx0 ] ...- K yOA.K-NO .-TS ' STAEET LIGHTS ra nee O ARrN y 1 !?IE 0. I? X r[STavEN TIE w W- 111 'N ^ 1 1 °-D.. - TEST RE FUSED C `? , 1E ,Qt.U ilrr x o iIIJ w? w rl OTHIP IvE D L ] k uNOrvIDtD l t l % % TEST RESULTS T YvESTIGA,IYG Ors IClN'S 1111 A"All L.T. _ FAO'711 . I. LICt DlsrarC•tN i i _ H., H +1LICL AXFIVEO B CC ICf LUw IYLLO IMF, U '1 ` S :+w A R rV ?l T an I nR4 - e ` I•M1 nvOA UNGa rKa IL]NwE • ?1 .1 y l Uce YO rHtr ) •51a^ue , En)nI nrio rn0v A 0 er OI rE `? ? .. T- ''h•1 '?t_, ...i `E r f ? ' 1 npu . Un -INA cU« I rr aI mN wrt lHm vw" . I V DUPLICATECOPY: LOCAL LAIV ENFORCE ME NT AGE NCV'G COP Y-TRIPL ICAO COP'. INV ESTIGATON:4 COPY 1 IN P S N - 4 .y t T J 1 i vh_ E iK F 41f V? 1 r 1 A{;I i 1 { 1 IIIf M,? UMTKI - ,'„ r,'?, iE Kr-.;,:v W J. - ; I I a,_ `kyI All, / 1 A+4N>Y1 . 5 r ti I 1 ?: -¦ .Ywu p r? r rill, A , t b ry r? P , ) T" D DATEOFCOLUSION P R SUN W WEp fNUP Ai MuV ...... OWSION FP PYE ? COUMY NO OITY NO. FNWA E n 77 . T A S 1 2 J 5 B ECL4 IU OUPI D } J (? ?UURAL' OCUNtt CU "STATE ROUTE COUNTY ROAD "CITY STREET Z O ApMCLS . PREFIX ROUTE Ofl STREET 000E CTION 5 . 1 r?n ?OTNERISPECIFYI ` / O ????CITYCR TOWN N S E W t??IN W PH EFI% EO. IAIIE POGTG' C .? , .MLLES ? ® ? ICYO O/E/ /OLLIid .S L'A,s? O 'I•? .?? ?6 ". A ON NAME SNO.OF STPEEi OfiNIONWAY INTERSECTWO WRM: SIREET(Oq ROAD ILLL RAMP - DIAGRAM DATA O I NON M1TE ECTION T R N TVEEN '• ACCIDENT MILEAGE IN E IKON, %RD NTERSECPNO S1111 R ROAD OR REF. I ]QJFL Ji CLS. EPENCE OSS TPEETOR ROAD DST.VIC ENCEOqCgOS5TRE5ETT RAE ND 'A STREET E ADOIHECTION RC. REFER "MILES N 5 E W. CODE / ' aPECULCOOING USE ,['S QFEET OF TdT/O// d ?. COLLISION INVOLVED: ?VEHK;LE VEHICLE ?VEH%:LE-BICYCLE -?OTHER(WRITE) ?HITSRUN SEVERITY [= NO. KILLED AIN "STOLEN VEHICLE • O U _ TVEHC I.ES ? VEHICLEPEOESTRIAN "NON-COLLISII)N . ?H. DCUSMATERIAL OPOPER 1 ZDAMAOE ONLY ODJECTSTRUCKINAME OF OBIECi STRUCK AVDOWNERS NAMEI LOLATION0F0SUECT5TR CK EST.OAMAGE El IN I S E W N ROADWAY FEET El C3 ? El RO EDGE 5 pRrvERS NAME-WT FIRST MIOpLE CRIVER'S NAME.-FIRSTMIDDLE(IF BICYClLST Oq PEDESTPoAN CHEOKI - e ?? ? • Q0& A STREET POORE53 R - _ STREET PDp V E ;.2 v o2 e dfR/G S . R CITY ... ', , . : STATE LP CODE PHONE No. E CITV STATE - '• .ZIP CODE .. PNONENO. o dstt? R N 0 ORIVFAS}ICENSE NO. STATE SE% DATE OF SIflM N CRNEgS LICENSE NO. STATE SE% 111 01 BIRTN • O' `p Jj ! 7V V O. yT'le IE 1 MO. DAV Yii DP,VERS OCCVATION. FIRM NAM E ' PH ENO. 2? -V E CCCUPATK)N RRSS O FIRM AME ry N . [ ? T Y CODES > wl CCpSY TAI SEAT REL ISI EIECTOtI ATUREOF I - CODES >1(3) IwURY (A) CLASS SEAT BELT 151 EJECTION TORE f NUURIE3 IwURIES MOV O iq MSC NE VEH. YEAR SY: TO MAKEIpOOGER:HEV.1 MOOELIDMTNOVAI STYlE130RCONV.1 PREMOVEO 'r OM SCEN YETI . VEA R E Y' TO AKEICODGF.CHEYI -MODELIOARTNOVAI STYlE120RCONV.1 d s . sE?? ? ' ?r,?, ry 3 E H VEH. COLOR„ lIG PLATE NO STATE Tf WLEA TE HO.. STATE E VEH. COLOR 4C. PL NO. ATE STATE TRNLER PE N0. UT STATE : H Y P/oeJ o7 77 ... C VEHICLE RFIGATK)N NUMBER .:..? ... ODOMETER, _. ; '...... (•` vEHK:LE IDFMIFM;ATION NUMB R.-. .ODOMETER :. ?' _ L 3 ZlD 37/8 / a7 e TSr1 3 vo S SG S -. . ..., 3 REGLSTERED OWNER-'usT . FAST..,., _,.. _ MIDDLE fl EGISTERED DWNER-UST - N Q: Y / r N O {?v AOCgE55 OF OWNER ' .. ' A DDRESS OF OWNED NAME MID AOO I IE 59CF WSURANCE ORAOENi ,f. N AMEMDAOpRESSOf INSURANCECO. ORAGENT . - ` C/ )`'t'ar.vc T'/ /•J9 ... CITATIONNO. FNFO PCEMFM CMMG , . ... CITAR N ..... . . IDPidtfS /' BoS? s 845" A cnoN ? _ ; NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES i _ 2 u A 5 SIX AOE STATUS L" u FJEGT. C N AME: /f. C A U I OCAE59' e? Q( IAT URE P O F OM ' P R UPIES N ' SCENE P TO /L N AME' T A RRES9?b'7 DD •S N ? IAiUPiES' .ALdGN jw/e SCF ERD R M T r T P.?Cd yy N AM'' T S T A DDUESB' 7 ?J T 1 N I E NJUR?P - /?! GJ / ee?/d SCENE BV H M /Ff /?/ T O T Jnd..Ffe.• d N S AME S A DDRESS S' I &n w • SG'IVF P / T O I II STATUS 131 DfA t PO SNK W IJI nRAAY CLASS ICI SEA'OFIT ISIEJF.CtKN1 C 7 O PASSE 1 'O WJ 30EAD --n'. NE 6015ADUIG IINURY NON pISARLWO I.NOiINSt%LLGD 3NOTINVSE I.IIOT EJECTED 3 T TA S D "'CU I DINER N y 5 3 i.OtIIFRPO4rtgN IBU9 MO'ORCVCLEI DGFADON A-11AL A OIEDw nOEOrt L IEVIDENTIWURY /.POSSIBLE NUUM USED X IINRNOWIN . O LLY EJECTED J PARTIALLY EJECrCO i UN I E 5 WITNESR ' B POSITION UN%NO'WN 6 SEA'DELT FAILURE KNONNIF EJECTCD rn A ti ) Y ? icAAd mh4"'? r .L . . J ,?,°) J ? A Y 1 1 S? w: T 9, a, a it r f 1 In 8 ? ? r ; R F -YP?t=+'-_iilFY N'-.d':i "Tn,.-?"'-'.»?_?..i 1. r•.e xw?n r i•I?,?+"? P 'rr -?_ i51'' 'W+i_::lo.u' VEHICLE DAMAGE .WxcwcLE EWMBEROFEAbIDN.IADEDAREw .' 2. SPACE ANE AREAOF SEVEREST IMPACT. : ?I !? Lx Tf ? ? s ?; IC w4 Y s 1 1"d°1q t ? k 4N , 6 11 P INSTRUCTIONS. - GOMWAPROWISITOSHOWPP?NCwKDIRECilOIVOFFORCE ©? DAMAGED VEHICLE N0.1 IUSE THIS SPACE FOR SETCHIW DAMAGE TO T]WLEFA MOTCRCYCLES,ETC.) DAMAGED VEHICLENO.2 CG ID ]. HU°a IJ P°°I It. ROOI._ I/?' R 15 trunk ? 15.T-. L la. naMTml.Bn ? - 1 e. wawvlno! ' r rT.OVenan _ '' 17.OvwnrD SEVEPItt OFDAMAGE: VEHICLE NO.1 9EVEPJtt OFDAMAGE:IOTHEfl VEHCLE) SEVEWTYO DAMAGE: VEHICLE NO.2' - r?DWYJNGOAMAGE - 3 QOTHEfl M.V. DAMAGE - 1QDISASUNG p• WAGE 30 OTHERM.V.DAMACE IQOLSABUNO DKIgDE- SQOTHERM.V.ONAAGE 2 FUNCTONKDAMAGE ? NO DAMAGE 2 f11NCDONAI DAMAGE ? NO DAMAGE 2 fUNCTIONK0AMA0E 4 NO DAMAGE TOWED n6E E5T DVj? TOWEDBY ?•'.\ -. Eg•0'V'1 TOWEDSY - ESi; DAMAGE -. DIAGRAM OF CO ON - - x•.. y - •.. I': I t ?d =n% L?BfS - I DRAW ARROW SHOWING ?ldd r= Sif 'i s L . opmFY _ Aow ^T.. . . - _ _ _ NORTH IN CIRCLE ... ? I I I I I I y?/lam I S idJJen' G I I j Ti?°.F??•Mr.-t .• 1- I ]?7' I • ICI Ssldtd O r"R!3? ? l I! I ?/ I I I I I I i r I ?k i T i ??I r ?w ? L ' ' I D AAei±.rer°RCJ z,^ I i l i l 11 1 • . 77i,,+. '•I f I I q '- - `" - - ' zL«AreFRCU,eLxPOwroP IT TT ?!T I? I-i- 'T r -1' ?! ?PDp or?nATIMPA< I I'?-i--C--3-1 ! ? I °frzn 'ce",u+oN °A` o,F - S oeil ePl : I I-- I I I I!_ I I L? I I I I I I ' I I I _?I I? 1 I i : r i r l l? l i. DESCRIPTION OF' j .',. COLUSION'•{ y ? ? A4?;, DNDICATEWHATPRGDA&-YHAPPENEDBEFOREWMNp MIp gFTERTHECRASN,INCLUDE IN FORMAVONNOTCNDMGRAM,EOORWER' DI 1A 7PE000ED VLSIECI EDESTTUAN CIOTHIIG COI R CONSR UCT10N R P O _ y c .,' , -0 j . fl E AN WORK ETC) - ?d?1.G?0'__11? 'S? ?.C.?..J ?_GISL/1L/_OL1Ed /'Cflf/'.?C (? loo ?? SQV?K?CJl?l ?,Od _ .. .. - . •' D POSrAOMBFFO .Sr..'. L_?_ --" !;:<?"i:.....?.s: _. .v i:.d7vk`I.M HOOF lANE3 s?EEDS VEHIC ` VEH. we MILE POST pN -.-s TREET OR NIGNWAY NAME OR NO IN g1EDIRECTION Pm En LEOKLY WASVEH. NO PICREASM ! PAINED OCCUP ED - I N 9 W IE - J a O YES NO YES . - NO ?' 0? '?L 41- l ` ? r MEGJIwFn D Cb?FM PED. ? ? ? IE wl D n Nb _ PED/&CYCLIST WAS USVI 9 _ t rlyDEy '] _ tl 1 L lvrpxnBr r-C110?W (^ `? Icro.?sw 1W9r ' ? x L-1??''Y ndrrE `TI prwD TD l'\ ?, -'. \ 1 ROADDS°URRFACE. yii. WE THER:L' i tr,?C.ONJRIBU - I ° TINGGACUMSTANCES? MLR LYrE On NDRO ?x,t, ??r .y ? \ -::i-mYatbaneACmus,.., b Y oNO. 2 . .... wnv . 1 , ? \ yn:a 3 ??{. FIICIE. -? MyW '(?} r? s°°°nNOnrMC . ? om -?` ? ? ?-.Gl?e?cF I . ? > ? '- r "]_S?aw?sl? _ PAavNo . ?-] rl ? Q WM I ? MIwD ?,?rWRDDxaF- ? n°? CIXTFA ?= Y . ?3?p0rtPN rI:.EMpT- 3?BdVW:,_ ,?_.vcaa.D , D !j? A]DT r,PMw.D ce t ?? NID ?_ nw °?=---- IairrvaEauwT/P 5 T °I-1 an»10 ? Xd°r?,.,? °I^l_ - owc°iM"M . . Sa,ao vrt , . ?e? acw.d , orHmlSxv-n o'R,Tnls•eD..r ?"'. j I..n?°I' ? J L_j+]I? w?I.sr°°Aa°,: f°? wvlaA ?' . ? f" ? °wn .^ LICMIcClOIN TIONS ';,7RARL COriIIOk•. i). Ls UTYPEOFROAU: cN a ,'.yEHICLECONOMON', BAIETT_ oA T3rrw.. ? 1 ? 9bMU I ru ar on „Dn]I ?] T ? OKwAY i r?+o.i ?ovi«n ., OCMneUrlq rswae IcIECIi o?w ] . ? AT ? •'??' RUOWAYw ??! } M/ICH! ?]? .sui t Mp WAY i.lJ MW? ? ? ;'? ? ? .-• ? l ? 1?10? Ti??4wE 1 ?. ?.!_.w ? `, '- ? i..J - ? ? ? L.` I J 5?v ? 1 NO , MD AM1IFD6PJD14Yl ' r? !? DUD! ? I ? !??._. ((? l._-=1 - ? ? ? ?: 1 I. n ..? MdIIYIIpTDIM 0 ?] Wlf DN _ • AW(P , ALLEY . fU ? IIR,wDN:- r t, - Hw?bT-?'-. , I ? 1 e - Lw°M`irsoa'r`rr°f f_:?_L:.-I . r?'dwl 1 !° L -i ?°? Dns'nwrlwrcTUmo oMnn CHEM.TT t -1. {--1 - . - -1 - i mnrtwlr5 ly `?] ^A°::_ 1 1 ( ? ; a? A I ?. ? ?--. ?? ?' ? --I 1J k-i I vtc rl ' r TC '. - . r7 m,En ?°I ` _ LJ_ L-1°f'•-1 M,? 11 L J ? i`7 No w]er3 I? (-, TESrRETweD _ 1: ' r ti 4 6, . ORtiP15WpI11 C (,V'1 CW f ]_r ET I - tl` Inol.rceo •r?y ;'a?^{omeiisie?n % % 'TEST RESULTS . T ,1VI q,r14bFCNY°N.W A,VII 5WLN0 ,r? v PdlCl AlwrtD A RDROw wRaro.rwbrc R°YwetnNM 3? e,PDe NO ? I iaso ?3is ].?D n sh ]?° o°~ d M N Imran wT,DeT. o,ranbnlPOm .nAOVTDn an pSTRIRLRpN:ORgWALCOPY: 6ENOT0 WASHING tDN STATE PATROL-0LYMPIA WASMNOTON OB50t WPUCATC COPY. LOCK lAWENFORCEMENT Af.ENCY'SCOPY-TRIPLICATE COPY: INVESTIGATOR'S COPY V': F r d @ tt M T? ? 1 I I }4 r \ r r ? ?u I kI 7 9 I Y .111 } G i y{s. ?y 1 t 7 ? ? M2 'A. ?. - 14 w YY'.: !w . E ' DATE tlF COLLISION p. MO. DAY Y DAY Of LOLLISIOn U a I ] s FHI E sw T J a TIME IUSF NtyRl z C OUNTY NO. •nU4 COUN`TY/ Vl??IV ?CITYSTREE COUNTYROAD ?STA.EROU ?OTHER ISPECIFYI O W N ? F TE OHSTREETCOOE 5,,1 TON L CITY OR TOWN ae pfl- JP= _ 7asvvsEVO..-_ SMILE o ? O % E6 ILE ;-e S F enN00 TOP WIG W N EPSECTINO wITn:STNEETOPPOA 0• .P A P T ON /2- i ° N NON INTERSERIOEI / `^Y?2T`l. a9K8A,PL?TREET lET AND n0 I CL9. R NT PSICTINO STR ETO O EFER CE CR 9 REE O GI ^/F 4 ?? I ? l OLS(?CeIM O ECTON SPOE PEFFPEMCE OR I LES n S = PECIwL C00 GUSE -. ??-? L•7 D J QiFET ? ? ? • - ?OTHEP IWRITEJ 0NIT A RUN VEHICLE-VEHICLE CLE-BICYCLE COLLISION INAIMVED: E TOT LNO. VEHICLE-OWECT gVEHICLE-- R TRAIN 0STOLEN VEHICLE SEVERITY NO K1,LE0 3 O 0RE0 FVENICLESI?rJ ?VEHICLE-PEOESTIUAN ?NO-COLLISION ?H RDOUS MATERIlL. -- N ?IOERTY DAMAGE -Y LOCATION OF OBJECT STRUCK OWECT STRUCK INANE OF OWECTSTRUCK AND OWNERS NAMEI EST. DAMAGE ?ROADwwv FEET ???? RD EDGE S 9 OHIVERSN?AJ'E-LAST FIRST -DOLE CJo?7c?//O I?A7?ifE?°tuE ?• q DHIV EN'S nAME LASE FIRST NIGGLE ECVOl 5iU E LSTRIwN UNEC% U._,, •;; Ni4MtLYDAI yn?G? FAEZ ?I ' STREET AO99??E# v RL Ei 4 AD v f "6 Z 5?3 o B 3010 E' zlrcoOE PHGrM CITY - srwreY?? e /V .r ' 4 CITY ADGOeKTe - g ?3q.._z D fi R f o, D NO, d 358 3 3R f tv RIVER9 LICEME n0. D 5i STATE ZG _ ? ATE Olj WHTn Gr i3 Y . ORIV IRS LICENSE NO. ?35f3 tS? 9TATE Re SE% 1 ATE OF nIRTIH M? DnY RIVERSOCCUiwiION ME iIRM yyT• CGIDLOGV - l?flT??O,? ( / Z - GO -AS OC-ATION APP?. 6Z£Cr FIRM WANE .,.. ..-. PHONE NO. 7.t? I LLB A-MS G-_Z,=?'T: CODES >4 I]I 'nn-7 1°I SEAT SELT .Z- ISIEJECTIOn CODES _ w15FAr eELr _. .".ATI'l 11 'Ers< I /ll URE Of O VE -ED NE w[ EID OGE-CNEV,I V Et J- R M TO MOO IOARI-nOVAISiYLE 130P._CONV.1 vEN MSEAPE AKEIOOOGE-CNEV MOOELI yIOVA S YLE 1-3L'n-CO - -rouo MG Cec.teA zA v run `?8 7 !u E N (1((?` EcaAIL. LI-f \ Ill STAT; RAILER rLATENO. STATE .. E N . I vEy?COlJO, LI??. I?IIYY?\JJ?. F+ ? STATE.. . P1.AILEPFLATE NO T M STATE C, VEHI EIDENiIf ICwTION NUM AZ90 i?t86o ODOMlTER _ 20-7 L: YENICLEIDENTIFICATIOn NUMefn ,, ,,, Z l3 16q i? z3z OOOMETE - ?fo48o E N REGISTERED own! LNT, InST _ ._. -.. "IllLl- .E ... E; N' nEG15TEa DOWNER-LAST. IRST - M D E ?..?'M\C.1'o.L7J1QF{EL -? O. ADDne#of oWNen ., ....... :..,.,. _ -..'...._..... V A DD q^?'!R, ..,„._ ...... ..._ ..,...,...., I'0 J3 306 RD( Q(/ z p ? NAMe AND AO -.1 IMURA E CO.OH AGENT, G,e,4,?.Yr E NCECO. OR AGENT Y2rtA?r, 7 At C.AR.. . ... . •:... ;...-. a ._ ,VoJV6 CITATIO O . E f0 CEMENT .. CTIOTI. CnA(Ry/?/. .: .? ......,..:. /I /(Tr•fr'? CT DON/O L , U LV E ernes _ y NAME, ADDRESS & INJURI S OF PERSONS INVO ED . AGL STATUS N CS -Al ,LT l eJlR. c c C AM.: •? DRE#: - 6 uA I 1 l -31-712-1 O neoF o55 "AAf. T 0,E xiwYeoPp " TO A E . ?? ?:, Z 6 2 f •UO ? 3 S D E !MOVED FROM F7? WORM, M W AAE! N To E S S 1 11 TG 1 1 •w SIII n AS5 ' ]1 lnluRY CL 13I 5f4r PELT ISI lJlCTION c D 3 P. -ENOEn 1TIAM 1FL4SCLIST 5.OlMFn K 1 1 y l ).OTHER rOSITION InUS-MOFOACYCLEI 1 NDINJURY ] DEAO AT SCENE : -ADON ARRIVALI 1 IFD IN Hm,i TAL 1313-INO1NIVRY ON DISAnLIND I-ilNT11N1UnY I, -- INIunY I,NOTINSTALLED ] uOf IN US! ] wKNOwn E? I UPf SE F 1. NOT^icc- D 3. TOr EJECTED ?rAKrIIDWNIPIF.tTlO [Jf-TO E Sw TNE# S n. rOSIIION UNKNO.. AT nELr A L S. 'R„fdT F ?.. ,, ?t :I M w ? TI r C fi N I Y r 1 :. '???' I ? ? ` I ?' 1 I '^I f t L:r 141 ? -1+•+++,. APR .4!plA?f?,° ,?q "'IfFW ">fiAal•^ueatm•m 777 :_!, ;? T-Tm1- 1 N II ,l, f t rl 1 y.t F I VEHiCLE DAMAGE NEACHBO%,CIpCLETRENUN ER OFEA GNpMZGEDAg a YFr h p r-,rS4dC h ?]a IINSTRUCTIONS• I SHADE AREA DF SFVERESTI -AC, LE 1 ]. OgAEV ARNOWIS{TOapOW pgINCIPALD gECTIONOFF p ?( • .4.. D'NAGED VEHICLE NU.1 aE rwyaF,cE FCH a'AETCHInG O CE. J K j V DAMU.rG ma GraRCrct-a, Erc. DAAIAIiED VEHICLE N0.2 • ' 9 S E Oa UH AGc. v I ClE NO 1 '"-°`?--1+ Y ,'. ? I r?OrGAJL VG OAM,GEEr ] ? OTNEflYV. OA •?'•r4GE OTHER VEwrCLEI $EVFq ITY ? Ow.`?.n?x• ? L ALOWAGE s0f MADE IE?oYOFp GO GE JL] OFO AGE VEIUCLf Y]? O Oi. IC-IOV ^ uAGE S Oiw zvAV.OAUiGE OUi rN O' D eY A Q e.U J F IrNG DAMAGE DxM I. DAMAG O ry'{ -"/Yj ••-r?? EEE T - L AGE GE ..WAGE 0 r ?? IC r.DAMAGE T NOOrHEquV Eo DAMAGE I ?4 r ` ??( . 7 'o SES ONEO Ur EST.CAN, t.E ? ? ,v. ? DIAGflAM OF COLLISION . ? n Ly iOUrr FV - -.. Y Fc,OUArAAONY. Feerunfa '- RALV „E, NO :EDecii ?n oF. wlADe,r r./ D ' ??^+, f. iriu. ccarrRDrs /].TG Ffl ??? -Q? RTH IN GRCLEING ? +rN. 1 DESCRIPTION OF c E ""A RL " _ " I ffffff COiLISION . ' - IsA cNE eE c c c° WCFOV PEOESiq aN xOoOR.fdxS puCTw .In WO .E Inm ONORORN,. t3r E4D vEq d J OR POBITIDNREFORE--• W LISION 1 - - "- L ?.n• I 0... E??CRfALNG O STREET OR RIGRNAY WANE OR NO .7.=E ON r 3 X; E IN VERI E. G OAI ..y-r LE L? . r iI o. j n 7- IES V. - ._-. .. ._.... ROSS rW R ? aP CV SE RUAOSURFACE x¢ LK ruLKNA 3- '? - El IC LYEACTHEA s Ew [ROSS E sm ` Dtrc T O Eq D F 'El c E Gut - CONTRI _ECClRCUNSTANCES TE T 'ca. NDE] NO`] N42 14 Cx / Eq ! V u a E'E OR! CS?2+ .Y ?• { _ O ERCASfUD IxaWE rKF Q !u? `'E x D l ] NET = p :_Alt D0lY :. ,T ] ? x,t -/ .. uENCE OF G OE O{Ff 1 O ,.. xrNG. ] U A R 1 a?,? JA ' ..... O GS 8 E E qR ? o n Y EO x T O ... 0 1 Yf? SNONr YOKRNG VSE CEEO ST ED O 10 .nXRW PS EF R ` . S w rG3 I • A FOG { .. _ NR _ ICE F ` -? ?K f CEFOI GgEAT. i0 IMPROPER S _LOCA N •A — ? G FiTTE{gN R S . ... ! S OI Or GgAN RrrY '- F E A ?. ...E r9ECIFYI -Orirfq l9Ebsv1 N E. C.E [ ST EG0.LG o W_. SOWING F { F — R HExCONO1T10N5 RAFFICCOMRp I_— G IG E IT six bcxsi Ov R µT E y ECKDxE ND] E IttE xD] TVPEOFROAO .VEHICLE CONDpITION D O N i SuvPrc FD k ICMFCK Dq Npne pP •SORRIETY . E SWxA 3 r F E I.(01?€ E ICE C ECK ONfI F 3 OPK A SIGNAL M IIGr _ .. - ONE O ] 4V01 NO O STO M ] O ' - Gk .:: A ] [ EC E M9U 0. L rM Op f O - F D ] f E . OR L _ INPA ED R SC O "IN A?ItCLIINE I] ova r r? I [ o c _ ] L T K NOT r 1] m VLOOP dANGF ..._ S I O PERIV Fr A kD EI ARKEOP?p • A RE w FT ?. STrrEl ON`E` E. EIwSRINO Al ._ .-AR TS 5... UNK Et' TM`gAF%ICE IFXTFNRyDI Tai Ef E ' E US— 411F T. ... NOT E -. - ,NES s Ar a p? FE1 L LHEM.'T ST OR S oLAawn ? _sF Tom-- X , a t R .... :. on. 'r rx?S?•-??. ] olv wo ` .. .a q _ Te3rG VFN Ex lvcnrr{ y ,. I OT [ Y O Nn rnuFT f TEST RFFUSEO r i ,;,,, ? raNrw, ] uvorvrofo . - -orREn rs.Eann i ' ' S . .v._. Nves.rwrrlgdFlttnS N.weApwK enrrro ?..?..?.._ '•? TEST RESULTS 2 YAOGF YN. •:.?5.-v r vssTlpgrl e? ccgs N. e K? g00 'Yi / caTE /(f /i-p'vs. 1l Y BE AGENCy - NIr U•r/?l?O aiF OFETf]rRVYI "Og LOCALCALLLACGWY.FYF SFIOTOM1pIgsN NGiGN 5TATF PAIROI-UI.vMPIA, WASxINOTONp WvtEG\TE CDa Y: ORCFIFNT 0.G[NCY';: COPY-TNiFL ICAT[COFV: INV ESTII GATOR' II O T .1 F 1 AC•; DATE OF COWSION Y R OAYCFCOLUSION MDN HIES WEO I— FRI EA, TIME 3 COUNTY NO.CffY Np. PRWp T ? . ) 2 1 2 A E D S IUS .A HOrRI ? ?URSAN COUNTY J SiAiE ROUTE COUNTY ROAD ?CITY STREET ° CNI U PREFI% F EORSTRE_000E SECTION ? ?OTHERI4PECILYI N 3 C7 S/?JO 0 TOWN I N ? ? ? _ •OF (2 I ? n C4 L't MILES V T N ENO OF TREF,TO INTERSECTIINOWITN: STREET OR ROAD ON Od-U LL 4R-PCIAG LR N N11JJ /? ? O P ET Ofl OAD OR REF. TREETOR ROAD EEN (? STREET AND ` SigEET • CODE Q CIS P GE VDOIRECTION FROMAEFERENCEORCROSS StyA^?EEi (? ?SI, I ?? ILE N S E W } ELL nS nouei SPECIALCCpING UEE J T OF ?F? C1 COLLISION INVOLVED: ®VEHICLEVEHICLE ?VEHICIEEICYCLE ?(ItMEAIWgITEI ?HIiB RUN SEVERITY ? N0. K LLED I c +1 N0 VEHICLE ODJECT ?VENICIE RR TRAIN ?ETOIEN VE HICLE NO IWURED O C . F .E CLES ? VEHICLE PEDESTRIAN ?NOH.COWSION ? HJZARDOUS MATERIAL ?PflOPERrv DAMAGE ONLY OBJECT STRUCK INAME OFOEIECT STRUCK AND OWNERS NAME) LOCATIONOFOEIECTSTAUCK EST. DAMAG IN 1 OF ?ROAOWAY ? ? FEET ? In RO EDGE . S DRIVERS NAME1A4( FIRST MIDDLE OR'NER 5 NAMEUSi FIRST MIDDLE ?.F Sn:YCLIST GR PEOESIHIA•i CHECKI LJ D C- 0 6 , o /D 0 . TaG???/? A /???L/ G• / STREET AODPESS R -G STREET AD99??E59 v ?T t Z 90 v `G el T! E&-S % S?tCG l . R CITY STATE Z P PHONE NO. NE CITY nn STATE LP CODE PHONE NO. ?f'h v/IA0Z4'il 5 4 N DRVERS LICENSE NOSTATE DIRTM STATE DIRTH SE °' '? °' L5?' YB l " ffli Q i f rl?il 3 y ? d OflIVE SOCCUPATION FIRM NAME PHONE NO. 2 DRIVERS CUPATION FIRM CODES >1131 ' u"sa TAI SEAT FELT I51 WURY ) NATURE OF Z EJEOTKYJ CODES >IDI Cu54 1°I SEAT 4ELT 15? EJECTION. I IWURIES P , R M SC INIURIE9 / GT WM . FR M rv 4r /J Tp AE. PR CM SCENE I I av: y TO v WECH .1 MODELIOARTA'OVAI '4 S 5Z v VEH.v_ ?7 MAKEIy4DGECH V.1 /'G,? MODTYLE 420ECCNV.) E . C OR PLATE W. t : GTAT ATE C VEH COLR UC. PLATE NO. A ER PLATE NO. STATE H H E7J /RL ° L E . ICLE ID TIFICATION NUMBER ODOMETFA D VEHICLE IOENTIFICATI N NUMB R ODOMETER AGAl50?2158?1z 37073 e li?f?ZQ?7B /z5?395? Iltf3o N REGISTERED OWNER-LAST FIRST MIDDLE ? REGISTERED OWNER-LAS FIRST MIDDLE 3A4-/Y16 . N 0 i ADDRESS OF OWNER . ADDRESS OF OWNER 1 2 N AMEAN.AOpPESS Of WSURANCE CO.ORAGE?j ` NPMEANDAODTiES90F RANCE CO. OR AGENT r 7a? s J0 G2fntJlts - ? - >??ex'S' r/TX C HARGE CITATNO _ . ! ENFORCEMEM OH'w A N . ACM N NAME, ADDRESS & INJURIES PERSONS INVOLVED OF CODE9 _ S SE% AGE STATUS W ro n AT EJECT. L. N ?J AME D A N DDRESS. E a' z AIUAE OF M L Z 3 I Z I P 4C DE ep FROM WUR.E4 6=_ EN TO A N N M F' T A DDRESS N 5 I ATO F WURIES C NV3v R M TO W N AME, T A DDRESS N M IUar4 4CE f9? TO E AVE 5 I4 ??PE43 E. AA ' - ' + C i P 4JA :J?S[A I PG MNU'• rCL+SS JI Ir10uWUR I ? +?4E At HELi I S,EJECIION l p ? E. ? Ar: • fr 1 T ' SAPUIK.IN,PIRV vOi WSTALIEC o' T 4pT EJECTED TOTALLYCrEO O ' I 6 D BQ I, I \ C pp ADIEDNHCSP ?i•, I• p551DLEWJURY r.pu:'E i l .3 i EFECED •k40 .ESS C L. SPO Si O U CW !I . ESEAi RELT FA.•?E U Y EJECTED a 1'1.7 ' is VEHICLEDAMAGE ,. YEACHWX.CIRCLETHENUMBEROFEACHDAMADEDAREA - SHA EAREAOFSE VESTIMPACT. 2 t e Pdn t+ 6 . INSTRUCTIONS: D. DRAWARROWIS)TOSNOWPRINCIPALOIR -L OFFORCE DAMAGED VEHICLE NO. I IU ETHIS SPACE FOII SKETCHING DAMAGE TO TB. UM, MOTORCYCLES. vc.) DAMAGED VEHICLE N O.2 u.Hme 4 Raof ? 0 iHDDa 10 IbDl ' ??j i . ? . l? ,B. UrtlrcwKpe to 1 IB. UnESicdrWe SEVERR 10 OLRAIKIWW NG OAM D AOE.YEN LE NO.1 AOE 3 OTH `ER M.V.DMAAGE 2 NNCUONALDWM E WDAMAGE SEVENTY OF DAMAGE:IOTNER VEHICLE) 1QgSAFNJNO DAM AGE OQOTHERM.V. DAMAGE 2 FUNCTIONAL DAMA(IE NO DAMAGE SE1).A AGEV'JKlEN000 Q ID,SASUNG DAMAGE 3QOTMEfl M.V.OAMAGE 2 FUNCTIONAL ONAAGE NO.- e ` TOWED By iJl11h L! EST. DAMADE C J EST. DAMAGE TOWEDBY TOWEDBY F. EST. DAMAGE TD SI I/' n ? ?'TVJ S TD 4 f nL TO t?hi= 1717 DIAGRAM O Frw>u?ON I _ 1 _ r ? DRAW ARROW SHOWING t- r I NORTHINCIRCLE oHr ?rxcwawAr i -1 ^! 1 ! I I _? - ? D? '+?+ c"' I I I I I I I I I f I I f I' M irzMPCGWrrt0H0 . KAA[[F+a", eic?DwDwDRDH m[RC[,xcwurtor a f ?' '_- ( r.I 1 r i L '-?1 ? r V ? I . - I-rt ?_ _ S' ? h r i- I ? 1 I i T? ? ? M ?I -?- C-41-17T-Fl ? !? I .. I I I _ I j IS_? I -T--I -- I ?+FT[x^+"iowslDx -?-?- I I I I ? ?( fir ?? _?_ ? T? I I I I I f Gu.T-icS Lc- EPS . ?! r I TT I I I?? i I 'i' I I i I I I 1 I 1 DESCRIPTIONOF':. flNDICATEWHATPROBAeLYHAPPENEDSEFWF.MMNGANDAMRTHECRASLIN WDEWFORMATIONHOT ONDIAORN.I.EA.DFPVER COLLISION ;' •,•• DISASII.fTY,REWCEDVOBIU .PEDE FWI CWD INDCOLOR, CONBIRUCTION ORREPAW WORK ETC) '? J rre:J - ?E:Y C!sE ,:r? ?.<lc?i.r..l,f.'GIIiD C/l _L-?i2?-?_y G^?_'-._ -r.?. 7"iP ?E??.u7 - _?? •P ? _f c / a J o(_ S/L//7 F <c? /J 5;? r L Y1r. !???t .c r?? ?C r!??=_/? -1??//J? LC?Ke-L? .C?c /I,GC? /?i'JG ?i7?cl[•.c; POSITICI . VEH HEAOEO MLE POST pR _. 1 - `. ._..: ON STREETgi HiGNWAY NAME ORND. ' w.wF Es NONEDIflEC110N S ;- PEEp,9 !-' + LEGALLY PMI(ED ?Pmmo WASVEH UP OCCEDD NO WOiIFA5PI0 DECREASING N S E W fv(-j?-7 (-- i 1 ? ?. l? tluY-/ kD 2 t 7 F 11 ? YES NO ? c YES NC _:y _ - 2 ? ? D-1107 tz Aj 7"-I ki) I ?:. tnH = r' i PED, n _DRDBaerD _ J - ECON nTO RD„ SEGOw EMd .J I iOWI O 2 a ?-t PED.IDCweusrwnGUBUa I ? I 'saulmr' 'I?c"110`RO.ss?w.ul [I I ,mwc ` i reA1FOa,r[ Tr'mHFa ROADSURPACE;. SURFA ,,_WEE'ATHEIL.-.;, ATH CON7IMBU TING CIRCUMSTANCES. NGCI -.,...hu::ta,_ :• - 4 t..Daavw[asAV,vn . . LCH M K --k 0 D H[ aA Mara D ?[R . '--? rrln .a rcl.G[.. uR 1, BITAHIM a ._ n_ - D QAri DDKZD. ' [ ?T? ._ t 2 ?'aa DEED . a2I1 ?! L a i X`cY wtT - a L! nwo a - 1_ 1 a Q ---r-MUBCEDF 1 I [ L? ? eeHtFR - L J f-?= i--I r I ,f l --/_ r') a ? M L • ° ? °aw ?? °'°."° C J a°.[rnc[m.aia.rn rzo! J P? ro - -- ? ? e nPrmna .? ' w- ?^ -t4 L_'' IL. r__ __W! YmOaEA at0 1e(? L CM[WINP. Z r ?,II 1 OMNNO?A u row:cu_ nnv - II _°B.e°PL°°n^- 1 trU1?LAibLtLYE B? aa'° Dnoli[rtcer, Drn[nlatHrsrt e4ti aoER ^e, 0 t2,F] m°B"H?ov wL[10P ?j I?;[? w.n?nw LJT? °ro`[orGn LIGHTCONDITIONB +ONDI TIIARICCDNIROL o u G TYPEOFMROAD > D , . VEHICLE CONDITION " SOERIETIETY/;.r •• u t O"? •" L O K H a Y . E ?Jt LI aDNNa r2 M _ K.KGt qAD '-j,l? lae w, w.aa DH[Tx oN[a, H¢ [ w°!`aniR v pa 0„ 2 ?.? BAO1°P Al . I. t. w _ . ar_I 0,01._ -? -. L. ? T°fwrrA"'Y°ive I ho - ? a w bw-_ _. .?_ la __"?'s..'°1'? __-. l,..l_'?--Win.-__ ? -?_?..I_rY""® -•_ - r ? ? I LJttLJ .rtwl[n'°rovnwml a Dux `- ReD LJ . ?°°?^""" ? ! J '? RU?'° r° 'a?°°wm i" ;'? ?,[r] m?.r[wiwRm[[[xD -_. - . _._- _.. ------._ . _ . ---- _ . -` -- - t '" 'faa n --'. aioNA< :? r__ ^-.art D . L° ? grxruno LJ CHEM. TEST I-1 -_1 GwtMO-•- l flKRLA1Mf OIrC[t1 __. [ FIAOVW KnlcILDHCI t [VAMrtO ? I ?r--•..--- I^ ? TL'TOMN OIHQ ryF[LI[YI [ ODMII a DMDLD S=J n•? MOVLLtS I I RRAOW[O ?' , .[? coNr? t `Y a •. o-amolo "'?3; I. cnynlxGF? % % TEST RESULTS 2 xwl[A+wt ml[T9ArrA10[FClAf 4 J . _ Y06[Ad AIG4D IY%K[ANrr[D euw ,_ I I _ AwArven G OwrGFLOw YnaO r" X msa D+aoo nuASN M[e uR sAUNO Aawc. ulrwo-sT,on F --T +PRO eo n ono 1 -4 --17 WPULAtE COPY. LOCALUW ENFpiCEMEMT AGENLYS COPY-TRIPLICATE COPY. WVESTK)AfOTYSfAPY f Low ti ? I. If 4 F 71 y Cr " 4? U s t ? kF. ? -4 t• il! Y .r,I ? I ?= AY 1 =1 1-ir,k AI6 >, ,i.y t+Pw >t,? s "??' .''' ,.?:, ; k F'At '` f rou ,n I l Yif H ?? ] V lq . - - t I T? 9, "q -red { ? to I ?s: F4 / ,L r ,v ,3 r i f J 1 ,4 M 1 /k ?li' 1 111 i ,', . ""^" `','IvR?,,,.:' i'R?"'",-;_;,""'.,._ •;. ., r ti -. - S T A ' , ++}} I ?N.?11. 1 :., - - ...A , l?r,f. .li? '4 r I. r r . ? err' k r r, A c ; MOTOR VEHICLE COLL15tON REPORT _ .A OF JO. I . .-,may r I ? ? - ! T p CLS N FIA n 1 n ci c¢r CTION ° ~, I . .r° „tip r? Lu?Ls? R O HW :, IN aE_T NG W iN HLLT F ROAD NwN N ET, - i A O MILEPOST PH" ." , , NO E 15KCT ON L OF LO O En' NI D ATA r O r x FF ?? xox?iwe r. ..xasr ox ruer.Nr.Ixe Lwnow•x^. . ... 11'' rec Zs., n " 7CD °u.ISnx G x /? .°... r.? i H x TIOH crsr Cw x 1 ,,. D E c C s D Es D L]IJ [ ? I 5_? _- I Hs LA I0. T E. O E ? H LAST NAME ^F E :-, 1 -, OLJLE TAEK.T - UrE A STI T ROUTE NO. AIVD N ?tSY ODE R CCU ATION-, o: -TAT ? TLC ''.. v'IStn c1:.. L7Y:iys? ? oD '/ ,Lra Pr. CITY ,"„ :?, E ?,?, „ ,.CODE Dji VERS OCCU T rY IP / H O GI r - L 5EN H STATE I Ali O T GE. 1LU , Ww 11 [ (o rsz 9- t E L S ?C RT , F. DRIV C N T T :. \ L ti F C cl. • Icx, •. MODE ? o^n DY TY.LE 1 .1 vrnrc ? M E ; I _ oo ` t., ov^ 1 8 Y..+ E.1 I i 5E E TAr LE P E O .'.ST ,. PLATE -?;, 5 T „_II 14 SE DE E NO. FAT PLC ( C O T nI fc4l 1/??F 1171 G(a/ 3Soo rl I TIFICATi 1 IB IODOMETEM .,c. E '- OR SE 5 'R TER 1 ,. lVE s,LCE ENO , O vR ar ?'11TE F D NEns s ':. I rs ,? _EN _ !. •. /Y 2S" f?T. az ! PAHTSO EHIDLE;DAMAGED• .. 'UGx .. _a(.. ..,:-. ... a..:e. TO.,w ^ vcN!aL ?Cp..n OL.v ntnl? ?- / S.w`a.rx S LIABILITY INSURANCE INFORMATION VEHICLE NO.1• COVE AGE IINEFFECr FORTHSncc DENTON YOUR GAR ? YES E] NO -' N E' 'L ABILITY INSUH ECOM n - : , •IA O E O fi U H EPOLIO O ,; ITY.INS R C6 AGENT '_? B.IITY,P YS+ MBER„?•!r-.. ,. ,. _.•: N _ S a J n S t C ELI I? r ?!.. (. _ Pi ?.: sr ro x SEC. s .... ? M F ^ ? ? r c.rr.rr Pv ? unr orox l . nxn Un rr ° A 5 F J L : K TH TA C - :RITIII (?'y? C LE NILLF a-" xc l_1 .. ? u nrrr .rc.I C.17 ° S 'o l I? ATU O I ED c ? n I, LED ? .;.MARNF T I 1 50 O ON TN T AP L n 6? VE G E BY IE I ? 7 JU N T r p I g ,? ?. I 77 O ` 1 ? ;J D--E{{ IDE BE OII WIr T H ENED RE T C L?? / .L... ?• KL. ... lDt?.. y.lJ LV '1 - jl G 5 ( 1_/..'. r. ..J.( _ k lil??1 ff? ..:J. l!!LC .. C I.7 ('t[Ci'.v FG? UJ1 V"?.. 1 l St 1. I'J C CG. CL t. C- (Z.. (C:t x7LC-1 I ?). I 2 u nr+cc ux nr n .r. n now. r? ? ! . rnoxw. -?I / _ /ar?TT n.F C!•.iQ GCr u`.. _<:l n.j,.. "; {-1 '1../. F. _. E . { l•71 li C 'Avi']lT :r r r I VFrfICI LC+ f?OStT ltl !.°BEF T A ''D r. w ORF fOLLISIUN ------` -_ vru c.r -- -- .GT.AYEO BY 111111T R nHNAY 1" 11* I Cl: LEF-J 7 PCDR HHnH U 1J G L.l - r _._... AL . SR0511NG. - FROM TO ' ..:, Y C - - M[A n -- rrT OONOItION9 • oxrl !R I. RC4 c ODD R r DRIVER/V r LHIC LAG 10 5, I Ir ..rcno c.r' I ,• I ?'? <I L 4 T ` I , r ] t' 11A n rs t II O Y T ? 1 !? L l t GOING STRAIGHT AHr.AD tI NG AND PASAINO INTA n f I 1 r f L Rr tl ] 1 U f n N ] 1.._1 I.l rrOP r1.N ' Y (.. 1 F 1 r? 1I _ f I V AKINO MIGHT TURN I W T I /1 NR I i? I ) ` I Y .fN I-? 11 n T l - L M . ] ! ( I .f I -. ? r? I r ] I I ,.FIND Nrn I I ? _l °on?? nrAi?? I T I. 1 ?_i MAwIN. LKFT TURN I, ] n I ] I'?...1 .I Ii 1 I - I? I.7 ..1 Nf. nr.InfR _ f I..i , Alt l'Y n i_i p MnR N',1 U.TI HN . . I ] ,. •: .oWA/ I- I_.l r? (?.l v.mwlNa . T CI R ,...,,... ,..,.., ..,.. ,., ' i ?b r ?r r I,_I I.? O ' 1 t.Ar,Nn ... .rr L i _. ...____-__ I I i,l ? I 1 C?l RiOPPNn fOR 1RAIFIC ATDPPrn •r amRnl ?. _ ____.. ,r r r, l , .r? w T r n ( 11 _ I ? f 1 GIr SrnK SIGN ViOPPID IN HOAOW AY r- G s? -y,< I.:?tri -. STpT? OV WASHINGTON PADS 1 - UNIFORM POLICE TRAFFIC COLLISION REPORT A. tt. OF COUJ: ? D p PATE BAY nn D u ? y-. - y Vrj-f.. "- s• L N O Ar /. / ES ? I I t" Fc C A T I NAMEa ON c ' . NON INTEKREC110N N BETWEEN DOiflEC: , ' Y DISTANCEAN ?MILES •410 QFEET 'N 4 COL LISION INVOLVED: dt OFVEH :?. n\ O. OF VEHICLES OSJECTSTRUCKINAM ?STATEROUTE ®COUNTY ROAD ? OTHER ISPELIFY) ?IN / 11 OJTTOR Tt PST EETIVR...wAY TNT EC INC i/ Q.- STflEET AND ROMREFEPEHCEOfl CROSSSTAE ,; ,nn C?' N , r No. 'S POUCE COUPWNi NUMBEfl i. f COUNTY NO. CITY ND _ - / FNww. ?I RAAN ?lVFi.. l C?_ AOMLIS PREFI% PLUTE OR 9TPEET CODE URA. bECTION •h . I , S/70 PHEfI% EO. MRE PObi . RAMP DIAGRAM DATA _. rn ry Q 'CIDENt rvTER %PO NTERSECRN65TRE OR AO OR REF EETORo AD 'A ILEAGE I T CIS. EFFNCE CODE i is 5nciU-cDDWGU5E ' 7 r . ., ' I sii EMT` ?RUN NO.IULLED VEHICLE VEHICLE ?VEH,BICYCLE ?OTNERIWRITE) ?HIT6 VEHICLE-0bIECT ?VEHICLE RR TRAIN STOLZ'VEHICLE NO.IWUREO .. AZAPDOU9 MATEWAL ®PROPERIY DAMAGE ONLY l VEHICLE-PEDESTRIAN ?NONCOL N ?H EST.OAMAGE: LOGRON OF061ECT SfRUCKS E }' A ISIECTSTHUC-DOWNEFSN E)'... ., .. ?POAOWAY FEET ? ? ? ? KEDGE $ N} WCYCUSi OR PEDESLRIAN GHECNI _ ' kA ,!3n. D FWERS{NAME-IJLS/T,..... .:.... .. FWST.,,,,......:. ..-..: '."ODLE OPoVEfl'b/NDAM.-TFIRST MIDDLE IP A b f\OF..CIH TPEET ADDRESS - V STREETADDRE53 _.. ?.-.t. ?.:. /yyJ?WK?/h V b u Y 4 a T'' E' VP CODE PHONE HO. . E C R . LPCODE , _. ,PHONE N0. RY - _ .. .STATE ??? 3337 9°??/ R ATEOFW Y rS? L[1.4, Per T «.• ? , L A ATE SEX DATE OF 1 N , x D ATE : ORNERS LLCENStiE NO. MO DAY YFL N D , y RNFAS LICENSE NO. - bT MO DAY Yfl. O. r. `t /N IYi aZS Al 3 GS 0. r L? M S ao 59 ?/ . ?oo •r v Cc r' f IM tt ? ' PHONE NO. 2 JIATI S OWCCUPATION ORIYFJI FWM NAME .., .::: :. : -? - D . . . PNERS OGLUPARON .. :..... ..... FPIM NAME T'TU I, C " C ? u EATBELT A( 15) EJECTION ( lil LT ?/ 151 EJECTION / ll Y t U 9 > 131 clq ,Si CODES SEAT BE I CODES > 13) cv ,S.R I NATUREOF -FIE WURIEb I-UF. """E - F.C. SCENE TO BV: FROM SC NEBY: vEH.VFAR MAKEIDDDGECHE'A.1 MODELIDARTN Al STYLEI2ORCONVI. IDOOGECHEV.1. MODEL(OMTnOVAI: 9TYlEl200.CONVl vEKYEAR, MAKE (??V °r.tesrae J V 6?/ Dor'ue 17-r-r pr adr r V E '?? 73 LERPLATEN? STATE. PLATE NO. ' STATE " TM Llf E FM1JITE RE STATE '.:- TRMLER -M.- STATE: ':. UC. G n; ;: vFN H , • VEIL COLOA ?. .. H _ . .: . .4 ODOMETER . ?.::^tif. :A I N NUMB _ 1 L ... .,:......... CO ETER '.,:.::. ..,..., ICENT6ICATION IWM ft..,..._. ?S '1?SZ , ' v Y C e ...- ? i? VEHICLE IDENAFK V ?/ SD7 1 ZUS F"4Sa CC-Z Y7 ? 71 s 9If I ? I03) . flST... MIDDLE v,; F RHi4T C-EN- E flEGISTEPEO.. MIpOIE flRbi :. ............ .,..... ... N ? N S o C.'-r- M n i. T-A-f•. O. DLA+" e. c ,.. . . O. ADOF1E35 OF OWNER; ... .:.._ ..'..::. - ,.. :.. ? :..:„. • . ... ....._ . _... AWRES3 OF OWNER :. ...:. 2 r,.v.11 la•+dAIoLJ. ) O. P t . . ... NAAAEANOADCFiEWOF%NWR MME ANO ADORE69 P4l'AI . Al AI GE ENT HAR .. C .,.. I,.._ .... .. . ENfORCE ACTWN CODES 1 E 3 A a NAME, ADDRESS & INJURIES OF PERSONS INVOLVED SE% AGE UTATU9 N EJECT:. `. NAME; C U ADORE99' PEMOVED FROM TO NATUR CF SCENE AY' P VMUWES' A NAME: N ADDRESS f 8 M YEO TO IIA II iE3: BC NE BY' . W - NAME: IN ADDR A ESS' AD. TO SCF.NF BY' N Iruw S HAME: S ACCRE39'. TO v ' E 5. ,EN aY ILI5EAT tlELT ISI EJECt10N iVUAIf S 11151ATVg 1115EAI POSITION JIINJURVC4G5 ' WURY SDISABUNGIWURY tNOr INSTALLED I. NOT EJECTED EJECD TOTALLY TE R O Z. PA5IENCER %.OK CUSin 1 S ] T.OMERPOSRION IAUS-MOtORCYCIEI I.NOI Z."o SCENE ]OEADONARPNAL A. OIEDINHOSPITAL ANa+as•BUND IEVIOENIWURY T. POSSIBLETIPLURY . 1UOf DIUSE ]USED $. PARNMLY EJECtEO EJECTEDNIP - 1 $$EAT AELTfAV.URE A D =DINER .11M ! $ B POSIiIOIIUNKNOWN . E 1L ti I _? 1 I? - +yiy T ? -. _ '',1?' ?i. R.T !'?• - ',"' "•.r} N{ tn'Li:?I. f'1':. ,f T q L. r 1 ? 1 ?. Y T It ?, ? .cL '):hay 1 r •,`I?i o1w T n ?s u M - r 'ir"rc. rYe ?i ' VEHICLE DAMAGE I.weACH eox.twcLE rNE NUMBEn OFEKHDAMAaEO,wEw' __ _ __ " WMAOWSITOSNOWPNU.CWALCPECnONOFFCBCE INSTRUCTIONS: so DAMAGED VEHICLE N O. I IUSETMISSPACEFCASNETCWrAO.UAAGETOTAMLEAS.MOTOACYCLES.VGJ DAMAGED VEHICLE N O.2 13. Ho°C , », far s , 131 ?-$? r li Awl la. TrtM ° - a ht Pmt IS. Trwy.' _`^ IB.UMwcarrW v.a.rwln 12 B.U v. orwlwl, SEVERITY FDAMAGE: VE LLNO.I I DOISABUND DAMAGE 3C]o HE M.V. DAMAGE 2 FUNCi10NAL UAIIAOE '? NODAMAOE EVEIN]Y OF DAMAGE:IOTl1EP VEHICLEI I TWAB DAMAGE 3 DOTHERM.V. DAMAGE 2S NHCTdIM, DAMAGE ! NO DAMAGE OF DAMAGE: VEMCLE NO.] EEVEPoTY 10 DISABlJNODAMAGE 30oMm .V.DAMAGE ] FUNC110NALOAMAGE ? NO DAMAGE TOWED UY !`//u r.... ;r 7t:ir rl ?.•? (. EST. DAMAGE TOWEO BY EST.DMIAGE -*EO BY _ ESi. DAMAGE TD 1 (cent, ] .SUJ°J To s ro -' ],7 ?J°i ,OIA?NA610F COWSIOR" ¢at. ali' I i i - 1 ^I -' DRAWARROW SHOWING NORTH IN CIRCLE 1 noADW PDwr.IEAl1PE> I -M ' ' I I P"r."oa- iANa oxr?rnorwr ?v I I 11 1 I i I I I F O . 3i4? ; i I I i ?? r? i aarwCd°crrigMB« ? I 11 I I" I f ? ? I ' zlcurePnolueLerwrcn ^i 1 ?' _ I i I --.I, I ? _ - Asti' i t i l i i l f' .: _ 1 -+. I I ( I f ? wFn .A w•Daw ? ^ .. oE LE ? ? ? I If f i l- I cis q• ,,J , ,? P F'? r I I DESCRIPT(ONOF°,S;'-Sn". CO WSION'AF.CAts`°k?.. pr1OICATE WHAT PFgBABLY HAPPENEDBEFOAE WPINO ANO AFTERTME CP .,-P?Po?•PEWCED VLLDIUfy, PEDEST1MN CiDTWNOCCLOP. CONSIAU .t41, INCLU =oO OA AE DE WFORMATIOrINOTON gAGAj.M, ED.ORIVEA PAIHW4)HIL ETC.1 .: : r _? SCR ,? C A? /? Iie?wod. I¢a Wes A•ro ?:n? rr+fo ?r 7- 1, -/ .,.re ?? LJn S T un(r ?( WeS..?ppUY SF?T OJ lr F'O??rNe AT {7?I_ ?rrr?h 7)aTCt :A/O J/?+ a SSr•? #-2 JH .'Igo. G l }? ? ' i a INTO Q'1T/'UG W4 Gr^ p . L?-(r, r? S Cry Ia 'Ljlxz -r-u- y ( ? ?JTOT IJQS ?(+ 4r I T _RO LLT veyr,°?•..DwL/ < TD_a w.??t twr pge>Lyt0.5 OJC+Y• ?.. Y'Pr I!N<?pe 59. C T r -' Uek f (¢> OOH+i',• 20 Fr -,9(• Slcr s nK. be T- ar•^d• Yve -sur or¢. - NO.OF IANES SPEEDS VEH I OILUSI _'^^h'w4%+j:nC:`i9dz_t?°'.'T"y°'Id3dtl ?i^al?.4'c"'•.'r _ .. ONE D[iEC110N aAFE LEGALLY WADVEN. PO.Si DIA. ONSTPEEi DA IM3HWAY NAMEOR NQ HEADED ... ..S EC AT PAPHEo OccU o N E W 9 ? ?? 11 ' ((?? 1 ? C Tt I ? S .«1 S YES NO YES No ' PED. ?F] L MG M L«nOS9w ?? on . wawlWFn roseDOwruom lEr wa PED/B'CrCLLYi WA9 U30q (? ? :' ,L•_iaoew.u JSHOUnu •L.:CFOS®AU 1.. !e?ros? -e°EerslDre'IEro?irre ,.ROADSURFACF4 -IChetx OW - jg: WEA 11]•ECx o.o, CONTRIBU , F - -? TWGCIACUIi1ST-EINCE$L Rb( trf On MOFB ...:. Y.1?"+...r. .'n'""` as '+fy?f5? ij /?T +rkii '?+="?"°` !'?NTOK M°`?"?,_ - - . ?T°O^' R l y - Dm°N-- -- _ • I]IN.B1 - -' - DPrrtA J"?P-A< J"SS++YY ?? ? , ? ... U C j, Y?:°F d ; c?? r ? EDWDEDw?, Do ] wE, ] ? w,.a - ?Dr ? ?. ?Ar ?a? w ?a? arrow aEl t>,oro i,-,, ?> Da;•A,® - ?>? ;D„,L.o - ?,?nvAnAaw ?.? IES?NMOTTww ?. ? IC[ . ? EDn ?. ? aYE9 R? ? °I T:M w DElEC11'I[EDUV: - ?a? 4NR?i -4:J_,S•a? ° _. __.. - io.e:o?tvw. ?n rj 'aic:•DO°r°Inwr i? __ (-'1°?avrvM .. 1 .: amwlraarvl - nmrA,vco» i- ?7 G•? ..mw ?,]:? nwiawlAirOV ? a? ° CAI rlor, LJ' ? T?Iq , LIGHT CONDnWM L,_TLm GCDIrWut.c, 1, YI-At-,rf EOFROAD? uwca E OA wn VEHICLECONDITfON, L;i:r.'?..SOBRIEf.Y.2;Ar +a ?:? ? y ltraa ann ,. _w.^nw> r ,?1. a? I B F IIe IDHEac onn -...., ?>?w ::. ?rJ_arwHr_ ?e?? ? a ? nwwAr ... .... ? 1?_.w ?r? wulw'?0 ?1°? Ii?OLVe . ]_4.?. p•rM ... :. .Ii? ?`__ ? r -+ > ?? ... .... ] -°Cf--_ a? 1q/wvurlE??.? ?11?' P? . e.uw 0".E] .E ° _? NMrolrr --W [J.[3 m- L. '=1°? nww•.a]?r Iuwl/.a ? ar aawcnmen ? mmwH °I•?Tn CHEM. TEST 1 w. ] i El L J V ' I .:IierwHn ]I"1-rjtB,? L.?___. 1n Gtaq vrw.rIu<m ?•j TFTOMAI OINO, 1 . IY]CVYI _ _ r El . .,. ?• ? o-. ? O - IAwen ? ? MnAern n n Iemnwa]o ?T . '; . i?• cwl,c• I. - .'j FY n % % TEST RESULTS 2 roTwuawrYr•n•nr vw ^ Ulu?^ IMmEM. amrAr rao race ANY.EO N'`rw""va?o /A., 47 07.rl7'M00+ iir''E`aoSOW X m?araAlroerrcana HM.a•rMNA 1 Y7Tnu e lu•t...4, nAOOaw ? AoeNCr T,C,ScJ Nronmr,•ort. o•re orneetr,r /?,: •77 Awr,oveosr ogre V WPIICATE?COPY: LOCAL UWENPOACEMENf ENCY'9 CCPY-TPoPUCA°E COP'I:INVESTQ?TOII'BCOPY FI ?? ' yc Mw Fem.. c;,? t f I / ??? 1 g t I t• i y ) t1J Ad • r J MOTO R VE l1 ? . O • or COLLISION E CCLLISION r - .tl 7 ' r C?/?oW?Y l 1 LTD" 00 t M TL li T. L tr{L'1 i !OWN 0 L". Pn EFI% xoV c o rxtcr <oes ..k iIUN T" p' ;SOY NORDLA.ND C ]E?lI NORMAND '35 _ _ E F ET qOA H GIIWA RSECTING WITH: TREET; NO A, gEFI% EO .11 L-_ . p r yrl ? Ta • ^ ? N N fEHSFCT 01 r IOl-LOCATIll n,<? L -- - ARAM DAr, D D-WEEN I S l_D TREET E -RO x 'r °l?a }1j•l E-1 W NORMAND vo,n cnasvrxu." xrrr, xJ L.xux..n, °ntx, o. uut I R NTER <L x is QcT an n ue< pT JECT ^+T IS>.c..zalH.vEw ouaci , •,^,, WNER OF ODJECTSN E A ADDRESS! -T (, r eF,ln onJ "lei H AT ('ELI -_.-. T ^ n r.n .a y0 9.u T e - I sr - F xvaLUSn sLASi RAMC -MI y,.::... MIOOLE rr,rs ORIVL .:.,.-., FI T ME_..-, ..... ..? .. L .,.:;, rsraxox uOHL _ CECIL EDWARD`","""° a fREEY AO UTE NO AND BO%NT a"s+.s^ STREET o°sc^ POD 54 . H . I qOU O. A O D h O _I- I SALISBURY LAP, F.•.,_... ax xr L T ?,_? - @TATE• -. 5" 3Pc DRIVERS . c Pq - LTy .: PCOOE flS,oc I N? _ _. .? PAR4DI5 CALIFORNIA 9594 RETIRED VER ICE EN BE LM: STATE E% DA rH AGE - OHIVE LICENSE NU ER ,:,,• GTA E ?11 IRT pGE_ -1. x -A -'- `_ - 1 BOl8b X92 CA x 8 'l a4 6 IT s rn: . E.)?;•, •, -^ooaacl NODE 1 1 00 STYLE 2aA.i vrxi<Lr ,,. MANE I<"av naeaF L Ixnv, n„-I OOOV STYLE'13'ox:l 1 FORD 4 TON PU 2 DOOR E PLAT H '?„y. T ;TN P TEN 5 AT LICENSE PLATE NO. . T E : . - T.. PL E ' :.. .,TE:,: bss ??N cA LL . YFHCED NT CAYIOH ry0 ,,,,1 9 O, oo%u,d'.rycsvc I OOOMETERI R[ VENICE N iC N • I r D Moe.LS a ODOMETE ccAa[ ftEGISTEflED OYVNEls?llw ., wsr-RIPq.?c -.?- ,, -i'.' O ERA LICENSE NO:.. SA.M.E AS ABOVE -,•? -REGISTERED .VER,- I -_ nsr.Nloo s Iuu[J ?,y ORiVER ICEH_5 , ,Y? A D ?s c•ir D T r VEMICLE;OAMh c-r.. F.. nJt ::?: l?: .C r ERs A RESS .. 1 -i ART OF VE rCtE OAMAGC . . . .. „.? . •..... RIGHT FRONT FRME S2,000.00 ? _.•._ _,.. ,_...-_, _. S „ n .w<.? 1 LIABILITY INSURANCE INFORMATION -VEHICLE NO. 1 SE HEyF E E of c 1 cE rHIS-ACCIDENTORIOURCAR YES NO i. nU RESS FWOILITY INSUR ETO CYM _'?. ? .,i N AB ITY R CE COMPANY -:c.:v .? 1 C IL E. HORL li SALISBURY LAND, Paradise CA 95909 ! AAA E ND AD Er90F - r,?,:-;, _LI ILITY fOIC UMOER'... n._wr?E.s«u iy NONE of 674 7o 96 3O r ,.? JDI R AcE. E N 55 F axr or rR I] ? I Fl ?__..... . To T lUSO NJU ED': - y H FIRST N T IES ST TU 11 11 O MARKF R TO E THAT Pt ES' [? IN. ENIOLE .... I o I x fl -?? I .A - . I}7L1yl D v..fl 1 r "°r .^. rr<i lat 1" __51] moo' 70 SO SO "T? 1.111W 101ITI 3Y ARHOW IN CIRCLE I R I r, La ",.,:: a AxP («n. i a. a? EfL \ nk C IIDE, ELGW. WHAT, H PEN[D:.IREFF TO VEHICLE GYNa.N Ge .%,' ? O1J c, R.,' w tt?,J _v E ?. -- - post Ov reRnxe A - u?s,rr t,vxu _ "J 1e ANJ? f4 i r TN c 6A tt S Db „ xr,Ar .. _ , - --'C? CK14 - `V ! . _. VS Ft- CLE . LP,NDED Or1. 1 f'?t.SSFTJ6`L? ?i O? LV?'? f?1F5?E0. Ti-i`L Dei-A. . 1 -ter Vf IIICLF 1 ITION BEF CLE IIIA 'U ?ooa? ORE COLLISION L 1 ON RTRSET OR WAYI ME OU NO. m,rcrrx YTG Ot° Cl n . cl Lti4i El o a o : n " IE I IF 1 l .I L I r In U I I CI x N P TD' I IEj ... ATOM _,. .. < " ?F -'? Llnnr cogn RlR??-"ln " 7w[ •• ,..o•n ., -- -r.r4TI FEZc --? o.IrnOL ,nxo ' 11, i K O gOAU - RIV(R/VLI,ICL[ IOHe, m. rc, nNr a. (d .) .IIY t" I_I 17 J II I I). 4 u ?. .I { I (. I10 ?V 1 L IYDO— STnAIGNT ..CAD 1 I ,I r 1 . l I J I 13 F1,11- .- o <N ) 1 11 r ?? r? (J OVCRTAYINO AND PASSING C MMINE. n1011T T.O. I„ { .IIOW HG l 1 1 I, - I .I { - ^ - r L.I W, .1_.11 . l I f LINO HEn 1 ; , I 1 .1 r 1 , .J (I MAM NO LCFT TURN {. I _ I ) { I {_l 5 I I L - C. AVnl11 .{ I 1 L 1 1, I A I.l MA IrrO II-TURN FA fJ WINn { I I _I x( I [ I C r f r0 f YF r I I I I/ 1 A-- l _ r I OPPfn FOR TRAFPIC f1.I ( 1 OR fl,d,SGN I I l --AHAT.. ._ _ Ca r 1 „ I ? p 1 I Y „ (Y^ I 7n Gf° z ? '1v F - s«Dt ? -':: J _ 4 .Y I I l i Iv n e - Sro. En noAD JAY T n P I ` i ( r l "' r C J n ?? nr? D t Ir Ny p I f 1 t ( ? ? ? 1 I I J 4 i I ? y ? t Y f t N O O v N O 'r-i H rl IJ 0 0 T t(1 I I i i i ?d Xl POLICE TRAFFIC COO NREPORT LA)TRAFFICWAY PIXICE AWI EEUMRER 2 IVATE WAY PR W7 Toil UAIF U?CIXII N O AY ON 5ux M IulS 1 IH S.t N rlMf IU ?.DDH?UtI ??C) COUNTY ?EE /?SO? COVNlY NO. ?r?' CITY NO. 9saoo MNA ?uv RAL f CITY OR TOWN NAMEINO.O SrPFft OR GHwAY ?N O I N N ??pCy ICI C. ADm^?)U PR I RpVy1/EJO?yR? ' SE Clr M IFS 5 ?W ?OF N Z NiERHCTINGWIr EEI O4 RO NONINI[RSfCIION .IL_ / .OA/O 5C QG?? s1RFF1 [ STREET R?" ER P EO. MIlf Po51 _) "?? C, , l ? DISrANLf IDIU 1 MNE f9 .CVO iREEI RNFARESt MITI POSt M Ifs 5 f lIEI Oi ^ , ACCIDENT MILEAGE CODE P DIAGRAM DATA RAM CIXUSgNINVIXVfD SfvE9 lY. N EUN lOlAlrq O%IIIFD?NO.INlURFO? ?SR WGF ? 4 OFVfHIClFS ?P90PfR1Y DAMAGE ONEY ?g3Ul1fD ? faCtf? w s INFER NL ?' ? I 'NIER CIS TER StRF lOR ROAD ORISrf fNCf CR0155rt1fETOR ROID - - OSJEC157-K IN- -ECT STRUCK MDOWNFR'S NAME) FSr. DAMPGF SPECUSICODINGUSE ? S() UNITNO. T UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST S 091vfR'STUmO W! HR5 T ,FS >W DRIV-NAME: - Bc? SlRtfi ADOREaf Pn6 577 /{Aaco?K/?o.) rKEl PDDR ?Z/ Poc,,% I Z -11 OrT /????? WAQ. ZIP CODE PHONE NO. R _ I!Y •Sst'AIE 7D 7;i' P 2 ORrvE4'SUCE.. NO. IAIE SF NIH I rv R' UC NSE NO. 5 AIE DA e M FNO. EYES IGHl FE GHt NO N OCCUPATION iIRm NAMtn P E acufnnoN fIRM NAMEe PHONE NO. EYES IGfII HFK:Ni 2 ? ? ? Sao. !g f/YE//L c 1 7J0 5- R L-H - ? CHECK (11 VTNKiEA A ANOfNf¢µ I OF ?CHECK (/) VENIClf ASANEMROYFfO ANOIH RAI 1 CODES ? 1 n ncr 011 < °s 5 t aN? 6 R r cfroN CODES P. D < < it 5 u e s,ri°>o= RP I N?a" r lFl J a E oI .v.n ' ;•; c ? .NSM.NCI ? W, ? 0". ? rl rNCI! I'oAHV N a 1o".. ?,MRA NL ? W." ? wk. ? n K? ? a NM s N H. EAR MAKfI {NFV.1 MODE IOART.FgvAI 51Tlf TED CDNV.1 E H R DGf MEV.) ?? MnovAi `'72 MA« Ytk,To SGJ e I lly wl ?7O surf N.uIeR RAIENO srArE DFE. H vEN.eaw AI N 02l. ?vAA -- A VtN{t! IX IiICAt10N NO. i E OfN11 IU I NN . L Z SZ- 7, E 7-9 1: 1? .36 &Z61 1; i I I RFGISRRfGOwFJfR: -1 F-T N-1 PHON[NO. O I rFRE00WNER: USf 1.- MIDIXf W. AOD9t550F CmmER E W A Ow F9 R Z E SJA>ti(E Iz -11 A11111 OF INSO1ANCf co. oR AGIN' R ` yp,VC ,QfineyC.R,vD -?i: i9,vGEPES DAMALEOMU pYR ND - N - / VN%M,C gAMA9DAAU. DS i wrD rA uNCl?+reA CNM? CNAPGL •D rDP 5 I Ow pAMAGt tN D IVtN R[M,JNfD SS D 5 ?P[MNNlO ?AWAY IO?OTIO? A*Al ..? ? 0 6 ? Aw"lly! iwivD er Ie OLlIS10N 1 m INDK NoRIH DESCRIPTION OF COLLISION: lusf s[JwuMENUIStIeel r cFSSARr) DIAGRAM - .. SHltI rN[C[SSA r1 er .. .. X077 77/E; --- 70 -u C . ?p?/i?iwervr/ NAME, ADDRESS 81NJURIES OF PERSONS n! surRE $. INVOLVED W y I D * •7 3? q ,$_ 6 -" H E H I T 0 i s A N N •, t Rl5 R, F#Cf _Ir AMI cUCGC NIJ Z3 I /F 1 7- 11 rss alr, ?/S .IjfjE,?7 , Alu.tor nr ? A Me ? cR1`5 ? ? I'SiI.EA w J6 ° dA L ? Et, /5s/,c /,v 2 ATI^Nn5y(({J '11; O N Mo FD, u r r ?AMe ? b , t 3 5 2 N ' . f.U.rlf ' ,17 NlUV 15 SCFM=v ?AMS ?rt I aiii,y S ,.wIP.O FKI.f MI I.AN, e Ar- x l?L? ?e .DU Da ? Z 7- wHNCT KI DIfFA1C,4D /QD? 4:1-258 r(%KZ A.IINO /?QS DAI(p Po Iz HK 0 U I Vt 0 Y I T? L, [i y 5 x It 4 ? ?t afiltB , ;,ifir v t r , a5? ?? ?r.ti •y.rr `. Vii:+? ,. ?'_.,? aai{. .; f''. . ,, . _:Y.,,4 r:;i /aw rh'? F Id"±6 d • ?. r ?{U?$P! v+N? tI I POLICE TRAFFIC COL JN REPORT 4TRAFFICWAY EOIICE ?.AINr NUMBER / C] PRIVATE WAY N 001! OII . 8o UAV IXl N RI.. R9. X AlR 1.R.f 1. f,. MF IUSf RRW HOVRI COVNIY - IG -IND. ?URe AO / 'RSa ?E -?:9' wL ?N ?E N RC6+?'.Eq NM!feNO OFSI9EF ORnGHWA' C? - -Cl Al"I P r RpUIlOS Sf I 6 mlES ®s ?w OF - ON C a. a •3 9??f7a n INItRSf<nElcwl R row ROAD wreRSfolon ? ooy p,e iRON DES. ?N PRRIx Eo. MIEE POSr ?? C23 BEM1V .e O. SiRlEra SIR[Fr DIS i a C905551PfE O4 NEARfSI MI PO R . I ACCIDENT S f w MILEAGE N R DIAGRAM MIA rftr Or CODE CIXIISN)N NvIXV[D. ERIN: ]'HI w o S M W Y1lV4E }OtAI NO NO. NIU[D??NO. ® E D R f?,? IME9 Cli CROSSSiRIROR ]S ? Ol ty CP VFn CI[5 PRO K-DAMAGE 1 ON[r RfS lIl1E0 VFaCtE 9 Y - 30Q 9 OBEKISr9UCR INAMF Or OdlKiSrRUCK AND OwrRtCS NAMfI ESr. DAMAGE PEUAICODWG USE IVE --c-4z' UNIT NO. 1 UNITNO.2 O VEHICLE ? PEDESTRIAN O PEDALCYCLIST ? RE y? Y DRrvtrS NMAf^ V31 iI • DRIVfR'SNM1E: IASr I ST -?? I J V. Mo R is?LO / Sr A J-1y y - 6i StREfrAUDRt53 .? ?OCAN . rRfEr ADDRESS GIY Sr IE ZIPCODE PNON NO. D HY SIA E a N ( d HN R r/ c?NiF- vI 3 / D91 LR'SUCENS 5 Ar MD R I I M0, All afX DA R DE'N?-aw - 1 N 1 ?% v Io o / 1- 3 %r 5 y OCCWAION AM16PrN)NF NO. Ett5 VFK911 M nl E CUPAIION rIRM N - PHONE NO. ftt3 NSHI MKIHI ?j ? R C . . ¢ o P ?crTa oFF /05 YJ?' ? CHECK(") vrwaf .s eN EMav Orufe? AN ? CHECK(,') MCIFASAN fMROwf orA IAl tt CODES D i 5 u 6 yHf,-C :in+?. «rroN [ n CODES P* 7 ?:y' A ifsvuwr 5 1- 6 f•Nrr Nr / rfilu9" a /N u S Rr it"M`e.. °° ? AMRRU.KI u M Y[° ? cm.. ? m'" ? r"$,.f. ? ""' ?:° ? c"':n? K Iu N SU [I l"YIO ?M VI KN YfgR FIDDDOE GHEV) SLID--AI 11YE109.CONV.I I H N .) MOp[t (DARi? VA1 n 6j Fv Z p 9l Lr E aaxT s w 7 S mo6F lKENSE fNO. 5IAIf -URRAIENO. 5TAr H V5n IXOR E 3 I? fnrclf lDENntx:Alnxl NO. - 6 3'F5'/ 3 2 ?.o ? vEHlc[f lDfNnrl . !S15'a!c5i `0+7! 1 I C PeelsrtReoowNER: IASr n9sr MIpD[e ooSJ-c aQGCF PHONENO. O W R ED w*IfR: lASr rlRSr MrowE S4 c t A D J .' rfo rK /. nooRfssb owrl[R .5?`, 7FRJ2gcJC R J?.[ l a c Q N E NER I NAMEa ADORl55b INwRANa co. wAUNr R A ' s DAMAGlD AREA w?rou`.1u „ asAwlw r3AMAGS I?fA P 'eHARa eHARCE "AKeO ro. f lsr, oAEAAU A.AY" pD.IYfN ?RUwNED [s.DAEAAee Igor loioiro: REMAINeo I] ® [OI AWAY IO?OTIO» S lol IOWFD 5 10 O Ar I ? AWA er: Aw S I lus[sarteMf ru sMRD N[eESSwrI COLLISION• DIAGRAM OF COLLISION yD lr lr faelssnaYl I^ ey.1y M DESCRIPTIONOF - __ Y.E'HF /_. YdS S. awroA; ..T o._TVAN ,,]RP dJ/T iN_7:o __ aLI0 -.5 PPf, SA..6?M,LAFi) i?,?}AF'N7' ' ...._ :.. - .. t ?. 2+JN0. .wni7F. {F f To FAeu..7A?k..}!Af!,Prna_._ _ '? . _ . :_.. R)'? 7?ARa.. 7?o.J(._-f+oiN[q 54/`E'?- - ? a aF.LE'Av-AT A ?.._ nod..-v?RE ,S. n ._ MD L6119- NO J._S.u DAF-Nj y...?r: ?Nefl .. _. / 0./f2r A wo NO'A . -A= f.Ar ea??_To.gvaJp ..-.. it Ni Ne / NAG... 47"47 Qa4KP Aj7T4' A4. Sep ?' , _. _... C Y rIJL ?.Kl -0 ONC -X-nA- 7.IPRr 4.C/T5A.0X.4ASO . NAME, ADDRESS & INJURIE OF SONS I NVOLVED P CODES 1 2 3 4 S 6 OCCUPANTS WITNESSES IUSl Slrl11A1lNIAl•M 10n ADODR>NLL Ntiw fl sl --- -i RR Ac _ Gt - YA,.. '" _wf I .-_-. ... R[SA enCl i iicr N . AMI 1 DO.rSf q k NAiuR b .. r nr ?AM e ?R1' ?CiT 1334o N o A we .... ... ... ? [NW S1 ? IArwfb . _.... _..._. R MwfDIRGM 0AM6 O'°"1 ?m ? R ? N A[ AV 110 NAM 01. _ .. ,. ...-.. _ aAnt wAwae s INrn.. 0-8. ?I.RF O?R' ?? „ Nvl flGArraG brSlrllYMl a1AN. nNM /Gf-r [??SPAIG40 POl 1 D OAt[ RIrORr AgRpyfD er DAZE X E• . I /6 ro n ly Y' ko 7 c So H ?- 4 IR a 1Y_' s ref nI§? i VR ? 1 2 'I+T D r APL jD? §TI y??]?R ??i • M t c• _ r•,,... .. CIfY.TOWH.. .._.. Fou`sOE MMES-:IO© .'..:., WxFx[ - .,z,.... CITY. TOWN . - PREFU< W E nlET SECTION ADMCL9 ?3 a u sT ©®DF er?so in/r//v?/ % Y^ ;. -' ATERSECTHO•MTH:?9iGgEE/TIOR ROAD ._ AO,ooN //jJ LIVE H.V.,E OFS REST /R?OA?DOR MgHWA ? _J ? PREFIX,;, FA WLE}P.OSTj Yf l . S ? ..L)- : 'l ' " ' !? oY !J C-Gl( rG?La,.2!! . 4'rr OccwiD ( '?i . . e 4 ' ' - NONINTEnSECTION-LOCATION O77H . RAMP pAGRAWI DA, Y .µ1 f ` 1 - , t TE?T OETWEEN STREET AND C:r. r7r??.R' . 1 . E I:iI (Ct..?- nsFCfMSIxEEi.nCn HW Wpe L.lu R,aaOHcnoiSw?M[Erosi Oxon, ErwcuMwWx. n NON %-P6 N OED « iEP WTFA CL?fwos•?,JS? FEET ©® tt s /,S ( / ENCLE OYEn wCV E O oM/FHIwHif1 ' ;IX' 5npwwlvEO '))1 / SPEGCOOE UvSwE?"? r ' OFVENClEO I_ nKLF PFM-ipW ONw CIXlW10n ?T, wry d{:-N_ Q .Y. S .:,%TL OWECTSIRUCK NwEyoEKCtsi,AKxf :.... ... .... ... OVMER OFOWECtS NAMEAMDAIDONE59 LOCA INNO TION IF21 Ell O• io [ OOeRn n AY FEET EEE- S x p)'^ O.si OWVERSLASTNAME FMSTNAME - WOOLE ;rGL- o/f/t( //V-0 F-AH O'er wEPwnVOAVED EDw?DHDR A, DRIVERSIASTNAME FIRSTNAME •- : wDOLE NkNcly e( - STREETAOMESS ROUTF NO. AND NO. b'/•/4/•t/E ...? ?c W""M IwO PE A. PN "? A STREETASDRESS .. MUTENO.ARGeox 0. r I CITY STATE 'LPCOOE pRIVERSOCCUPA110N Cain COY STATE LP CODE DRNERSOCCUPATION _ ofe awNSEn/? Ss %/2r R H AGE EPDRI)IXP, AGE DANERSUCENSENUMSEA STATE SEX DATE OF T. T MNERSLICENSENUMSER:. STATE SE% DAT OF& we-fx GJ-,t' 6f<Tff LLIg M E MD off' ?i 7? N F D,Y rEAR VENgLE YR. MAIIEICHEV.-0ODDEI- MODELINOVA-0MT) - BODY SME12CFE VEHICLE YR. MANEICNEV: DOOOEI MODELINOVA-0ARTI BOP(SIYlE12 DRT -- NO. TRAMERPIATENO LI PUtE C EN SE , STATE . STATE . MAMERPIATENO. STA UC HSE P UTE NO F g / / , / ? ? ? ? ? / ? ? VEWCLERIENTIFICATIONNO.. , 1108AMODELSENEWERI:.' i55?yW? 7irY3 ._ ODOMETER INIILEAGEI -av?- _. VEHCLEI-TIFCATIONNO. l1BBSMOMLSd NEWFAI..... IIRER 1MMSAGE) e < < /, REEYSTEREOOWNER .: ILAST+TpSTA11TALENAMEI;. :;i '-..-:.OFWERSLCENSENO. '... REOISTEPEDOWNFR ILASTFIRSTMgOLE NAME(.. -'.._DRNERSLCEnSENO ::..::.:,: S. n?? 095 ??o E - 41he W6W,1/ - OWNERSAOORESSISTFEET,COYANOSTATEL „-._ ,,.. ,.., _. DATE OFOMM rq 1- YEAR OWNERSAOORESS ISTREET,CITYMDSTATEI :......... I pATEOF &RM FFD I I" 1EAR FANTSOFVENCLEOAMAGED _ _' ". EOnMATEDFA-i Sio . •EyE PMTSOFVEHICLEOAMAGED,• ;. TO vFNCiE AroN??- 5 WAS THERE AU LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- COVERAGE M E TOMONLE UAtl UTY INSURANCE FFECT FOR THIS ACCIDENT ONYCUNCAR ES ?NO ' NAME.WOAOdiESSOF II.ABAItt INSURANCE POUCYIIOLOER - ;:.: .• . ._. . :' NAMEOFLIA.LRYINSURANCECOMPANY_. -E SF `?lE? /?S ?f`t3odF -- II - =P .IFyAemE,2s' WS, <5e0l NAMEAH.AOORESSOFLMBMltt EE.,, ;,UAWUTY POIKYNUMBER ':.:. %f? o? ? EP/ 7 37 ?f1,Plf1F25'I//S. ?/16r+1/TGE0?6E W tE6An0 Ar o??'?'??? - '. ADE 2ND AGUNY IV-E FP ,... I OA rpn wAAUEfI :.., AGE ISTIWURY - - . N E NONE Yo NAIVE - _M i? ?OOnE55 M % ADDRESS M s D nfroCTDw g 1 E.p.p, w.,M?fDR Be n.Mf MAAK FIRST ONE THATAPPUES STATUSOFIWURED „ STAIUSOFVAAA,EO MMKFMST ONETHAt APPLIES O QpwTK =k gL D6AIxn0 rAW M,pP10 P0.KtiRLF 0.- I VEHICLE -Nunn FKx06,4M PO-Yq[ QIASMrNFw LED 19ES EI IwwDx1 IIOFV?AUnA -H NO _ KILLED lyvEUFI 'SWOT P?wwEiG II: 60 0 ?nwuNW ONOLlIpW 5[1 60 7E] e 13 so • SHOWHOR HOYARROW WGRCLE D.DRw :A,4„ ,ce fru Dun..e THAT >, . rROw caLaw a«re. nan .NEE w r y ? DESCR OE DELOWWHATHAPPENED (REFER TO VEHICLES SY NUMSEA) ?V6// ?/ cags 41dA,11v6 A EFT 7yUdN. ?--h z- two i45 Af?/.?PO/2C /HAJ6 ?o? <H/Y=AY?.G/ED dF.?Y s[/ge7' Ais7s!!?c== =r<Or?u7 [?.?iQfS-s EfnDW M?, DH ltas -??? Qa- STOP I? (7 ( ,Y NE.?OA? ,. - __ ._ -eIAC!<K6_t/F/t!?/___oN _GFf?ctTFF?_ ?S?ENEo iD NP??/'i?i9i)? (7 D YEK "? -F -- ce_e? /? _ e ceA z 77 _ _ _...... . = _ CerDE.vr DR/?/?.vskyG? _ ° ` - •: .cyAs inn /e?tT 1'Y-*?1_ FEATPirf<e _ ?._ '--- -_ - _ -.. - _- - --- ' - VEHICLES POSITIONS BEFO RE COLLISION OF STREET OR IADH FAY NAMF OR NO w o,;: ° dCf? reM nHL nnn FE tnN Anr vP 1D l nisi acu.iD of r18 IM,ESTgAiED „, ? a. 1Z. ? =l VEHICLE H S L M, POFN ? ? C7 C7 210ViN6 [.afT / ? ? ? a ? O ?CRY ?VIW"1. x ID + , ? 23-0 O Co, R'o'?`i? 9/'??Lr1G7//A/6 sb7 ? ? ? ? ? ? F LavARN ? ? ? ? ALOFAT a FRom DIRECTION To DIRECTION MMlTT.-WAl IJSA,O ,?N.- 20 W.-AY ]? S„OLMOER A?<I:;sawnx !? rnv +Ywwyx ROOMER NO.DSUNf ACE WFA1H9R LgNICOHO/IONS iFAa FX:CONTROL C.1 1 M1PEOFnOAO DIINEn.L'fHCIEACTIONS KrRCary.I r{FW „n2 P 1 ?Cin?rAR Ufw I ?M'iI IOHT L ' a,r1.F[ v vlrxCLt IFEMnr„I. MI Mi ? 1 ?ONP WAY YNICII. KIRCA d•l MFgx[I M) ?I I ?p01N6 STRAIGHT AHEAD ? 1 [?{yM/Y ? ] "I--nD ] AWN O ? ? 2 SIW $KN ` WAY TSYLF. ? A ? 2 ? OVENfAK1q ANO PAS N0 ? ] ? MANINO Rq.T TURN ] WET ? ILL ?'?SNoW ] ? DUSK ] ? ! vFI O A?FOO A?LAµirfl5ILNF1/!/ IDN ? ) ? W. ?y???••' ? IrJ"^"'y,n nFn / ? ] F10 U ? A ?k(IenCI,ANf.E 11 W Pv RA-1 ?MAKMOL[Ff TURN ? A ?OEHf ! ?ISP CItYI ! ?ll.. BOFFPT [per ` U ' ? 1LA•?-AMnfx ? X1 A L_I AILLY O ? ! 1:1 MAMI U.tUNN ? A ? DP[CIFY A ? SI11ff1OLKMTS ID A ? IW fl- C) S C3 III f IUIH ? S EAOW,HO ALASON TOR WtSeE• w]DANGER ) ? ? ) ? UIfK.f.NifLA-H LAIRS ? ) ? 510N•40 FOR TRAFFIC fPFC lY IA:Fn0,.4TMfAM.i[M Irt1 C; A [] OTHER WECIFY U ? 1 ?4,PMATED ? A ?OO`ifOPAISSAL _... ..... 4 1 ? 2 IFWOfD ? n ? Aln"'FOIN,FOADWAY EANI r,Fl 11 ? e ? 0IN ] IOED ? 10 ? rnunc I.A.e STARHHRlRWIAA M:OnES! ... :' ?.,. •.. SEX AGE ? IF ? PINAEOPOSITION ' . n -- - ----o f/. !Jr_N71'N1/" - /v :•?s:cr. 011 , rAHA ? 12 ? TRAFf CI IENTERINf1 - IMF ERE I STATE OF WA I INGTON RAD[ 1 DE f No ' POLICE TRAFFIC COL N REPORT GT ? TRAFFICWAV 'f'? .., IN[N M U BF9 PRIVATE WAY VICE AIEaEC l N DV l E I couNrr couNr?/ arr NO. 6G ?o 5 31 ?° R,. »?. D "IR NRn It X wse/ R ?E?'??e_ orK.J (o 2 NWA Rµ [ ?5 ?W ?OE CIIYORIOWN 6N0 Of SreEfrOR NIG"WAY fCr ClS 9?..? -`V N i' = RWr 09 %[ MA-n INTERSrrnN W? -sralEroR`ADWN ?"-IZ.P.s'eoro GGGIIIL -90?17C.7- ?f NON NT[9YCI ON PREfI% FO. MRF POST J2 F [xS1AN 6 BETV/fFN SIFEEI y STREFr - I -_ RE 9 .<ROSSSIRfF OR NfARB IE ACCIDENT a IAGRAM-A !3 N 5 E EEIT W OE MILEAGE <OllISpNINVQVEO; VFRIM ??]] ?ODN " ??rOrpl NO. NO KIIU:D-ENO. INN9fDy ? SrIIIAGF ? H drrLf? -_ 'N IM[4 D IN.? O?VENCll3 ?PROPFRIY DAMAG[OVIY Nf CtF wNRxOIN Cl5 C905SSE9EET/o9 ROADR- _?? O0 SEULRO ? fNi 1(Cr STR ? UCK INAMf Oi Delfl STRUCK ANDOWNlRS NONE! {D0/20 9' FSI OAMAOE sRECULL0001Hp VSf -- p UNITNO.,1 Delvtk UNITN0.2-. VEHICLE - 1_ .O S NAME: Wr M ? PEDESTRIAN Dew ? PEOALCYCUST, E'OU>><I?CDS 7'IzE.OEi?«t,r; L+, /C06E.?T c'. sretErgooafss 'ul/«/?ms L?T,IEZ FR fIAODRE v, 5 ti e2 Y ?l x Zg ' z ??C 333 -Z a ^? S AIyE - /121P DDF PNONE lb D n F ,E •? 2 ORNf9'S UCEN3EN ?l? G S A? ?653 /T 7?.wNSF7'JD? u/?. SO 1 S 652-,01.1 2u.4 r' t, v A e A N tr oc?c?-u-•PA?noN iIRMNAMEBRNJNENO. '-[ 'b? V 77;z FYFS OHr HIOHr UPAIIO/N? f19M NN.1?E+6 PHp f Np. 2 /N? /D l'? ]r fYIS IGNr ECN! lQ Yr , ?CHECK (0 NKIe.s ANyNniv'r ANOrNfR CHECK NODES to. D ^M• % Tin - S FMIpN 0»a ryeCrW (? I NCIE AS AN FMROYf A ANO1NfR.u r 2 A? o SSA F CODES D. + 3 uau % »inM"? 5 Fxcno«. 6 u'"0Tn ?. - ?r:. "°F ? uy? ?:n. ? „vAl. ? Iar K fno.,D ? A 9t= N ? ;y VEM1 YEAS N MA%E IDDOChCMEY.I RI .WVA) StYU: 120} -CdIV.I Y R » euw ? 8sm ? yr KU {?iQHy. y: 5 ?f0/ 4A 71`O '?21 < Ir...y? N v.l MDRfl1oM - vA/ 1 Y . -74: UC NSf M E STAr E I? ?? IRAIIfR RAZE NO. SrAIE H mf' m?+R. av4 ''Tic CM(OG22 7Z wq_ V[HiCIE IDtM ICARON NO. C Y lff f` I l ?C8 SO 4?zooG? L ICtf rS 8 36 ". REOISRREDOWNtR: FAST F-t IOOIE RgNF NO. O 9 IS? ER`• LASt {IRS' mDf%e ' + r ?L(7 u AoD9fssdoW*IfR W E E4 llOA Z -.?-yY1?-- " OQ 5?- CI CALL a ? ' NAMEy AD Ressa mwRANee o oRAUNr E J ? 7,{J ?? T ! ff?? ?S,d r?' IZ ?67C c??/77>F- %ALClrUSE7V.A R > EowAa ARU S t5r. 04MAOE AwAEyN [NA9pE 10ifI»u`rnp'"ON AAU ,fy.,y9•, # I I O%9iTU?i ?I[AWNlD DRNtN ?R INED •O 10 ITOP IS ,±{?{3 COll1510N GN:, - rove r INOK' Io rN ifw?,r ° AWA? S 00 1 r0% TiGii "». er I ? %? e ?f, ` - - DIAGIRAM OF 3 0 p SCRIPiION OF COLLI510N: Iu5E5wREMeNrµ SNfR lr frtnSSKRrf 44?? I f y utiP.J E_ Z> ; 7 Val 'd ?e .,?cE,..;:..w. `isArra". , n ..• ryYlllEeG CT. 7ZI.C.t? /?,UG Odcu/l,cf] . 111. v r.... s. . 'It CCCU NAME, ADDRESS B INJURIE OF PERSON ,?y - CICCUPANTS/WITNESSES Too E3:o1PDlraw u ry f S INVOLVED A3N'Ie? ' CODES 1 u% AU rAr 2 I N " W - e ur; ? ?? ?' ? ,?/ ? ? i asr , erer ; ? I> E S3 I N r ?{ ru9rd ... ? . e mac , ' g, ? Anolfss io r 1 I ? ?, . ? T. THEY : l I . HAIU1rd R MovroledA ? r ° KwY ? y1. ft j 3 AMV155 { L wvISIpAIAgdIS11'3NANI411 N. yAODI p1 AGINC? 1 X ?. J?XL7[_'n!/ y7 NA r11r0r NANAS ??y«rr ,elonrAraeD ' c IM er ?JA'MB ?? j ray J?.IrEO / a C 1?+ ?n^»Y D wn ) •EY ? { i. t. tl b4 1 7?f.?:?t^,. b 2nn NFS .KON s ( / O \`V + 3 , .?F „r G, y I rp '. I - fU 1 ? NE Ss n i, NsY ?TOR VEHICLE LLISION REPWLT- I,? l x. DAEE OP GOlL190N. m-:DAY OP COLLEAtNI .,.TIME OF COWJON : COUNTY NO CITY NO f `J'`.m rVN 4 G? I. a.r a ?u +{r /? t "'as Ou'? „? 7 ' ? ?NLD I?IMDrI WED HuH f rKK,A AIW ?, /(R-,fi+ ,-tee ? x ?? S?Y??r.:..clrr rOWiir.<!z:,,,.. Frtou?w wLEa ., „„, .r•"' T >r Q© ._.. „?_..clTV.rowN-...... ALOMCyES ?E 4?marRED ? ? ?- ?¢ cwEl[U -' _- GVE N/?AM?EJOF/S(REET.RO INTERSECTwO YoTH: STPEE READ Q-r.. FREFL?C(gi?j EO.•..:. wE-08x_- __w1 fi + ON.I.-SECTION LOCATION OFCOI}?ON? !G ?r-,cc htMP M7 "? y`• J•? i - AA?11I DEi1YEEN SrREETANO STREET ?. Of YE - nAAMfEDCesI'q ISpNiEIOSr On DExrEVx6tAW!Ein En uM Owl } ©® FEW ER.2 Ct3.Nfl?RipC•F?D/V?USiSi/MtRyy,,,roAD' ER K-M M w„ A6 ?l' t IY%i t+/:Tf•OA/t•c'..4" f d' ?. t vDl n ?- uvMxcul ?v' ? nlvmlTF ? I SPEGCOOE USEq-?Y? L,?K. ? y ( m? ,C r, ? KLeaAlECr Ov F{ ?„µYR?4L.F?a??+3}Ca ??'.?'?Y . UivE 5 (7' ? wclE lvcesraw ?xDNt ? !. +.ry OUJECTSTRUC INMN DTaT1%IC x -ntvES •.._ S _ _ 1. - ...r .?,.. OWN NOFOFUECi MEPNDAOORE59 LOCATION ' tnlE'? IN ROADWAY ,._FEEL O® b O. =4 DRIVER NAME .•FWST NAME .. .- AIID INO Cws DWVERSLASTNAME •. FIRSTNAME -- MNJOLE :, -.L L fxe ivavfo / U SIREETAODRESS: „- pWTEN0, AN000%NO MO E wD STREETADORESS FK]UTEW,ANOErp%NO. Si 3Y7 annAr Y . Giv STATE CODE: ON FN9 PATgN .•, C A GTY. STATE, ; • ZIRCUOE 01WER9000UPAiIOta ' M ?, ii ,. f ?l e ! d ORNERSLCENSEMWFIER ,; •„r }„N.,:f.•L STATE..SIX?-_ .; [IATEOF BIRTN .,? AGE.: fares OPNERSIK:ENSENUMOER _: STATE SEIt _. DATEOF BwTM _AGE. y M E Ap PAV rEw ?: N E Ap 0AV rEw ?y, ? vEH4.LEYR MAIfElO1EV.D000E4's AIDDELINOVA-0NIT1BOOYSME13 WI VEMICLEYRMAKE ICHEV: OOOGEI MOOEIINOVA-0ARry:.,.:. BODY STYLEI[ORI yJ ?V - .;, '' LICEnSE RATEMO.:. ,[,r Si E---'.;d. '. TRARFILPIATE NO.r.-.; :....:STATE ...... .LICENSE PLATENO. - .STATE - TRA%ER PLATE NO.?: STAIE YEMN;LEI MfIfYCATION L - 'io NQ, ;_,y.:::{IV0BAE00EL.4l MEWEEiTr.?:: ETF711MLLEAOEVENICLE ?.DERPIACATIONN0.-,__. 11903 MODELSANEWERI i. .. ETER IMM-FACET t` 'v UI BEGS ONNFA:rL,.:y_µAYTi -LmDEENAA!EL?:k',.:. .? 17' DRNERSUCENSENO.,:: .,: y„ REGSTERETIOWNER L,.•ILASTfIFISTMgOLE awL OWNERS '??.._ (STREET CIjyJYN3TATElr?y DATEOPBIRm, , OWNEASADpPESS :-.,w:;- ISTREET,CRYANOSTATE) pATEOFIARAH rE Sj? DAY C • p`- PMTSO EMCEE AOED;taati?:u?r.lvvli:?.::>,. r2Y _rw•?i: i_w-_ F.?I??r,. PMTSOE VEHICtEOAMAGEO.,,,,,'_ nr. 14sr } ?-'fr f E/ - - . S OEV - ,tr, WAS THERE AUTOMOBILE UABIUTY INSURANCE LIABILITY INSURANCEINFORMATION-VEHICLE NO. r- COVERAGE IN EFFECT FOR THIS ACCIDENT CN YOUR CAR YES ?NOVr.= NAME AND "+10R wuINUNCEFOIiCYNOLDETt 'tp? .Y NAIAEOFUA[[l1rY WSURANCECOMPAHY,v .H,lt "yyy ai:•ak E ..r_ r. .. __ _. -T .... ........t a.. do '?' t?ryy NAME O SSOFWBIUTYwSURNCE sy '?- 20 UABUTY POLICYNUMFIER LL ,Jp V V" 137 wlUilY_ '.`?y4''1a.Ja?. ..?. ?..:CY.T. 1 AGE 2NDDUDNY , IU]E I EREPf%1 il%I 91' u .Y• uY.rAS%' .... iµ . T.,.. :AGE . N0.ME - -. L NM1E .- *ip SEX F ADDRESS SEX AwK ? O r , E Df Nw-ES _ ? t Y ?- ulwA a'O(,CiDNr El F? -_-- uAro?.edi oocran ®? MIE _ -..-_--- I. 2 T_ Y St TlL40Pw1U11FD ,4.{pi11'_54.:4ARKF3tSTGNETNAT APPl1E3 STATUS OF INJURED _µARK RRSi ONE mAT APPLIES •VE P tt = OAels.a No" I "U" I I' wuulAa -i' p wR WvEHCLE 0L5 wD ruGV is Melra iroS_ ?PfMarRw KILLED IYVEPfI N"wUnv I 1.. fv ET I ? x6ER KILLED IlEYFnE1 IAwgq 1 7 1 ETCI O w 10, OEa L[ ?,rRER wnre•IV ? 50 8? ?? r t r v ? 50 80 7Q SHOWNORTNBIIARROWWClACLE ?? I DEOCRIDEOELOW WHAT WtPPENEO.IREFEATOIEHICLESB NUMBER E NTE, NM?MHeDLS '` O ` V?w?-? - RX- DR a w - y , i VEHICLES POSITIONS BEFORE COLLISION Nn Dwra YaKle n.n.FD w.a wv6lTIOATFD BY v E uaur PAKffD ve?alt occuPKD V[NICIE N 5 E W ON STREET OR ..WAY N1.E OR 1. ND ,ra, ? 0 ? ?'- ? ,.? ? ? O O ?m. ?o"W", :'. r° nLrIN ? 000 ? 0 0 ? ? ? ?aaNff C , ? ? ? ? yy,D a RaM DIRECTION'S To DIRECTION W rLnESTRAN nAl USAA IOEAoF-K 20 wALKWAr ]?LHOIILOtR .0 s? n omfe NAO SIAIYACI WEATHER LXwTCONDITILW! TRAFFK;COWPOI KFlCK brO TYPE OF ROAD ORWERN HCLE ACTIONS ??II? ?vl?w'[ieWl ? . NO 'rfcl[?i pn Alwl VrMCIE • ICrMtAOxE(W AYIAEI ?' T l .: }~ ?•:. vI I ? nWKnr E %DAYLIGHT Q 1 0 SIGNALS ? I "ONE WAV?A ? 1 Q GOWO STRA DHT ANFAD It ?DAY S QRAJrIlftl [ ? DAWN Q ]• 910 :JG PN t 1(Ly-?Jt TWO wxv ? 7 Q OvERIAKINO _o PAS4N0 1 'L ? ! Q1YFT ] Q•?rOvwaO ] ? 0u!% ? ] YtEl05KW ? ] Ll 0%,WME ? ] Q MAIIwII RKwT MAN 01 QSAfOw F Qi00 A ? o.NTSONLT ? A 0 FLASHWO RED ? A 0 WTFIICHANGE ? MA%wOLEFT NRN -L ' ?''. ? F ? C[ s OTHFR OAPK-lIRYLT ILCOP/RANaI r ? ! ? LIG Tl OF/ ! Q fLASHwO AMUFR ? ! Q ALLEY Q ! MAMWfI U•iURN r " ? a ? SFrasY PIGIrI OIAK W TWO WAY. r yes ° r-1 Cl OTR[ET LIONi! ? 0 Q RR 90NAL ? U ? LEFT fWN 0 0 3.OWMK1 r 'i- P?ASONF011MOrlEIEADANpER - y E OTNFR 0 T Q Of/C[RrILAOMAN LANE! ? I STOrYLOIOR tPAFIC 5 , t ?1 M[w Fa1?ACrAM E C Q I ? EP[GIr _ '?' 1 •e{I Q 0 0 OTHER, wrew, 1 ? ! ? ? Q BEPMAT[D 011 STOPO31(W A1. ?t : f •, T ?`j th I.'h r -__ ...- .,......_. ? E OPMOFD ? D p STOPPLDWHOAOWAI } 1:?. ? R ? fh ?r,AA'fN.C c] ] 0.,.,Cfo 51 ? ID ? riAiflf, ?,WE A 1 µ li' 1 •_-,' W ? ??' ?`L ; q ? Ar T F'TtL1LrtU!(r,{f+YEIU f AtNA•T '.. ? ? r? , r,. , ..><? a? 1??i??'!!?FL,?E?•"" IAA ...r? 9 ? la.i. ,i A..E_ I ;L..JL . Si r nrRnu ? ??,-0 Y ' 4 ? 1. ' - r 1 I - I° r, Ii 1 rElir auk ? . I 'J`'?J POLICE TRAFFIC COTWON REPORT Id In.ArnL.wnr? roue , nAlm NtwXF9 R / E] PRIVATE WAY DAN OKOIUSau O/ 30 f! DAV 11 ruu suN r ttI Nr "? 1Y11 >G wH •e IU$f NLtl HOURI 0300 couNrr Jam/ 6c 7PSOx? couurr NO // O c9r NO. NwA OuRBAN r(l u- / f SIREtr OVMGrINAY ClY OR IOwN '.Eb M10 0 CJN CKE N KT CIl IA R-11 OX SIREE CO SFCr:ON /? . / ME,:d 0,Y 6F.'10147 aVicZS&vV ON CacZ /z 3 9si7o „ INIERSFCrwq.,I, TRfEf04 XOAD NON INTERSECT ON EFIA EO MYP05I BETWEEN V-1 I STREET ? II SB / E. Cx 553 f OR NEANfS MIIFroI USIANCt6 R 1 EM IFl rROMV ES E W r / _ FT OF ACCIDENT MILER E CODE P OAGWN10AfA causaN NVavm: stvfx lv. INEURED? ?SPI{IAGF ?N18 vV NO NOKtLiD N noefom 5 IN ; RD I NT ER CIS s Fr RROAOOR UfERENCE (g g5 5 1REfi09POA O _ . TOIAINO dVEHICLES 0-KRIYDAMAGE ONLY ?IIESUITfO C1VFNCIf j . ./.. S,R YT z? _ (} OBIfCf 3tRUCK INAMEO{OB1ECr STRUCK rWOOWNER'S NAME) v'C7'v Ae/4N EST.DANAGE I-AL OOINGUSE j U m a/CR 5 SOO UNIT NO. 1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCVCLIST DR RNERS NNAk: Mr IXS MIODIt bf 10 ?Y N.Qlvc I c c= OnVERSNAMF: UsT iN MI l 51 fEfAWRtll ?Q IRffT AODXF35 2 SIAIF -C.. D U D Y 31AIE ENO. y 11 3? 3.srs-Cy? L5 V R 12, Ogrvf9"3YC . •?J L} 1-1 DAIEOBIRTH Mz z% 8 I ? DRI-11CEIRSEN 3ATf ER Ed09tH e?j OC UPAIION FIC3 _Eb-NE NO. EYfl wEIGHt H HI - ! ? j 4 E R OCCUPATION 11-NPMEa I- NO. E f5 WEIGHt HFIGNt e /0 e ,9440 / 111 flA / / '9X,1,Woo CHECK (.7 IVEHCIF+3 Aru?FMPIOrfEOFANOMfaM ?CHECK (?) FNCtE ASAN FMROVEFOPANOTirfeAl c CODES ?; "A" • es IR 5 CIIw 6 ° p o CODES ? * 3 ii 4 i 15'.a- 6 we ?' Z _B c LET s ? AMRw.2r o u, t ? C&,,. K t ? t ? AN ? 1%" ? C&- . E ? vF .YEAR mA,E IDOOGE{HEV.1 MODfl IDA9irvYA1 lfYIE IR DX 1 c-1 V 1- r AX x ( NEVI DEIIDARI*NOVAI 1 R. V.) 11111 _ I c LOJ 73 O y I I ? 1 tl M ? / rH. . N 1 STAI RMUf E- H Vfn.COIOR N lA 5A Il N A ?J ?v fe. m O? A ^- p O F3 VEHICLE IDF iIrlCnfaN NO &,3 I 7, e-3 R/ 3 0 -7: eo L E v[H <It DFNUfICAi I f J w RFGISRRf00WNf9: -1 FIRM E PNONF NO. ss ou?3 MIDDY PL. STEREO Nf 1A51 fIRSr fNp. > A)C L W I.F„ ADDRssd C-,I. AD ESE OwNfR rf??9 9 NAmf EADOn . 1 ANCe CO. WAGfNI / e .t I I R V DNAAGIDAREA A r xrCMw?l rNi»Nicn?oN6N4 DAMA GfO EA y Dr CNMC`E c NA9Gf DRWE lstD DtAMAGt r 3 O?Or;C? -.. DAAAGf ^fN ?REMAINfD ?AW Y ' ry ?AWAY 0REAWNED rOWED . T - IU?Gr10+ 3 S Q? eY tOw Fw+rD A O nr er Aw f a OIAGRAMOFCOll15lON AL I c. NORTH -111 ICE63/JEYI eY nRROW DESCRIPTION OF COLLISION: WSLI- E lu sNElrl NEC SSn9r1 D 6 _...? ... ..., I ; .. Qa', _V F= N ?(OI/!!!f Div Y _ CCL Ku cr ... T r?r . b0 i CKosSG'Xl _ Cc FT Ca.yG-? 0?4AI Od&n _ N Gr;. /l1To OJV p ?O III All% TiAV/te>7Y .. NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED * CODES 1 - 2 3 n 5 6 OCCUPANTS/ WITNESSES 110oo ADD,lwui'+ SVI AGE 1AIU1 „?" ,' 9[319. ?Itt y, •MI H rq"? +EtoFlss NMI REOr flNf nY. ?AM e. 0 'N" 1 3-, IwNv NAM1: j I;,, lD ..... .. •DOflls.. .. N+IIIR d .. _•.... - RIVORID ExpN r NUI n ?AMe ?raRlOmr W ?N 0, M) N AVI Hpr' 1 .. ADona . N+r ?Rror n ? ur4. Ame ?n., 1 C7 7r Cl »X OS' r X , RRVESI rlcusr.AAV Ex nAWlw Ainr+cr sl nul o} om f<AK + M oTAlEd nroRl Arrxrvtoer o+rz C7?//I ry , 3 Tm R, oL•?o• O Lt CSO _ ?Lp ?b yHP]}'E'pW _ -1; 1 r'Nt1?li?Tr-rr.. 1 Et?? Np: , a Y' , T , ru? II t? ? ,k +iuti =4' - t; { 1 r A. 'C C . l Ynryv?, R T?' .. fi t4:? ri N t 1 _ n< 'I ' i7J POLICE TRAFFIC COWION REPORT L?J I-lel.wnr PoEK RAm(NUMRtR E] PRIVATE WAY DAZE 1. R .F l ;yl K.r reY run.: NI IIMf COUNIV itmviv-L..) - CAUNrv NO. CIrYw.. FIYWA DUR RAt / pN pE O'N CIIYOR IOwN PMEaNO OFSIPFEfpR NrGNWAY iCtCl A ROUIEOR Sf KN ' Mnts s pw ?,oF .i .'.v ON R If .?, .J 9$'!y0 INIfRSERING M: StRfE10R ROAD NONINrfRSERION PREN% MILE POST , O EE-EN SiREEI6 SnEEt // Q D I / DISipNCE 6DIR[ REi ,CROSSSFRfEi RNEARESL MI1F P05 MILFS N s F 111T w of I ACCIDENT MILEAGE CODE NM1v DIAGRAM WT cou1-114-ED: SEV1-1 ?SPLLIAGE ?N M1R tILLED NO INIURED NO MNw[Rm N %aE IMFR CLM1. t ROAD eR[F D OIO35 ORR G. ?.5 . _ . ? TOIAI NO OP "",c- p PRORRIYDAMAGE ONLY ?Rf5Uln0 ?vEOHICIf E,// ? ? ZO. _ 9 OBIECISIRUCKINAMIOFOBIERSIRUCKANDOWNEW5NAME) SI. DPMAGf 3 E SKCYECOpN AE - UNIT NO. I - UNITNO.2 ? VEHICLE ? PEDESTRIAN p PEDALCYCLIST - 2 DNIVfR NAME: 1,35i t E D M D DRIVER-5NAME: - r 11- 7S 41-4,61 - 2 StNffr ADORE / O C3 F AUDRES Po > 2 z i 1 OfY SIAIE ZI CODE PHONE NO. D I V S An / 8 &1,9 q938 R ?5-3J ©? -77-KRII IvfInSUCW Atf C` ND !z 3'r"Y. I V E w '760 F - Tell 1 PAEIO C Ea 7X IM IR N 2 OCCWAtION FIRM NAMFaRKINF NO. EYES GH( HEIGHT -8 R U N PHONE w. .urn pc ?b EYES WEIGH I(K:NI p CHECK( 'v Hr As AN Porf aANO Hfa? p CHECK(?) vENlaf•sI FMq vEfo AwrHER, ?" CODES P 3 n ss r is 3 u 6 Drtox'c CODES ? 3 aA%+s a iin "' 3 exc N 6 A T 2 wllmlES L" SS, G'• E w:ol D. p ARR% N ' O vtN rFA9 MA%f DODGF GMfV ? MI. ? . ° y DARtNWA $fYLf 2DR-CONV 1 EI @'anl%.na ? . ? m ? rH I Y I(DAR-NOVA) ? F:- . .) I . I 1 I E . ONT ? E5 v UR l StAif TRAILER RAZE NO. SIAI H fNCOI R ' ? Y 2 WA G?i? CES?o O 1 vfNICn IDEMINUigN w. 3; y??? y? 9 7? 131 L vfnlCl 12! !7 ; Ci (! i 18!3?o!SI i I I R[GISRRtDOVmER: lASr IIRS MlDplf J1Q?I11PS UJ, c o? PHONE NO. S-S y3 O W t R : Ull IIRSt T MID N? CF?.ILrI? cJ?YC?i X r; C4aX slS 4/z e, V4 E a X QAYRTu- GeEEK 012 NAMta ADORESSawwRANCe co. cr AGENr ' A ,/ 5 AG Anu _ CHARGE CNARG! _ ,D+wE. t?N"ADS .wu a ,;xt sTDr 5 10?0lIOii t5t?l5UMKiE ? Aw,tV ?REAWNED ? aN ?RIAWNfO t31.0 i0i-0TIUii 5 S Tom.°er: /GE?adEtJS [ D wsnr er• f?SGd - RAMOFCOLLISIO u f KAiE wRIN swnuMCUwr) - DESCRIPTION OF COLLISION: (USE 51ARFMtMAL Sf.EEN HECESSARrI le ? r Ww- I r i '° NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED + CODES 1 - 2 1 3 4 5 6 OCCUPANTS/ WITNESSES jp bp,Ep"UN,NU NAAV SI H% AGI i i _ "r'" L°n -iE Rt5@. EAR 1-4 . nnwu " 14, 'w ,"r oRl or IS._ T WA ranc ?AM . ?F4L"f p ru. .' 0W.0 NArE T ?ur44 s D 937 -VI/ M A I lXaf tl NANO?d AMa FuXf wV. N M A [ b .• _. uvvr S NAN?a. ? f sn Gua ?u"O='. IBM ?"°..w N Y sT nc ' 'u cE?51. e,•N. n x .oFwa low AGINCr KJnnrj yrD r )E a]?rycy o r?'[?? ? wnDiwFORr AFr.ovloBr oAn E.nnn E EEOB H.s ? All, A ikq ? ry 3 l t ' .n art' -.... . a . . ,. r. ? xN ,..I ?.. Ale t? POLICE TRAFFIC COLN REPORT IJ?TRAFFICWAY fp cfAININUMBEx y PRIVATE WAY UAIf UfCUllS N ISUN IIMF ' <OUNtY COUNIYNO. CIfY NO. iNWA O Ivl ?` .a IUSE2"CO HOU41 4 x ug, D AID , „ , I 2- O I JE FF 1250 ?UgBAN RpRAI r ? C IYOR o"N O. Of 5f4EF 1 09 H14N WAY ?N DI N .E ICI CtS, D/n 05 Ni 4Wtf ONSlptE O SECTION ( , // ? l e :W Al MLES ?5 ?W WOON NT !( I z 3 9S/J'6. J 22 NIfRSFCr NG WIIN: SfgEEI "OAJ NON INIFRS...IPV VR[H% f0. MILE RO51 O BETWEEN M-T 6 SrR[EI /I S8 ';' f? / UISIANCE8U4 I MNOFxfNCF. CRO5551Nlfr04 NEARfSIM lF RU51 Mf. S fp N 5 E W ACCIDENT MILEAGE -P DIAGRAMIIA l HFt ? OF CODE COLIISgNINVMVED: SEVF4HY1 l ?HS9UN OUt NO NO. KILITD-NO INJURED- ? 5 DGE ? wN %n.H 'N N N %. p INTER Cl5 INr[ SECtING SIRE 04 ROAD O4 RfIfefNCE CROSSSmtEtOR ROAD 22 E 5 GEN OF VEHOj © PROMREY I-AGE ONLY DgF5Ul1fD ?VFHCLf S•!t. ZO ? F1 OBJECr 51RUCKINAMF Of Oe1ECrTSF-KANDOWNERSNAMEI F51. DAMAGE S4fCUl CODING USE ,- 111 Is UNIT NO. 1 UNITNO.2 D VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 5 DRIVEN T-F UST FIRS MI LF DRIVER'S N/W.F: USt fIR E 51 (Et ADDPf55 0u 6 OREAI AAIJI?d IREFI ADORE55 3?/2 Gli, ?{ VAIE ang !d Lou! ?3 3 S'S y D R ZIRC E c?u 6r 1 `1336 - Z SlCFNSE NO. cm T' G28 1 StAlf f% OBRIH W? F /z zs3 I IVt4'lCENSF NO LATE ?,? - o ?6 I,vA SEX M MEUFB aiad ?a wr10N {IRM NMSf BRHONf NO. EYES IGHI fEIGMI E OCCUVAI N NqM NPMF b RHONE NO. EYES w NFIGHt e GRu R Cons T/ NONE R ?35 -t/ 0 CHECK (.? yfNCl[AS PN FMHOV fOFAUO1HFn.At ISIY6 ?CHECK (.1 AN tMROYff OFANOrHf VA' vfH ' S' O pi u' a i. 5 ' B MDrDrc.n' CODES 1. H D a: i' 5 prclroH 41 6 i kr i • DRIES - - 5 te'F D D Mg ? by<l D C-894E ? 2S ? Cu ? MR 1 N [ ? " ? ? KD ? oA? p Xe VEH.YEAR MAKE IIJODGfOHfV.) EIIDARINOVTTAI Srrlf l2 UN: CONV.1 ? U4 ( CHfV.) MOp[IIDAGI-NOVA) v FO?v Gal V.1 1°? JJ,? Jr V O NCtN ERUIf NU $ qrI AItEN HAtENO. "A lf H L vFH.<at N S A 5 A /1 7 (? VEHICLE.-FCAIIONNO. L 1 4!-T ` NII f10 NDFI N ,4 544/ ? / ?lI SCJ i i RfGI51EREDOwNlR Uttl FIRSt MIDDLE RHONE NO f 514[DOWNF4 -T .- MlpplF f S' m ss-v 11-3 5 W s r 2 AD SS O, WmI4 0do E OwNk 2 ?GC 333 "' 7 Ocv vsel NAM lb AD04t550FINsURANCEC0. O4 AGENr /? t7 r 1l A N /Prr) 2JSGcr7. p2 DAMAGE AREA ' ' ? . .. ? IZJ DAMAGFDI%.gU • "/[aM CHA DGE ' f TOR ? M? o+ • [HA4GE lv >L. ? Rwc! . ? 5 15r. DAMAG< [y? ANN yI Z MAN' tD. • RIVIN EST. DAMAGE Iq qI AWAr 04tAUIN{D iG ?OlYUii S .v/'1 ? Imnr CN Ar : w TOWED -Al nr: $ ? DIAGRJUA OF COll1510N: lu u Mw AI INDICwrf 1. sHtel FN[e[ssA q-.., er ARROW . . DESCRIPTIONOFCOLLISION: IUSLSURNIfMflIA15.EEi IFNEC-Y) DS le , ... ..... _ _ ' _ IRAs Nyl TsL o f (Jb // / _ . > r-a NAME, ADDRESS & INJURIES OF PERSONS INVOLVED F CODES 1 - Z 3 4 5 6 OCCUPANTS/ WITNESSES Iioun wallEw?luiuNi i stK AD, unn '"„'" ° RESn uta ; N Aw Gr /lli u ?O `//OCIf/ ?•r?na .?G,tl? .Faer H _ P1' D D '" mm 0 E I /vl ; N Y - L '46 '6 Ad /aC?(/ 3lor n/R a ?; ornlDl ? AMn D aa,D r a X ? Iii M N AVI Sc?e Z7N?c- AJ FAD ' s - e . rJ^.nt c Gd/?.t3Gv/J7 Iviu:asO1 oU 1 Xli•l lir ?.Me ?'f'J'"' LJi"D:ItR tiS ? n xrgnr ./oarK.[E?N.ME R 'V?I.?C.? nADCt OR AE:fNC• ?G "G roL plN•yao ?7?IH.5 nax ? AD 2.N'111R5 D+navlwEr /?V1'J AFrwvlDer ogle +Mal?y,L?L"4fS (? eff 4 ;} ? 61r d°. -° ' 'RtTJ7"NtrSGKMdT1?Sf 11 r 9f?N,.,9AU?? . Y It + ? I. M^ \I '?/ ? A f/ ?l :. 1 . I, ,, E I ? rat 2 STATE OF WASHINGTON D?l P GGL Df No. _ POLICE TRAFFIC COLIN REPORT (Iy TRAFFICWAV pIXlc[ A,Nr NUmnFR '.:..«?' !' DnFDSLIXUa oN DgrD IX N nmf couFJrr PRIVATE WAY R IUSF ]Rq HOURI _NT,No. // avND. IHwA DUR6W 1 DN E IN cl-rOWN NME6N0 OF IVff104NOHwAY iCfRS A?5 Y41 R-11ORSrf RuR SCT 'Ads 0,l ?W OF ON =< gyn. .C t i NG?H SIRFfIOR RO j Np/??JrM IERSICt ON {1 . ? PR FIX !O MIlE P05t r B. S _?' 8[IWf[N wl", 6 USI.wCf 6D UKD Rf ] / SIR— ] ? ' fERfN .CROSSSIRfEI RNFnRF51MREPo5t ES I Ml N S E w AM ACCIDENr R P DIAGRAM MIA MILEAGE IFfI OF COU-.IN--: Vf 4IJY: 1 CODE l N ?, ?j{PC F] TOIAI NO ND.[IIIED?-NO.INJURfD -ZID SNIUGE = dvfH ClfS pRORRIYDAA1AGfON E Y 01 RUN ,Uy pq?oiH 5 f %' 0 INIfR Cl5 I 5 O ROAD R qt I ]J CirDSt SRIEr OR ROAD I A?y xK.s? ?' L D S OeJKrSrpKRfNAME Of ODJKtSiRUCK AND OWNER'S NAME RlUIiFD tSt.DNnAGE SYEWL CODING IAf UNIT NO 1 s 5?86a a °" . URrvfrsNMle: V51 f.4 I a MIDOEf C1 r NIT N0. 7 ? VEHICLE D PEDESTRIAN D PEDALCVC D LIST '7DA 4Nf ' E. IA51 Np , MI M ? L':' I ?. a - Logic^' :rx StR[f. nOD4f?'r aS J L ? ' ?` (( ?? ?1 e saa M[nafz Ws?J? ? V z stRffr ADD4ess ,? , 11 E?{ LL ?C. CITY 1p CD HONE ND ? Sc?cb£?? D I fi . ZGSI \ Wrl 1C7 ?j S / ? R C E P f I (?? 6 m1.?? E°-. k % hI DR t95l CEN5f N0 StA1F fk ` H I VI WI` JLE ? wW U ENSE NO. 'Al. lClEL I(oT OAf I t w:Dh t LZ ? O CCURAHON FIRM NgMF6 RgNE NO WA ? ? Iq ? ? L441ba7 v tA M 11 !i? 5 ??f$ ''? o . H O? C ? f.. LY[S IGHI rEIGN O? FE?EEG Ili FO 6't I E occuvnrlDN fI MN?]E /6?pHONF NO. EYES R 16. L TI-[?E } IGH rtwflrLZ 17e 6'ly 151?{e `L D CHECK(.? vEH CAF ASAN_ I CODES ? +' J n AKS 4 "ll, ANS Mf DKr R. S?'? tC w u , D CHECK(./) yFH CIf ASAN FMROYEFdw MI. CODES b- * 3 n v ll - ?f : g111fi 111 Es I % is s e%erroN 6 sMOAII.N • u a t r. ? KwArt ? i..Qn[r V[ tAR w OIA CHEV.? a t fIDI DARD v - AI 1 J SIY ] CO K I „ii9Rwm unMFInANCE Q Mc t ?rrtR ? vein Clt ?itiA y NV.I ?? 19 C to iTaV K . vA E 718 CIML =s, 3 r O ??.? P1150 [ICFN FYIAtE S1AIF iRMIfR RAIFNO SiAIF TJF?3z3 u.4 l 22 H v .CIXOR 1 I ?N X b WELL N S ? tF V[HICI[IDFMt fIGI ONNO. ? C vfHICIE IDfnf NCq N it I".L I L ? RLG SRRfDOWN fR: USi fIRSi MIDDLE ' A-i f HONE NO. I ' I ? ? O REO LSI_J fIRSi MIDpE I F-t ? l r ly AUU.I.- MMFN W A NtR 1 t, N ' uAERADart55dINSURAEECICO D.AUNr E L (..?•dt D'r STh I Rare APT. Ic?,tiS4 j, R , nt 1y? _ ?? Ih+XS DAMWlD ARIA aH.1rNa 1 3 IS Up o'INDµe CN DGE _9 A— tfNA I Wru y CHAROf NJIow r 1 i0%}OY S LSi DAAUGL AY C] REMNNfO S? iD ?DRMN lSI.O a. .ID. ?RfMNNED AWAY F E IO?ORGV J " e COLLISION Al) DIAGRAM OF I INDIGN Na _ `weru ssAR ergvROw Sd ?AW ? AYBr DESCRIPTION OF SOLLISION: JesuprtemtNru sHEI (NECESSARY) d? ?? y '41 .1Gd?? . rh ??^._. C o T. ,rfp lef t To 0 0,4ro ? adT C CQ y/. .. _. _ s . ._A ?TecFC? .gyp ? g'I? UELK -- ?fLSS? Q f .. I,^ - • I,?uS . • ... / D..o+ .ykY. 4T or oL STATED -451 .G.o4s L•'? or G L, d T<.i= ¢ /J KAL' A Q?sT AE T?e r .. Z , ? . rjJ r h 0 ? L s ?(F ? E .. ibSt' . / ... J f . ?h ?!J L ?a'lE (( ' IR NAME, ADDRESS & INJURIES OsP^RwOµSg y i? JTJL.•a S• d, .... 7AJ f NVOL?cD F CODES I 1 OCCUPANTS /WITNESSES 10"LR ADgigN 4iNN4 N AmI = CE STtVE A, ll - 2 3 .1 5 6 ]I K% AGf IJ1I IN VIR YAI' .. ... _. MKY? I RtSrR. tRCr . At rft 2. V ,U rvo TAI-/( M 2Y AlaRfd (• A INrer ?AMe 0nr D"N,..?mr v_, ?-'?- NIT te, A..rI r word Rfv?NDIRr'vA ? t ? KIO„M Owo tl ADV. N 'AIr,Gd.KI. t N_ ____ -A`m.E R EAE -0d AC,aK?i Y <n I X ? ..v rNIM 41M efr r,•A Na Nv R r IIAt IfpAMR e M?l AiMl .DWCL'^ D! ??i,T DA? rI D pr IKLI . ?DRp) AIONp V IO1A? RV NO OA? JRID HRS JL0011.5 ? Z'/1 ? ?p a$T L?'?1, n] Sko?, ?j w 3k f? 2 ' ? J POLICE TRAFFIC COLL' 1bN REPORT UffTRAFFICWAY ua INrrv-- I [] PRIVATE WAY DAI OfC I N wx RYn u•5 N H .19"p, n I LIME IUSFDAr1HODR1 CWNIY J EWNTY rq. CIfY NO. MYA iU9pAN Q ?? !f VO O7 D O ?CF.V'2<SC.r- ?G? URK '. CDYI N NAMf aNO.Of STR[fTOR HOHWAY 0. 6, 07, AN,S Ims OW 0O1 ON fCIClS RWlEw!sq 9?.... CI wre.urnrve vnl sl. loq.oAO NoNw1Ee qN Fe?.,?e R .PR PeeNZ fD. mlEe.osl BEINRFN Sr9FFi 6 519EFT NCE 019 R .C?55 SIR EIO R NFARESTMIIfP r '? AC CIDENT q DIAOgAM DATA E MIE S N S 1 rEEt Oi ?h MILEAGE CODE ISgNIN vFD; vfRUYI HrtaQ IOTK NO. NO SILlEO?NO.INIV4ED_ ?SPIILWF tlVfHiCIES Q Q-KIIIYDAMAOEONIY ?FI wLlED O-IN Iurvow9?H3 IN IMEq CIS CFOSSSRHNT„'^^A" CM ? 9?? --? _ jN V 08JtCr51RUCR(NAMF0f00JECT3fRUC[NVDOWNfx'S NPMfI CSt.DNA/LE SnCIKCODING IL S UNIT NO. 1 - UNIT NO.2. ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 24 DRIVER NAMl: -1 1.51 I off DRVERSN- ST I J SN yAI/I??AOD.E YJ '? 5 YEft ADDn G O( 51A1E EIPCODE NONE NO. I ?J D R TTY SuTE I DRIVERS UCENY NO. 7 s c SIAI ,I? % mD D,? I IV R fNSf A E Iq N mD. YAr Ira R CWAIIC.V O. EY ES IGHI-T fIRM fNMF' E OCCUPATION FIRM NAMFL PHONE lYES IOI11 fEIOHr z 'Ej /1?,w. r? ? L? 7 2 LZ.J L'S'T'rvsvµ UE.U R q,Yr O CHECK (.? vEH CI[AS /W.N Emnov E AlmiolHfR. O CHECK(! vEHla As AN LmxorEEOfwigrHEF. ?? r CODES 3 a i 5 111- CODES 111- + D p s°vs 5 EIFC p S,y '- a ES L INl,mrt a ? l o sal. ? K,j X] 1.. ? AN r o 1.111 ? mPR. ? 7.'a I y Y KN.YtAR lIDODDE{nfV.) Fl IDA4r NOVAI SIYlE1EDR: ONV) n [M I HV.1 MODEl10ARtNOVAI Y( R. _ ply 7 aL+os eUZ/1.SS a •t E m p b w N MA N SPATE 4A lfq RA1FN0. STATE H VEH CaD4 l Gv?1 c ?n 17 VtH1ClF IDlNIIJKAIgN NO. if ?( ? 2? i VfH CIE DfNl f1 11 N I I l f S tD MF9: N5f rIRSt PfgM NO. O ISIERDO-R: L%yT R9 ST M LC LL 1 Iy L DDRtuof !e N A e. 1111 /OP 11 4 AXI n l'v'l. E HAM[aeopnuaww.A eo. oR AeeNI R tJE Nor 1NSu/_GO 1 11,96 ' ' ' DAMAGE A9fA ' a fAwiNO .? CHwCF %, •J L/.LL'i CAD' .Yd: .• CNA9GE• DSAN E 4 °FEA a Dl ! OP S 10 Rn - 131. DAM.W! ? ^WMN ?RFMNNID ?AWAYN ?geMNNID lS.D IO?O?IUY S S (dl T° y- E G A L/ LOWED AWAY BY, S IE DIA OF COILISI N E U N _.. SHeIr /o" Il MC[SU IWICAItNaErH 4r1 er A9RCEW DESCRIPTIONOF COLLISION: luseSwRlMEMKSrenlrMU5wY1 _. _. -- 1 s VU A lll L ' ? t, r . Wir [./uG-.Ar fy!ro? Sl$roep - .....i7?A - .. , _ I I .. ? lUld 1771 . 019F?16- ?/<OEn.... hGLe_AJ. /OuI+SOGd_... I Ix NAME, ADDRESS 8 INJURI ES F PERSONS I NVOLVED .H CODES 1 - Z 3 4 4 3 6 OCCUPANTS/ ITNESSES woultoMf'iu rKiAI. ." If I aci terns _ -el. - Ii i IfACI rcr: ! CLIAJ 7C C '"'M° ljC LC iJO ??V)/, L"?r' A ? pD.r1S S/ NAi :YID L r MOY. AM p. W, C I" ?= ?{S 0 N AMI' ? A A DMISS - -01 CE .-. ....- MOV^O,IROM []AMe. "R%KI ?Ixwn. p'X ?n.uD A hVl na ... HnMia wJrer. ?AMe. p.EOIKI ?E"?.R. OvT;' ?- ^x ?hv1 Wd IR a ++t eA x L. D(AW p?° AGENCY cs o. d,l E A K M CIAp (H IK%KIA-IAD 2421 DArEMq kl 1 AM 1Y I f DAII ,'r ATtl'; T r :` w7pR A.I ?" lr Y '?.!t I0.Ea .S.r . i q? 1S9 J air dog I I 3 5 A r ' 511 ? L Y ? 1 ?• i ) A F ?x t "8 1 r ' { 1 it O O t 4j O C O { O O J 00 t? 'dm0 a O V1 M 4 ?,Y P Ur 'V ..] ? ? Vf}3( S ?. ?I 1 fQ^?ht F,,, i s?'f ?y/ ?1 r` ?'^' I I 5 ? ??I.i.4' 22" m-M -1 a ti? t ClIF VVHS G7C)hl GE I DFL No. POLICE TRAFFIC COLLISION REPORT Lcy TRAFFICWAY POLICE COMRAININVABER PRIVATE WAY - I A C ll N `Y i?•I - A l w.l ym iHl Ii:? IIME IUSE]Wp HOUR) Z5a COUNTY COUNTY NO. SE FS6N /G C,YNO. FHWA' pu4eAN 9s?aoo• J ( ? S N -.J CIY OR TOW ? E p N N MIE BNO....... .RHGHWAT fCIQS RURAL I ROUTE OR54 bFCtl N - "^S MIlfS 5 ?W ? OF IN,nSER NG VA,H S,RFF NON INIFRSE 91 Z/ilr=/? RION PREf1X f0. MIEE ?, I M•fFN STREET It DISTANCE R? FifRFN OSSSnEEI RNEARESf MILE 1 S S W SfRFEI ACCIDENT RAMP DU RAMDA'A nJ .? yy'..?!i\ Y'J.c.4 FEEL OF COll151ONINVOIVfD; VfRHY, CFf I'C?lFS NO. PRO,-NO. INIURED? ?SPILLAGE IIBRUN ? PROnR1Y DAMAGE ONLY ? R ? MILEAGE CODE WHDOiR?H ,1;?+' R 'RO N R IN R I ROAD RROADORREFnfNCE I E CIS C40SS CFIN OR 'I -.lY' ITFD OBxCi SI4lICK (NAME OF OB![Ci STRUCK ANDOWNEM'S NAME CiF '+.o?I' ?i' - ] I _ FST.DNAAGE SPfCW CODING LAf a - 93 v f ,y S??fj • UNIT NO. I DRw[R'S NAME: tASt (/E/? n I Dlf RS??? ( R IE ? i UNIT NO. T VEHICLE ? PEDESTRIAN ? PEDALCYCUST DR fRSNAME S i T1ST-' ?'? / rl kY 1 Y ?,(S STREET ADDRESS ? c•?? ( ` ? `--'- ?? C ? , `1 ?.. 'cY 4? 711 81(?.?/'lI\'I l??.p S,4Eflgpp? 6K SCJ /"'I. K ? ? 1• CITY EIAIE -CO MONENO. D PT. -?a`U1JSO t.,)A, . a - d:;U FR'S SEN D R 1 cIty C 0 q RH NE PT, TD'wN SSiAIE I ['r?$ 2 Se.? o i 3?Q 5 E I. f BIRIN ?L,A I o° i"• ! I V f ' ENSF NO. c©cu??R ?Bo?J IA E SEX OA Oh BIR,H 91 1-- iY 2 I B OCCUFAi=ON IRM NNAE BPHONE NO. Ett5 IGHI F I HEIGHT E R OCCUPATION _ FIRM NNAf 6RHONf NO. TES VhIGHI 141GH1 5 I?l?R ? R z ? CHECK (1) yEHCIFASAN FMRV--ANOIHFR. CODES ?* A n na .-. A sr :sR s f oN e p CHECK(/) EH ClE wSAN fMRDYFF Of ANOTHfR CODES .A1 ? * G ? a ::sn"."' s [x e wn°C ] Y? G ` ' nE, INF .oM If"°rir. AAwAANDF ? Vn 1 Tb.R. ? oRYAII ? , _ YIDI.D ° ?° N , TI 4 Y? . I'E??f }y-E?ao Ev.l IrA C /'A l(D M1NDVAI str?E l]DR CGNV) en. ""•"'°e p K Hfv I H Y M- ? c"S?R MODEL IDM i. FVA) ?CR°Anv. v IFf] Cw .) • . . [•I l? ! ?J R E E ••`li 11 oRE JEI'• ZE D, E .?J T -ae ` . - • ' ' IL?N• VfHICIE ICENi NG, N RCIF ly+l ON NO. If -IT rtiA IRA-.RAZE NO. - - IlAll F{ I C vfH OR ?R 17686 EH CLf PIDfN 4 lI 4 I . - A - '? y 5Ao;5!?IE3'2;Si215;2 L L3!21bI31o!0;21116 ! - 4? ,.Dy PfG15RRf00WNER: cNFIp} „ALE NDR,.?A?s AK S FNONF NO ° , I I! I R- IfRED fIR51 MIDDLE H F ^? .. ., k" -", ,35. Sf r ? '^ DiUITYri ///rrr -'" U LVNNFD DRIVEN ESI.OAMAGE EIii s ? IOMDeY:?pl? Q? • TOWED AWAY R[M?N\NtO 0 ,O ?OiIOw 5 AW AWAY er: ?N s E I . ' DIAGRAM OFC lu Y ?O?? I ? 7? 'r y.IC DESC IPTION OF COELISI N: (US[SUPPI[MfMAL SN[Ei 11 N[Ct53ARYl R swa[ E R Row ? ' F D?10?Tk1LiOUN.. 1 EI ?f fl , OZS-??] V Z ? ]F ' .T ar".? ] •Ue}I F? Z - V?R>=D fir, Ar ?-- g? . 1 .. _ . 29- A 0.- L110e k 12 c NZ : Bo<ro? ; f , , ., 4 f ] R NAME, ADDRESS & INJURIES OF PERSONS INVOLVED + OCCUPANTS /WITNESSES (USESIMnIMINiNSNFI COD_ES_ I_ - Z 3 4 5 6 .. - .. '.) `` Yi; ?. NAME TOR ADDIIKxUI NAMES) SLX AG[ IAIUS KEN ?-V .. l??/ E ry WI assnuER a°ry - - t y . .;: ? 10 NAnIR a r pr.._ - . em er. AMe cE ?,.1?. x ? N?DDAMnu ' ? p A ?CEMI.E. - ?! +'. 6 Z ADOwss A ( `?iuR s1 ?3 EDrROM I r. N E. ? AMB. ? U KI ?"IMIF ? N,Y ? n2i.,. ' ' r R . .. ... No. Aro.ns ... INi1wI?°F D D s E 4Y. D DAO x ? . c1 ? Dm. ?GS ? n _ tK, W PS fANK BADy OE AGENCY AP 0 r DAIe A 4 q,? - Y _: i n - ?' ". ., ?2. lr.• G" - s", ' _ 'Y,?I` a wUJlt'1'-i ' .. 1[ r'-, ., ... .. .1,1_ .? ib?1 -. IXISIOn Y } _ ... E COUNTY COUNiY NO CITY NO 'iHWA y?r?i 3A7' •. ,NU w -'ERI IDSE RRW OUR) T?/'?, JSSO? ?URBAN I ?J r ?I? i e3I/v 1 ?JO - RURAI ? ? ;? ? ;G%Mt[ ^• ?, gq? ? ?IN CIIYOR TOWN N f 0 N'O OPSTREETOR HIGHWAY iCi Cl3 AEW ROUIEOR Cll N C]. ?E LES ms ?w ?oi?TTdWNSBJ ON?`Z-- p? , , JI[RSE[UNy.Vla11.N?5tRFf10R ROAD NONINIERSFCIION-? PREEI% F ', MIlF P031 BENVIEN STREET 6 SiRIET DI IANCE6D 9f?1 ROMR fREN ,CROSSSIRE[i OR NEARfSf Mllf P05 ACCIDENT RAMP DI RAMDATA LFS N W ,.b a ' - MILEAGE imp iFET OF CODE A CIXLSNJN NVIXVfO. IR Iv: "020- INE CIf RfE R DORREffRNCE ND K ll[D NO.INIURED ' ? SPILLAGE ? N I6 RUN V IunINTER CIS CROS5EINQRROAD ' W :a IOIAI N .-13 LFS ? :? OF VEHIC PROPERTY DAMAGE ONLY ? MSUltEO ? VEMCIf '2 OBJECT SrRUCK NAME Of OBJECT STRUCK ANDOWNFR'S NAMfI Is DAMAGE 5-CODINGLGE x? f .H , P 9 - 5 - ?i ` UNITNO. UNIT NO. VEHICLE - ? PEDESTRIAN ? PEDALCYCUST" DRIV[R'S NNAf 1 ' ' : LS5 l RrvfR S NAME: Ap I -1nIS?l PW r- It/ K m --[? STREET ADDRE 5TREET ADORE 55 CITY SLATE ZIPCO PRONE NO. D UIY LATE IP P NEW. 5 I '.' 2 R mo 9. F x1 9rvtR'SUCtN5tN0. ATE F MOA R^Y B RIH I DRIVER 5 UENSF NO. AIf E% DAEO IRTX ve L '`. . V Aw. I DAY YP I ' B r '*A tt # 0 OCCUPATION FIRMNANEB fN0 EYES IGHt HEIGHT E OCCUPATION fIRM NAMF6PH NO. EYES IGMI if IGNi m 'r EI Z R = - ? CY.ECK (?) Y[NKiF AS nN EAworEfaANTHiw. ? CHECK(,') MPIOVEE OFA CIF ASAN FIHER L aw + 5&, CODES ? * a w 5 I aO n nDI?. ?" TD • aNl RIH .KYEN CODES 11" ?RY 5.In a i° RR Z o"J N R ?, . fi ,HC'' °;oF.D ? MeB M I o av ? zsnl. ? o ? VlH.T[AR M MMf eODGLCHEV) (DMt?NOVA) STTIF IZDR ?CONVI C ro o NA N<I o HfV.I XM f M WE ? s)R. o o ;°I ART?NOVA) 5 1, yy. 1 MODEIyyD ry ' 78 2ao CTP?. E ?, RD ? ,, COAL -' OR ??u ll U DPP SLATE 23, RAI f9 PlAlF NO. ?. SIAIE I'I I C VFH CIXOR Bcx, r. rn`65 w? F[ N.," _ „ _ r V[NICL[IMMINGTKNV NO. LL (? Z1!0G16 L VFXI EDFNIf [ 3,???!410, ?16 18 r6i3' 91 .? " '. ?, I,?r? I I RtG15RY{DOWNt9: ?? IDOIf PHON=NO. ti l`J O W g0???? ?tRs MIDDY =NO. ??+.V 6 a ,issa Owrrt Aoogq ?(JC (oB I ?03 ,LU • •DG g3 LS ??yOA.q ?? E p S rg M 2 a( NAAEesADOfu arwwR.JAC[e DR O R r IIIM/.Gl MEA TKIN vKw°u CN?IX R- a K ? ' O E H.- 0 f}AMAG ARU R CtIARG[ TvwcnNN I :d ]-`I - EA el P S l Gq DAMAGf WAY RIMNNfO o onou ab AWAY ? 09 VfN REMWN[D E alxµp [ eTOP ? AWAY ? oeono:i s "?I . ' a TZ BY, I yo rowtD ? nwev eve f 1 ?? 1 ^? ! l u Mw L INOILAIt NORrH DIAGRA MOF COLU51 ON. NECfsuarl IuSISUPRE ENIAL SHEn FNeefssArtrl DESCRIPTION OF COLL15ION: ?, . EARwIPAa 1 _ ' ' .?'! ? ` 1e ' , . _.. .... ._. .._ .. , W E i r •? Y NAME, ADDRESS 8 I NJURIES OF PERSONS INVOLVED + CODES 1 2 3 4 5 6 ?j ... OCCUPANTS/ WITNESSES 1.ADER o Ni t- 1 u> AGE IArm „1 u 1 Rtsre ulA S c' X NAMI: ?1 , d F ADOPISS X10 01 AM ? X e G'Y? F ? ? 'VIn [ ? C7' ? vaLEJ ? ? >m 9 f r :? -` I ^nrin <: J 10 HAMS ADEfeEu H,ME: _ _ .. -_ _ - NAru9t 01 !'°..... _. ... 9 MOV10 19 ,pKl r?u NI HOT I ?a9e ? .e ? m. ? W.7 ?T. N[P a ,^ ? M ? 1 )? ,T r A {9 .R l1, i. , If 4 ? .vw ", '?' N,S,?EL?i i' 1?4"PF4. •y SPe°'+w5•If?d xY 1„;.?`! n ? 1'Y_ - t?+ ?.. + R'D' ' LR ?1 f ? y ]?! I? 1 iL H r .,r vvws i* G?i 0 Y? ' GF i . GF a- No n v? POLICE TRAFFIC COLLISION REPORT F T? U_1'TRAFFICWAY . EDUCE CamrxAlNr NIRmDER t' - DA F Of a PRIVATE WAY ,h $ of ? ? a ? y i C w a l?.?. IV5E2- OUR) OUNT = couu,r NO. cm ND. F"A t ? 04N pE lNl CtTOR TOWN /? /s O aCG.. , ',!.:+. ti , p /) NAME6NO.Of 51RFfi0R WGHWAY pG nulES p5 pW Q§DF ON INTERSECT NG MtiH 57Rtfi AD NON NTFRSECIION , ?NOOy iR ClS RWIE ON TRf URAI f 5f I N 70 ... r { • ?/?5 BFIW?F??? ?' STREET PRfFI% f0. MITE ( RR 1 f F 5?, < DIS 04 I h MRff IES E f,CR STILL-NEAREST, M W FE EIRE E} ACCIDENT RAMR UG RAM DA}A ' -.. _ ET OF CO11150NINUgVFD V R1, MILEAGE CODE ,., .' .; •. i,?, A'%1' ^I, TOTAL Ci V[HICI ® NO IaD?N0 IN1URI0?? ?SpIIIAGF ? I, RUN FPRO OES PERTY DAMAGE ONLY ? RIf E IT51N IVNRRERIH Ni[R C IS YJ CiN EIOR ROAD OR REEERFNCE CR05SSTR[F10RIR[ RpA p GGG P? EN5 y E S VIiFD _U,C} 5TRUC9INAMF Of OD1FCt 51RUCx M'OOWNEkS NAMEI V[H ESi !'? ,( / ? EV??DV y Y? T^,! pNAAGF SPFC AI CODWGIRf ?e ?• ' u Lx K UNIT NO. 1' s DRIVER'S NN°E: IASi NR r , A / T UNIT N0.2 DRNERSNAMf ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST D. Uf5} NT q ? ° .',1 t. O Q fI A ? INEEI AO ' ? I yT ?L4t ? tl .3,E ` DFf ? ...r 5 Eft ADD ?S ?)?N - ? _? FZ rr i' <e S JP? X-4 ? ?_ " ' x StAiF 21PCODE '. PHONE NO. D IIY < S •? " • I' ( ' ' A.f? OS D Nf9'SU NSENO. ' STATE [% A R rAlt E p(!OO( PH NE n 98FoSrf r? , F A DIR H I nR' lCENSE NO. Alt q? E% DAI OFB RIN ,Y1 6. CICCUPAl10N NRM NAME.PNONENO . /??' t7 /. F EYES GHt XEIGnT E cuPA1 GN FIRMNAME.PHONE NO. EYES V/fIGHI ) Ix GHi k R >?( ??'?S5y?:yE}}eey,, ? CHECK (? -58 i C j vEH tt V i o 'M R r Q / v f ^J Af . <1. 4 lws wN rmN r FANOrHER: Y CODES ?+ u d i 5 ufclwN °swlox.c a5 in u CHECK ? (F? vIHaEASwNrMF%[irEEa ANOrHER CODES + I a NI 1o G ai i 5 [x<tD H pnY[I .!}> d iiili.AUN '•" 4 T ? N .AMxI ? uy`[ ? b ? Y Ny3y R xO I ?M VEn.YFAR MA9F IDOOGE{XEV.) flIOMI NOVA SIYa I4 DR{ONV V / FY p H TFA9 EM Na cc] E o ' . ? <8- ? yjNY U ? ??HY M i $. l`;• ' Gi ID l R N / . U fN PtAI N , SIAIE aR RAif L 1 H O HfV.) mODEI IUARAi N A) `Nd ( DR.,p .) ! f a C E StAIE /J 7 OF/ ? H.CIX R I ' y ^ N A ID Y p"v'F E? ,? F! .. IClE 1DEN,ICA, DN NO. I ?. I J a. ?I C c L v HlnEIDfN T An NN ? f Va If Dp . } ,/ p - r ytLi?l t ? I P(GISRR[D ONME R, wTTT FIRS} MI(> ? Q 3 ? 7 aI AI 71 IS I I I I 1 3LJ _" ? E5? OR[SSOF OWNIR ,r d ` PFgNf NO. O E ISIER[D OWNF4: ?/ / IA5! (IR S Da N yA F ¢ "": g' S • O?tiJ owNER I N w.Me aADDR[55alNSww E ? NCE CO. ao AGwl ,? A jf M[A L °1DP ??? CHw9 ?' L L' CHA9GF IuryCt OrRiu 4AMAGFDMfA MI., '' { . E _ 5 151. OAMwGE DW^YN alw9oxGl IO ?Of1Gil - ® R[MAINED ' DRIVEN ?R[MAIN[D ESI.OAMwGf A 1O ' ' 9 ' WwV ? BY' ? I.M. . Y WAY DIAGRAM OF COIIISION: u A Ar ev. - ICAIIN09I - . SHEET INEClSSA91). I I ...? H DESCRIPTION OF COLLISION: 1.1-FUMENrAI E.IIT Ir N-SEAR') ......_- QA G ? ?? A ' t .. WAIF- ?1 d! /e FT I ?' ( Tdir.•Ea? iirTo Tae ,(ofT. t$ , , S ? ? , . iovro`qoe/6.Lfvvorfl?e>fi•.iP?..2.Evi?o! k ? ,I y ?y r?Ja r .r rooms. ? Iv r ??E? Srvf _S..D.? o., q? fg ,. II» NAME, ADDRE5381NJURtESOFPERSONSINVOLVED +CODES I IUSISUFRIA OCCUPANTS 4 " M a • - 4AT1-11 E1 Z 9 4 S y / WITNESSES TOR AGp1,ONAl NwME51 S , ; , • .'. NANO w Hx AGl S}AIUS NDH mf i cur[ Rf319. [x[I .. ?.: + , w Ifib?l POLICE TRAFFIC COLLISION REPORT LKJ TRAFFICWAY POLICEOWFLAINTNUMBER ]I ' PRIVATE WAY ' F v y Al OEC?IXjII, WK AY. jl N .. ?/ R wIR.Iw lyT. / 11ME (USE 1100 "OUR) /S COUNTY D A COUNIYNO. // (O CTY NO. ?So2e c' iNWA; oU A uRa Pyr p ?• G mN QE O .N Ci,'OR TOWN NPMFb ?0?5lTOR IY?HWAY !/ / i CIS h+ RWIE M I y SECT N AvlE3 oS ?w oOf . 1 ON _ ? ? WIERSECl NG W11N: 5`?Ef10R ROAD NONyI1ERSECiIONr?? JT, RUC 55 BfTWG- STREET 6 SIR[fi PPffl% f0., MILE PO3t p 'u, // t ktl DIS AN eDRfMIFSf NRfSRENC .C`OSS StREEt09 NEARESiMIF 51 MILEAGE T VAMP DIAGRMADAIA, IEFT OF CODE -: TC'? { ? COLEISKIN NVOIVED, NO KILLED-NO.INIUREO- o SP IIAGE ONITe RUN TOTAINO ® PWPfRIYOAMAGE ONLY pVfNCIfS ?9ESUl1[O ?VFHCIE wNOVeom N- ' ? 11 l IMER Cl5 C "[11* POSSS1RfET0/G ROAD OR R[iF ENCE 1i.3'3DD• ?S OBJECTSTRUCK(NMAE OF OBJECT STRUCK AND OWNER'S NANF) EII.I-11 SPECIAIWDINGUSE ? , %L f UNI7N UNIT NO. Y VEHICLE- ?PEDESTRIAN. ?PEDALCYCLIST' ? ? S DRIVER'S NAME: -T I 1 f RIVER' NAM I MIDDLE IAST STREET A-IL. "Ell ADDRESS ?? 3 ? ? E' ??. ps arc AtE HOrvENO, IVCODE 1 S? D R rtr sTAi Iv N 7 T> e !d/J Il Y y 9 T RPYfR'S UCENSEN StAtF E% y?/ ) AI iBINM !V,:09 I V V I ENSf NO. iATE S% DAtf pBRIH MD DAr YR ? a y OCCUPATION N ESPNONf NO 72 EYES G 1 HEIGKT E OCCUPAI ON NRM NAME PHONE NO. EYES IGNI TIE GNi '. i4. C] CHECK L V) ,AHw [ N o ? CHECK(,') Nr OYfF OFANO1HfR C F S I? i :I A rANOTHfR. ? ' A ° ' °c . FHI I A A MR rn + " rv "' ?'}> P T #.I' CODES ? D a: a inv 5 v IoN a f , , f°, ,: S excN a wm CODES 10 7 n :u . is n.. 1 { a INJDN ; 4 7 1.1, o ANSUNNCI o PI L o 89"N.' o -'M o r N 1.0. ur;; .o ? ,MN N ? .?KL o s:TfR ? o a? ' VEH Y1AR AMKf IDODGf CHEV) 1 L ID AR I.-;-I StYIE IRDR ?CONV) 47E v E 1 HLV.) MDDII(D-NOVA) HYA Y ( R. I ' A J7 ' /N . . D' :. , N Bide e N S S1Ai tea 1RA UR RAfE NO S1A1 H ' No 5TAlt vIN Ca R l TRAILER NO. A . w C a veNlculoENlmunonrvo. 9 T )I : L 5 v w IeID N III r .. l l l l l l l I- I- 1 ?I RfGISRRtDOWNIR:,?P IASt IIR51 MIDIXE PHONE NO. V O D WN[R; -1 FIRST MIDDLE "No., T I ADDRESSp OWNFR W A NER L?I ? N R E ° NAMES A.- OF INSUNANCICO. OR AGENT STaJI? R U , DR DANAGDARG D K wipl CHMIG D? JAMAGEp TAU. NMCIiO,Di ; CHARGE iDIfR? Sf - ?? ' ?1 A%AEN 0RlMAINED O ?OTRG? f , E''I F I ULLEAINED ISt ?AWA O ?OIIOU B w I ICY v .w r by: Y I (OWED s ? AwAr en Ia IAGRAM OF COMMON; w u SHEl1 R NlWN- INGICA(A0WQIN Ow NIa. -Y) eY DESCRIPTIONOF COLLISION: Iasi si ft ENIAI SHIfnF NECISSARYI _ I O _ 1t ' J? NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED i CODES 1 -` `?` - Z 3 4 -'? 5 6 V . ,. IUfI T=- ESM OCCUPANTS/ WITNESSES ADMSw'EHSNAI NAM tf ISI ?? 'R,, AGI IAIU IN YIH r f N131R l1lCi 1 , , ASV N NO ?, I.'" _ A W Rrff NAIUR Of 9? I er. ?AM e. oK"Jll%I ?"L' R ?Nr?' {?rl}iA1 ( A F I I ? Iq J ( ? fiI 1. ADDRESS rl IUP p ... ID IP oAMe. 0la%I o?tH f oN ?li0 Y N b ?',r ' Ego ? b Si ? ADC IS "M?? F Rr oAMe oQM ?wa 0 t• 1L ) 1'= 1 VMSIgAlhp plKlfl EE ANE IAOGl01 AGINCY ?I f(,t60 R%Kl-?f?{?p DAIIp RfP0E1 Y /? R? k? ?u iG r t N ? nl ? r i4 a v hfil '(\J R ,7 „da - t _ ,e g? o < E r A 1 h s T,1A ? J If ? 5 ? err'' (+I s+ f t 11r 4 Sf r7 l P7f1 eI ??? ..M.,A,,11 RE? tr f? ? ?1u qy! 1 ?Ail I ;- .?• m1UlUB VL LLE COLLISION REPO GATE OF COL 6 ON DAY:O L LIS ON 'I E OL ISION F NO. UNTY C CITY NO aAx -.,j ,O ,,;• O M L O , r{-yI PM / LL JJ .. /' 1? l4NUn• • COUNTY -:CITY TO?((ry . ?? w MI}ESy ?? '':?' ' CIT ?; 7 WN 0 ,y _• , • ADM•GL6 PREFIX xoui x aina[T COOL SECTION 1 ? o .., t ©®D 2? i ?.TZTO VE N ME OF 6T RO - °KYlAT.n w ?i'..INI,.EHSEC.1I7 YY-DIU S. PE 19B, R4 ? • I PREFIX E° MILEPOST NON INTER6EGTIIN? CATI IIS ION ??G ETW EN PEST GTREETAND AMP DIAGRAM DATA, n. •,ono c,oaalxo, rvl[[POSi ox oaxi FNxo urvoxn,,. loo INTER IN ER CLS. R oaa [Txt.T n ©?W OF • [T T Q 9!/a rv[, IWRIr[I SPEC, CODE USE Ax xo MICE[ rv•c la oN IT,uN oB ECT sTflucK -' I .._ __ tiAl.k-9E',2§dFG.I§_,MM.'AHP.,:AP3fl€5ft[:Yir:Ui"?N4nQ ?1O,N ..isviiv.i..l: ?N •fiIHAT[o caaT•., l ' FEET 6 DRWERS LAST NAME s '? $ : ?LP` T.i:A^.1F,..a'..... . MIDDLg Ix PRIVefl@.LASE.I/ASE.S`.51?6a...!,.?EICIRLI1AMEy:,1.._.._.--.-NIBBLE r:: 1-.. BTRE? AODR 8 Ww GU?CO:.TNPy@,qNO A T ? . n[IO,[ x C TY 1.T ?i I :-O.PsF. ..??IY?Ti'?FI.OJI.ff_LIC? CI,I.'frw.?t - - = LATE..y.:. 2. .. ,[.ZIP.EOQ 1 - €_RHSY6H's8>iSYPAI PIL ''?''''( .] _ , DRIVC-R..II EN?wE NUMGER'?j wsT,(1wT[ SEA" .pATE.QF 91RT yAG.E !u .. IY,E6lIGENSS_ NUMBER .:- c?STATC ?B :yp? wOFi 81pT ?O?-, yl. T I [ IcLC YA MAKE: .'IMP ?v? ooo,••o-[I MIDGE 1 .•o[ 404D ;STYLEy?2 Jry, ?; ?F IC?r,?wRS il,icXrv:-o99P[I j [ -?.e:'INOVA_oMTl1 BOOYlsTYL['I] 4I?1 I IGENS-EEPLATE NO. STAi<E? - _T?AILEp:pEATE NO_? ::.:67ATE? rICEy4yE-?FJj;E:H??. •=": BTA L.a'RAI{;Eq_',pUATE.XDyt STATE : 1,t CHICLE IOENIIj`JCCA lO'f''1j NO 11908 Mopf GI OQPM(,j?Rl k_?-- ? I '+ VEbIC?¢? °E ?wfCA710N NO.:::'"C?I.IPPB gofu:b'x[v[[RI OOOMETERIxIL[.w REGIiTERE ER '? f..7._. -. [. SI:.,_?::.'..PrLVEfl LjCE i?BE ° ':,;.HeTL1.6LEOe?.[IYJCI?B?V!'MT•lILl1T'CIF4hF:k11?.U+P?JYFi$$:A•?CEN.SF_7!O•'.-. ~ ?L.C.!L41/.iJ •'_?.f11ftl% 1? II! I?.-('T•?Il'>?i OWNS S.AD R -6 • ?.1.--. s::4 y?(T[?a.?-L Y:MO.T-E'OF'8f',Hp? OWNEIjS?DO.PELS ?irw.ie?',?1 [_ T'?cITY: _..ETL'LLI •.: n: ::a cur. 'vOASF EB'HIIL P IjT OF VEnIC4E QA AGE ..-.u?.,L' 1..•..i4.... I?Wiiu....,L.??u [ T PQBT6,Of'1,L.6HLLEE<B?MJ14EH..uCd2li+'r]NU'Lwfaj•Y + a * Q F4 I ?. ?' 471[fdlPa[IlKl94F. $ $ LIABILITY INSURANCE INFORMATION - VEHICLE NO.I COVERAGE IN EFFECT FOR THISACCOENRTO YOUR CAR ? YES ? NO NAME AND ADDR uil -T. N MCANDADDRESS OFL _IIITj IN I1RAtlC¢_Gf!(r,•y.v.,,vu?u?- .•j.4.?. TI-.<w:. i...,.._Irv'4.?I..I.a:c'?ISS.Y:POLILy"•[{I,JMGER: •. •++•yyy:.yy}j?•i:J; 1 T JURY Y..L AGE ZNOINJUflY IV F f T,I P T„ r 1 ,,may AGE' E TOTAL NAME ADDRE6S DOHE6 • O M .__ ---- F _. - U P . x .R . ' o o - , I J I aIf Ix1ORl[[ .1 A <, ,. ? QA,x ©PA[TO,: o o P ' BTATUf OF INJUR¢ D ., M RN (`IRfT ONL.j'HAT tLPry LICi STaTUf Op INJURED - :r p ?ZK[PMUETi.ONo sINATsA,?,PkIFA: 1. ,A .j N.ViHICLE ??• ?` Itl.Y4H!D6R FD ' : O T oI D o S6ET 6? 6 O NORTH 13Y ARROW IN CIRCLE 1 rvl,rvr,.. rv O \ ?. *? 11? o \ i.• = I a tL ,. l_ ! t . t 7_ IY?.LC i1\.. 4 l7f IBC yl-:.• 3? ?b?C is t? b "I.J?cE olumox e, , I ?• l / / r •r 1 t ? ) ' ? , y? Qom, I 1: U_.. .L.. t•L.l o y r ? _.-_. , = ,-• ---_- --' I ? ? ? rte _ . _ 5„ LLL U! - s VEHICLES POSITIONS UEFORE COLLISION RIVCIITlI ATED UY a w o Nu°cD VEHICLE ON?{T?R.t[T OR HIGHWAY NAME OR NO/El ^o . ?oucs / ?IIII? [{ HO F6 NO NO. IYOURI L xv ,19H ??? ? C?I IG V?t??l,l > > f !'f --• i I ? . L [ , . ..O? NO, IOTN[RI ? ? ? ? a a IL .-.,- RtDESTRIAN ? ? ?.? ,AlONO .,,._:;.. . ,•. CRO{SING •., .. vV...w. ..„1PO11,.;trL?lY IJ.L 4i:TO wl?a ,,L ,, :. • .. . . , ._. _ I[Dt$YRIAN WA f V61NG 1?[ ,A., ov.ou ]? ]?[ A?c S?c [?o rxu .ouwa.. .• ROAD SYRI C[ WEATIt[R •• ,LID TGONOII;IQNf TJIAFY IC COHT110LIcP[<[OI;[I• T[F ,O`L'01?0 r ORIV[fl,p-nq!,f WC12 Cw o.L'Oll uo ^`'execa D-Ilr -,vaxltt [[. Ilx I t un, 1 D Y1I011T 11 ?]f10NALe 11 ?]ON[ W.-,HH a 11 b'ODING 5TRA1014T AHEAD 1 ] ? DRY ] RAINING ] ? DAWN ? ] ? STOP &IDN A ] TWO WAY ] ? OVEOTAKINO AND PASSING Eli WLT ]O f OWING ] OUfK ] ? ROADR{IBLt ? ] ? MAKING RIGHT TURN ? {NOW ? O FOG A ? ?AONlY CN tT ? 1 ? FLAB NINO R[O ? . ? ILOOP?RAMP? Q. ? MAKING LEFT TURN ? A ? IC[ !? I{ICCIFYI 0 ? LIONj?GI?tT ? ! ? FLASHING AMBER ? 6 ? ALLEY S ? MAKING U•TUNN D W* I, 4 DAM' NO DTR[CT LIOIIT{ ? 6 ? qR SIGMA. ? 6 ? L[IT TURN ? f ? SLOWING ? f ?{IlC%Y REASON /OR NOT {[LINO DANOIR ) jr[LIIY ? T ? 0r FIC[R//LAO M AN LAN[{ ? T ? STOPPED YOR TRAPFIC ro r,[•Orv. Pear, aLlierva,[ac. ? { ? ¦INKA ? [ ? ON PPID AT SIG SIGNAL v' "a' I ? {EPARAT[D ? • ? GTOPPEG IN ROADWAY I I ?u " y , ;rte 1 ? Y ? } I • I Y _ C ' N 41 t ? ?? 1 m m ol t a ? w l O ' w f v 4 "k .. `t r rt 1 {. WAS r 1, t ?? 7 10 L: k. a, L ? ? 1. , 41 fly I TI 4"??? 7 ? "?F' S'11? i U"' ,+P}r, .gsa}?} `511 ,ae MEMO . ..,u wsP lsv IRFV.I eDf L ?? p? '! STATE OF WA NGTOfV PAGt / GF / No. .. 51 Ruh! SS41•E ra POLICE TRAFFIC COLLISION REPORT Qfj TRAFFICWAY ' FgKx cgWn,uNINUMwI I PRIVATE WAY /S AI orcqu N O %2 i7 F3 1 "° IRD .le Iw% "., C Mf D (USF R,W NDURI 6 25 coufrlr <pr? gSa/y cgrfrr NO /w/ O. 5; Sa-> o FUFEE Ru ON Qf OIN CIIY0410WN ?6NO. Of 31RlE OR rvIONW.Y GY /J/ N y Avlfs 0.5R- W ?oF Ch/iM.Oc-'M ON'C-o-RO-I(-.?-Y= CLS RWIf OY a le3FCtING WIT EFIOR ROAD IFRSFCIION BF [fN SIRfFI 6 SIRFFi PRFf1% F MILE FOS DISIANCf EDIRE 1 P0A1%FREN E. CROSSSIREEIOR NE-5-1-51 MKf3 B F FEET W OF ACCIDEN MILEAGE CODE T RAMP DI RAM wtA CgIISK)N INVOIVtD: SEVfRIIY: fOIAI NO NO KIIIFD_NO.INAIRED? ?SPIIIAGE ?HIIERUN wrvoaRl"s I rte RD IMEp ?l3 IN n rfEl RROADOR RfPERENCE OSS INSiP[FIOR PoAD as l OF-1- [] PROPERTYDAMAGEONIY ?HSUIIII -II IF , " ZS? OBI[Ct 31R«K(NAM[Of OBIFCI SIPUCK AND OWNERS NAME) FSr.DAMAGE ? S COOING USE -1 UNIT NO.I UNIT NO.2 ?VEHICLE ?PEDESTRIAN ?RDALCYCLIST 3 04NER'3 NAME: -1 FIRST r -1 IIR I , DA i n/•v si%f1 3 oS3 3 71Y A v,:F S w D D%ss ? o SAM J D COY IA` 'I'- DE PrrONF NO. SE'4774- wv, 98/R6 rf II AEO ' s O D R I .-E [IYCOVf PFgN NO vc d a wv 9866r 69?-9098 . /? DRWtR s uCOr f N . 0 7 N S su vIV I F o B 8 ft r ZD R v 0 EN NO AE y oS N wN M A C6 tlIa1H y D i5 60 n M «CUPAI,ON PNONF NO. fr[3 IGHI E «CUYAIION FIRM NAME PHONE NO. EYES W[IGHr wIGHI /4 2 Rr7 f/4Z /yo SS' R KAV us" C.ONS7t Ia d// ?ro /60 CHECK (?) vtt EAif ArMiominl"I ?CH CKI?) vtwnl ASAN IMPEOrEI Or Ar oINIRA' _ C CODES ?' ] 5 1 e',",° .v CODES?' ] SIxcRDrv 6 ;' ' ' • x al ?. , I C 'wI E ?AD C.JT HAO F/ Y A: - S c s ' ?cPo H(v : ° ' D ' EA MaKt IDu V, W '7z v w MODFl I -T1 AI 5-o DR Cp I b3 Taw E I , I 66 c.Frv , rgotl(DART rp?Af Y? EaD T pv • ,a r / vH ON vNJ7E CINH PUIt NO G 31AIF IIERAAIF NOSE SIAIf H VFn.CgOR V ,({ZC G l P2. 308 Il A A N v ? 5 -10E IDENI11IUIgN NO. 3 o z 73 5 i tNICIEIgN11fI AJ S. 09 %WSR%DONNR u51 fIR31 MIDDF M OORCAG MA/I_J.JA C P,pNf NO W DOWNER: WI FIR31 MIDgf A/fk vi A H fNO. 3 " I_ ADDpfS3p oWWR ' 30 7TiAV- Sv SEA7TJ•? N E [R V4/ j NHI ,E ISi N y E Ian NAMIEADDRISSPINSURANCECO DRAGINI ARM i RS R IN r , 7 OAMAG D%1lI ?? n W Fi. ii?x V ?w pNAAOfD ARIA 1 n N v " 131?'DAMAG -Of AwI?V ORIMMNfO f CHARGE ??W?Y ?RIMAINID IO tD [ u F3?'DAMf ' p.s as f7oo lowfD U Ar eY A 6A4 Vr BY /l y$ G4Q aF.; s 7a?"AL Iwlure H Ge DIAGRAM OF COIUSION: ' ssApr, - DESCRIPTION OF COLLISION: lust sw -N1A1 111 -IS-) kp 47 v ENi Mo /. v^?S NeRTr1I3a.,nlo oN c.o,Ro. o -?J ?L 7 ? J2 CoR1D /$ Vtili• No ',? wA5 $?JTH/jeIANA ON Ca RD v -^aZ alx •,? _ "' *,ZS VFH/ 2 FAAA.kD T•o YI.F4D RIGNTa!- -4y To No 4 y.,Ne H;7• No k I" THa ),£F'r ? Co (?p R-IAR Q-A411aR CAf,Sr JNB. IT' To FA,f.A. ON TA/ R/GIJ7' S IO tr ANm ES I.10 EC P.1ARI.y J AaAinFST SINS GARA0.?] A/+O 50'J°RoM real 6 AND 7A' FROrT Tq h )MPAcJ' AAICA J NAME, ADDRESS R INJURIES OF PERSONS I NVOLVED CODES 1 - 2 9 < 5 6 OCCUPANTS/ WITNESSES Of uws %I,R EnC C NAw /N.00 EL<I wFCI,I 4^% A nrwss v O1NeFFr.' KAYe Q INF aY - FE O"A't" L . ?N O T-M A.IW P4TR/ CJ A . o p A grfss ru.f orN K, MovforROM AMB 0,. RI ?":. ? F ? N Aw No . nDnro r'u:ds°f NF nr' OAM CI": ?[MI. 02+ ? m+u?cArwD DlrxusNwa uAFM eAfxa u. 0 AuFA:Y c1 DI:.A¢wD rtaue%a0 was%nwl •rlscnopr Duf ?''. -,ry uL' . :9 f b i rr 1 ?, I. I I{ r - ?Pagl nw aR`? 1 KLE lri? ,Fw a ,.f ? ? s t ; ? ? ' 1+-,a L K ( i t (.??. l g... 1 1t'. I, t J ;RI ?L r? f; v m ! ?LLt A, `L I, v ?a POLICE TRAFFIC COLLISION REPORT Lg TRAFFICWAY Pdxlco-N1NI4Aefn PRIVATE WAY DAI OiC l az O'Al R9 R .IRTwR 19 f,l IUSf 1.0R HOUaI C I OUNTY a,-Fr-EACIO(V ODUNIY NO. /fc CIfY NO. INWA ?D9 u4u ON p1 0.. CIY Oa IOwN ! GHWAV Aulfs ?s pw ON Co 'K` Cl poliF 1 95/7D InnRSFCTINC VnTR SRFET OR ROAD Nnnasfcl ON A. wellx t . mxf POST J?t• W I V 4LA 17 Bf1WtFN STRFFIE SIRtFI f?5 / r 1 Dn1 AN {DIR R OS S(R fT ARFSTMIIFI 5 E Mf1F1F5 4 Of ACCIOENI MILEAGE CODE R D DATA 1I 510N _'A:'2'- CdINVOLV[D. VE911 NIte RUN .IAI NO NO KIIIFD .INIUR[D? aElGf ? © vllsiN Il N?1O IMER CIS f R Of IRiERENCF CROSSSIR[FIO4 ROAD 11 StdfN Cf-Ic- 0 PROPERTYDAIAAGf ONLY ? RSUIT ? VEHK 1? yam, ?^!?/O 1'7 T OBIKISIRUCR INNAFOf OB1fCi 51RUCK,WD OWNtR'S NNAfI ESf.DAM-1 ' BROW CODING USf ? UNITNO. I UNIT NO. 2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCUST 5? ^% NR 1 MI LE D4rvER'S wMf: - DRIVfR'SNM,E: .51 OLIN -?Mi-il ` GETZ F C-lZ- AN C-1114 RA i e` 1, SO SIREETAI-Ess 13 0 0 o ho IRfI AODR[ T/ 0 7 UTY STATE IIPCODE PNONE NO D SIAIE PHONE NO v ot- ENA WN 8.176 732-y6 R fdgpx.oc w.V 9 339 y3?-25x WnFR'1 UCINSf STAtf BI H A I IKfNY EIO A IF K AT B n D a 722N L/r 8 9 V ?SL2 L/ 3 ? F 2 66 OCCUPATION mNAMEEPNONf NO. [vf5 IGNT HIGNt E OCCUPATION IIRm NAMf EPHONf ND EYFS NRIGNT IEIGNT ? RET N 60 ,J R ST OKr+T crr9 qco His A7 /20 ?/ CHECK (.1) 1 v-11AS AN r. wvr of o ?'' NODES?* ] wA+. n wT/ ANSTI cTw„ / e i°irwc. a ?CHECK (?) 'vfwdEASAN rMPIOrfEaEANOTHf9A' CODES ?' D n:ss K / SIR N e i°inK• N 7i . lVoAIIF D M:. p A,.DA.,KI Ou." O o: r. ? v,.I V v Hx ? -..A- . ? ° I O " ? Y . I. ? ' r H N fAR MAKEIDODGfCNFV,I 7I 7a OT MOD[lIDA91nWA1 S Ylf 1109. COn l CoRo!- T 1.0R E vH.Yf meal fV.1 MOp[l IDA91.N0Vw1 c. 71 C1-114 v EL G9MFNO v111 V.f ,¢? ?, ?° UCEN PLA SfATF 4.UUR RAIF NO. ImE H MH.COLOR t A AIf /,/ [T13t E cFg C 13cgc GA?7/7 vtnKlf IdMIfIUTpN NO. r7 02 ?3C 3 P[GISrtRtDOWN[9 ASI FIRST MIOIXE H L lnlUf IIXn IFICATI N /36 So/ L./ -off 1 E IS RED E1E4 ,ST I O (1 : I P ONE NO Gr-T R C. i32 ?1 d 3 w : t. iIR51 M D IE R iA ?w ?nj A, w --IA ENO. T3 527 7o 1I IS Alwassaown a 3 o D40QD Po 4viLcF/?l?' E ; f ?j00 o K 8AY RD H40JD-4V NAMEEAlxxt53-NSURAncf-MAdnt ' R 7E35EP I.O.OP;tEFRI 1- IN ' 6 n DAwRGtD ARU t E runic°i9rGiN ISL IW.UG! ICppNARGF =7 ?-NED 9 cNAacr a 7L 1 • ?UYNFN ?R[MNN[ CT'Nlowu ESLDAAUGE (( ' D-11 AREA ??jj???_ ??? // ? ?? s . 11 s7o7AL 1?I 0 A-1 Awnr C11-D., i ic5 G•A QAr 1 STo%1L L ? r ???rt o? _LJ ? DIAGRAM OF COILISION: SH[I II N[LfSURrI I ecAlp In DI.IPTI.N.FCOIIIIION: Iln[su4R[MEMNStRelR was5Aer1 e T WV-4"Qy "O VGNl ND Twv HAO 57OF7;D At TrJG' /ND?CAT /.vTeR3EcTioN /,ND Had a RossE'D co, 2D --, ;IA /.1, JRv;r ,VotV6 7D Ga NoaPN.. 51 CoRO:?" ??a? R<gz•=•+ve? TNnT v£Hi ?/ .q? /2 DO Cx.oA$E sN< PP'-,D To Ac<tl-c1TA7"E' oLT a F Twe wpy. v4tii. !Z 73RD/r4' ? fi R.dGT/DN ON. TNt VX!' J?O.47 ANO AO20Vf: /NTo nE??-S?Oc of /vo. / NAME, ADDRESS BINJURIES OF PERSONS INVOLVED CODES 1 - Z 9 4 5 6 OCCUPANTS /WITNESSES iW 1?0 u fN9AS,w1 OSi uR Aof 'Al a ts1R I Icl ° N AAv r°n A txwv DREd pAM ev e ? EI ? " . ?N ? r- r .uAl P N A lawss ? wld MOVIUrROx ?AMe ? ;"' ? ?.. (] H ? ;` o N - 0Il'Z . ?? ?;A " RNi11R:AI.,GdrK1 II NAW ERA N. eADER O4 KdrKY KI DnPATCNO WIKI AReI?, 0 DAIIp MPORI APIRONO eY DAtf L ' t 1 y I] 1 wL n ! Xe `4? 4? la I C INr /SFCIING YAIN: SrRfF, ON NOM NIN]FPSFCIION - - ? - ???_ PpffUf (` MI4t Pp51'v- c.. S Q ??? WFfN SIREEr6 SIR(ft I::p 10 I DI MCfaDP M 'IEEE .CR Sisiq ft Oq NFNES, mIIF O t ACCIDENT AORAM MIA MRFS N S [ F[[i OF CDIUSgNINVIXVfO: .q agllFD O NO NIURfD I tOtAI NO MILEAGE ?ODN SIR[F RROAD O4 R[iF1ffNCE E ?HIT... PU YC N IuNI"IRIN D. C C . lY V[HIQU © I-ERIYDAMAGFONLY IS ROSSSD1EII oR RUM IT ?V[U'[I[ SR 2O Q OBrtCi 51RUCR INMI[OF OD1fGI5lRUCF /JiOOWrvfR'S FY/Afl / FSI.DAMAGF SIfCUI CODING l6E E BLAME: UNIT NO. i DRIVEPS BLAME: _' NRSI MIDDI 4EE ° ? UNIT NO. 2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ORIVfFSNAME: USf I MI UlE o L R Cfd/,,R? SiRttT SS .EA -.0 03 S'TEPHErY Ey Igff]AD... 7i2 Z. ,Qtr S7 4CO, 77/ Y S,AII ZIP CODf NOrvF NO 992 o)- D T/iRUo L,Onc RDA.,o D ItY I l . q IPCODE PNONE r[A//vG1? rv. 981.2 6 7-OG3 / R CSR ?,A.Gc/Y?' 'sS+N 732-y? Zi N(4'SUUNSF SIATI % DATE W BIRTH ( lKENSE NO. A Slgrf DALE Of BIRI.1 30 /° NV M ?° a 67 5.s^? /?v ?N• r? 3 3? ys «cwnigN RM NNAEatsgNf rvo. Fns IGNr IZiGHI E «CUPA, orv NqM NAMFa PHOrvL NO. Ens wE CH, HEIC"r ' 4ve oR F j1 W5upv'A & d 6-3 R ce s)QDc7 UN,A p •M eee >z? 6-? CHECK L I TINKLE AS-,N EMAiV v Arvo,NER'u o EgiAl ? CHECK (.? VEN ttfA w rM OrfE OFg ; S M s nclKw o .<L CODES1 * ] ri;' a i S I a',° ' CODES l t ] a v <IroN ,I? nI. ..9 IN „R, N /Y G VTS F tE r R ? p p i ? M". ? „ r ? c"A'I ? < ? „ Ii ? :° v , DOFfV 5<"O AR x N. YFAR MAAt IDGDGt.OHFV,1 .' 41DwRr wVAI S l]DR ?EAa . v I- N V . 77 C/JEV PU, . E 6 I A DARt NUVwI YII]OR. Yol_VO 2 K 51Aff gNIIR 0.wrEN0 srAtE H nl p M A q t Z t ? (? ~N I C-0v, NT 773 wEv gKIEIIXMIIKAigN NO. cK ?, / 7 zl 3, o I I F C E ID NUFI w E 7/ RFGKIFR[DOWNER: UA51 FIR51 MIDIX[ E $ RL.C Aawssa PHDNF NO. W IS REp WNlR: 4A51 IIgSr MIDIXf ED.W4RW STc' Al ,W Cj fND. 732-9a ?S oWw x,.30 L/SA A41vr C1.Lr n/F E 9`?? OHO TA Q)3Up L RO ?)L,[.c /vG NAMe aADURlss lr wwRAnel eo. GR AGENI 73A/-O O$O R IfiSDC:WGFfb"dA - V NIPPY DAmIGI AREA 11-1 CNARC! • 7 C CNARGF ONnAGfO ARfA ' to 00Raii f IsI?MMwGI fE7-1H ?R[nu Nm -Al ??w"r ?R[MAIN[D Lsu DArnAC4 s 10- I f/000 AINAI er C,T S TA L_ ?/ DIAGRAM OF COlLI I N• lu l N SHL,q IYCI53ARYl YAILIRDWI DESCRIPTIONOFCOLLl-EI: Ilne surnLmrNrM SHE[t rNFC[sssPrl VIEW rro 2 wqS $ouTHl3o Np Tt,RNiN R 20 ) G /c2oM S R •20 7o co t) /Z ' ? IP "F+/I. Nv / ,M 40[' A J:t FT TVRN D12fC)•?y " •L P , /NTq TNC 3'ATH of NO ]? TR)')nG To rQ P o Tc ' s /j ,Y ? T r ip Tc ? TN Ir ` NAME, ADDRESS 8 INJURIES OF PERSONS 7 ° ^ l" " INVOLVED ' CODES I - 2 3 4 5 6 W/ : OCCUPANTS/ WITNESSES ??, lD D a NAey riau si SEA 11.1 A' " "FP?sN+ RL AN?Rt W. D NONi 7.3 AEDr115 O N 01.0 C NAI11.10, F H e ? ,"A1 ' ? ? I=Nv ?'s'Rw/«,-0/s'?T S M-0RG vF2lT?' L ' No/r? o woorlss O /S4 View AP7- nlo H40, flRl of RFMOnDr pAme ?:,R'?':.N. ?D ?.` ' VEy/ No.? No Aun.ESS NAIL wEa Aei L C JTi IAe e. ?AMn ?,"::" ?"o:If. ?H. ? :R X .mslwAf.,GpIKIr SNAAU a.wN. A(L,1 OR n 3 AGI.F'r Sl .ul ICIMD °oO POL D DAlld rl.fW, f // ° j0 ?' APPVDVID eI Dwtl 3c5o , ,1 X 5 x Z x ? o r] 4- 'A ` ]P -Q ? 1 L A } ,1 e l E b !'4i T,a?j ? 7 De ro 5 F a 4 WSP 1591u[V &> STATE OF WAS INGTON wGE Df ?? t Na ? POLICE TRAFFIC COLLISION REPORT LL TRAFFICWAY PIXKY GaKrwNr NINIBEY 0 PRIVATE WAY OA1 f au 1 I Mx uql rv min n Yf (usF alauRl cdlNrv WIXf1Y ND. cln lq. % n- F I ? ? 1 5 ? s a ? i? u y??? ? b ?N ?E [3IN CDYOR mwl DSI4EFIORW W ROUif ORTI f uR W-A ucucw NII SFCI ?W ? ON ???? ? ? C ?. • ?WtI?fEl fpNIN1E45FC1? pREi% E T? MIIF ?? ii AN v[MI ` 1WFtN TIR(Et 6 SlRfft ./Q ",. K DI1 v[Fj{R f. CROSTTIREf104 NFAFFTIM IE WTI y 't"" fy , •T' - O lL5 5 f W ACCIDENT IAGRAM dIw FfFt Eai l1 MILEAGE [? heE$, ^ _Xr' -.f[ , COIITgNINVIXVLD. SL VERIiv; 4K?.? 1 CODE -Al Ib. ND K ll[D NO. NIURfD?p? w Y ?SPiEIAGf ?NI6 RUN .-IclL1 ®. ?WPfpivpMMGf ONIV ?R T ' a µ AO IMfR C4T L SfCll 114Ff10R WADOR dfER[fKE a CRCSf StptFi OR ROM s yG a K r ..P hv5r uliFp ? tP CIf "' Opl[CISI4UCK IINwMf OF OBIfCIt TrpUCK MID WNFR'T NAMEI FTI .D A M PG E SPFCNL [ODINO UTE ??0?"?G d L T{ it A ,. ? E[ ? UNIT NO. i UNITN0.4 DRI NAME. uKSI L [ pvTNwnf ?TVEHIaE ? PEDESTRIAN ? PEDALCVCLIST p E IV1 l sr4fI ?i ssQ "" . E 1ADD i ?r. ?: ry a 51AIf PnONf D IEV ? F F P NO a d R ? i I D TL taD D4"' C ? ? ' - . s1AIE % I u fNU NO. OCC At M [f PNONf NO ' wlf DAIE Of - ? ? ? . fYFT IGNE HI NI OCCUPwII iRM NPME 6PNOf:F NO ?- _ - R ?UDtnt --• Fns wr Gw ?ICm T, ? CHECK (.') vfRIRE AS AN 11 A ... 1NFR w1 fE CHECK (?) CODESP* y S 1c1- e ? f•s wN fMPiorN OFANOII°ieA' '•'' Nx. iorM CODES 0- t 3 i ss vFN Ci "` ?? 3 Ix D" A s IES n r . pM ? K , a ? uy 1 ? 8.1 ? U11 , °yT I DM 0---, ? IM", ? ? ; ? ?? CNEVI MODF IDA4?'N TIrIF IID4. conv.l % R N ° fi vI vl MoDFyD nRry+ov%I • uDN 1 , H g Ck'r ? ? ?' ?? ?f, ? Y?l ? ? f S F wI1FRnw1ENO TIME n c on 1 KAIt wlL N •? ?T w M . vFNtl[IXNIFCwI gN NO. C nCIE DFNIIF UD f1 '' E o 4- 2 Li 6i flw a cs i i RIGISOOV • ?' Mtp'ylwLAfi Sl MlpgE ONE NMO O 5 R[DOWNFN. IA51 FIV51 • IDMF ,V,W \ ? n Nf NO ' I] ADDM5T OF ER j -- yv%k S u? S ??'s` ?? ?? e : • a - NAMea t wwplweLCO. MAGI., E ? _ ? . ,Y ra u. X e. ??yyt?j?? F ".>?'" R DAN a DAMACfO •pu ,- ?1 . ? cN.wu _._,- cnAVr,, ?,,,In•., DunncED':nu. ` ,- ; ?" $1070 ?____• Jg ? ??,,tuAa.st ?DuFYA ?0?'d- ®C.?X?nW? CODES -.1 1 2 3 4 5 6 u% I Au MI NT r c NG - *?' ? A[wn5> IwF Of N MovfDF.DM ?A.MS ??. ' ?« . ? ? ; '° -?-. •a*ns H:rur?oF ??,,.I ?T;;n.?'XI ?(: ' hRF51K.•I aFCFra NAW arANE r.DU DN wca rx. IN ,,,,? ryu[feer ?wMn ?( w ND ? u Ewl ?jrN'?' I?f ?'?' ?yl? •PPNOVtD n. own ? RCS 4 R :Z RIIIR'ei4n,._ ..'?,'m-( ( ",• ,6'?`Y'?PeiL''Diif9"? ? y;?;4? IZ ....4s_l': £:m. .'"arSu11.:?'CE?_ '. AM1! -YXX <p?'stt-`f S. x p?'?_.Rw? 9 ! STATE OF WAA _ INGTON RE I OF No. '+ POLICE TRAFFIC COLLISION REPORT S.TRAFFICWAV fbI CECOMRNNINUMBER Ll CI PRIVATE WAY 0 ,f Oi.CIXII .. .. A7 .}. N IM, COUN IY vn wgn 1 Mry i 4 IPI. iLI IU ERx00HOU91 S COUNTY NO. CITY NO. iH :i F4 ?Of% l x I G < P.'I 1?-' CY\ ?? R '. p0 ? ? y Y 0N 011 O.N CIIYOx10WN N E6 N09f 5 TREET OR HIGHWAY s , fR $ M ?WIEOk?? ?° bh NNN? ARIES p [,Ipf ?<' r ONCi• ?? 1[45 " ?.4 N` - I`6' 3 y. EC1 NG .3fR i RROAO NON IN fR5EC110N CO .T- Z IiCC'S •Ca^ yy - BETVFfN ?? StafEt 6 r"? SIRFET DSIPNC pR[MII N NOM REffgfNCf, CNOS351gffI O0. NFARES MII POSt ACCIDENT lf5 F W 5 PRFrI% RAMP EO.. - M1111IT ?J ??J DIAGRAM DATA v } lEEI Oi MILEAGE CODE SZ • ' -' EN COllI1.1, NVIXVfO RIY:? IOIAlNO OKUED?NO NJU0.ED 3RRTATiF-?O Hi1e RUN OVF © •aPPOFFRIYDAMAGE ONLY pFIRE UL,r? nyEOILIE OBl[<T St 1- wrvoxtNlnS N ? F" q 0 MFRS Cl5 IN N SN TOR ROAOOR IIEfFNfNCE 3?Qp CROSSSTR[FI OR ROAD I 72, } '+ , Z KI( NUCK NAMEOf OBJECT STRUCK ANDOWNfR'S NamFI FSI OMAAGf SPEC AI COOING USE µ f s 0 ^ ,F UNIT NO.I Oxrvfxs NAME` UaSr NNSI .-WE UNIT NO.2 U.-F NAMf: EI-VEHICLE pPEDESTRIAN pPEDALCYCLIST I/ur IR' k4aa • a , LY-F t_ opaess L Cl `•? Dl smEED`s ?`/1 _ ?INa?- ^e 't `ce ? .y7' ! H ~ : of f , OI SiAIE E11- PNONF NO k ' - D v ?` ??31A1?5 C Z?-?•? ONE ) k ( w5f•. SS CtNSf NO. S3 SfAIF ? 3YS+u R Pori Z. - E- L f;EY?r 3S?=27SS " ~? L ;.Z L OCCUPATION ?r NM1E/6 PNONFNO. - Ek FBIRIH FttS I ? I E I RSt CFNSE NIO 7 v1 ? ?I 'All DATEDAOFBIRIH I I., 7 3 I 3 L WF GHi GH1 R OC ION IIR AMfA PHONEN pOFTES I EGNT L'M J (N ? r .7 p CHECK p7 cLF As o o " 1 p CHECK (,1) vfH nF ASAN EMROrfE Of O w f - I _,-' v A % P, CODES cI «. 3 a .:RM 1 1 s r a "3'w°, n 'r-L AN rHF4 ,Ux CODES ? 3 n .ss a s, s u H e i °r?n ar,.? tmN1 cllo 5 3R L 'r5 x - 3• NI-IS w cl ii n Po w R Es ?(L d +E 0 C] Amq .: u urvcl ? v lDg1?CHFVI - [/g /' c'!- y 0 :q.Il p vi 4t I vsr MApfll i P pl S1YlF ID Ox CONY) Co] AmwkArvcl ?a vlOfwx FV.) [ p u cl ? ilP ? niav. I QV.1 ' R N-0DElI 2,' OVAI S11 am' p r, `? 1. 1? t1 G c) r E 3 c?c. z C 1 R L Cf ... 5 , m 31A f -UI RAZE NO. ST AIE H . VEH 0104 TLFRS . NO Lj •' ' CFDE i CAI . IONNO C " „ ? "? . ti I;I I?!91LI?li l,I>;c?"; 7, 4[ 431 [ fR L VfH ttF O[NIf UI 211, ?3i(=315 -I ?I'I I I {TL p M Y? E l { 1 IR31 MODtt PHONE NO. ` 4 f Sr OOWNFR LAST fIRSi .11- PHONE 10. l .}K IO ,^ ]? •^ W SC µ1K_ ADD4f35d OWNt9 9I 'Ey Iq L.. 5 ! ' NA Mt eADDRESSIXINSURANCECO. ORAGENI E N I 1 %%%; (j 1 n 11 ,VYL'.: •H [ I e7CL -ti 1. +1 Zavn? • TM DAVAeeDARu ^ 0 R AME I ^ IN`U I.I i?YY?f. vl ?a l ?, r IEk1 YC} 1'i t • l• ]] L 'l 3 • -- OP x 1 S ? , 21 l5i D MAGE CIIARGf r A'ZE N C3 RlMA NEO CNARGt I?-OaWFN q 11 ^ ruvn, n OTHER SSt DAM gAMAGfD?EA BIOP , m' , S • ,. f IO e0r10 1 r S T. ?J Y ?WWAVDBY. (.l ? L 1= AY ?gfMAN 0 L AWAED !?-AW 1 I? ? Y BY (?\Y SC C•\(I Q AG( I E ?S?C: IO eOTOM S 5 ?A 1 DIAGRAM OF COtIISION; w u LmNU IN UIAU govil" D ESRIPi SHE[IwcE5URY1 NOF COLLISION: (VSFSU PIfMFNUl31 F[TIf NFCE35AR) 041 Ls; ` ? , L.Y VICY- 1\'L^K\"c.L tE C1.A ?VI/ ... -y it Wr w .- ?. [ { I ? I? a/ O ?T- ?rnh LUµ}.• /?„y 1'.?.'C'(1 // V . `R- & lc? lis b 1 F IB ; 3 r . i ! el J .? r R L , , ? T NAME, ADDRESS 8 WI ES OF PERSONS OCCUPANTS roiu n? M E INVOLVED * CO ES I 2 4 5 ' _ r I A q a5.. C y ? nfy??' ADB+Ixs S`//? UI I•? I1.,.}/? u47?Z^y r/! DAE•! pAM IROM r. F e 0 p " q „ J' p b x'. I I !v v , K ., H E. E7C 1 J •AMI. q N MA Mo aiD rRGM pAMB. p?aKl CJ rte'.. ? „; ? :°.:I° "? +,, x D A Exwf sr N nrvror S 13LGAIRHipIiC1K'>NAMI {MANS IAlNA 01 AGtrK 55 CENE eY ?AMe p1iN1 piri:R. 0 01;° ° -. . e x ii 4 1 lJ , j ! - I' ) T CVCI IP ¢ fp IK:I kVl r 6 ?v VT KLA ND OII OrNro POVIOB t 1 J ^S f ? '?' Y ,l? 1 v I s uQ I k a?? ,? 5 n F? II !v ?'? "" 'l L: c 1411 r. }N. - I 1 "°-?f•'u . I i( 1 r ? 1 ?? ? !f h? NI ? T ? TI ?f 1 I R w ? II t . ? 1 p A ?ti ? F N Y 4 !' S 1 r? s{. ` , } 1 I` 1 t ,; J ) I 1,j ?,JII? ~ I I ' a JA s 1 r Y + { a ". + yI+ 77- ?x r J n h? F? l ei ,ee vi - "-' ?••• COMPWNi NUMBER PRIVATE WAY DPIC OL GOTH N . AT COUNrv COUNRY NO Clrv NU { a „ 5 I:,.? (USE ] WOM O iH A i?Y I°° I R,II 1,1 v ? =R' c i cg 3erF MCP, ?r??URBA C TYOR I R N I ?N ?F ?IN /? TOWN -1ANO fSIREETORHIGH— iC145 'E VON v? AARFS ERS ?W s-, Por"r S, ON ., INIFgytCTING MIN: S1Rffi 09 Y?ADYE NON INTERSECTION PREfI% f0. / 1 M ?51 n r4 / BETWEEN STREET IT STREET ?? yc? ! DI TgNCf aOIRFI iF0 Rt EREN E. CROS STREET OR NEA REST MIIEPOS, ACCIDENT R .lfS DAGRAM W q N E ? MILEAGE TIFF ? OrrII O. -A COIL SIGN NVOlYEO SFVERNYI TOTALNO NO. KILLED -NO.INIURED?i_ R,I M 0 ?N RFEI OR ROM 044V ERFN4 Of"II-RCLE5 L I'1 TIREI IOl 'ON Trv ,;/,, INTER C. CACSSStR fiORROgD AMAGEO [a'NIY la'e[] ( / / -? ® , r0 NAME) FIHI E .."C' STRUCK INANE OE m_ SIR_ A ANONOOWNER'S EST. DAMAGE SPECUI O WE ?- E ' UNIT NO. I, . S pgrvER'S NAME: LAST fIR t Dl UNIT NO.2 ? VEHICLE ? PEDESTRIAN - ?' PEDALCYCLIST TIRIVER IF -- -r c C ' 1 : ST EI MIDDLE - LE _ .... rADDgE33 p O W, lark L. `Z IREVAL). al SIAIE ZIPCODF DNINO. D I,, SIT 11 _ 04SKN I? ki 9 2 STAY .77 79.27Z64L,` Ip R ? -7 4 318 3 i? 0? I ry /s= i ,3 V IV U N N E% al M ND. i DAY I - r B MCUPATION z N VV? Elvyy EIL PHONE NO. EYES GHT HEIGHT 11 V1EK I bloc E OCCUPATION FIRM NAMFS PHONE NO. - 1- WEIGHT HE IGHT ? CHECK (?J' * . HaEAS UDVAIOVtF 81ANOTHERAI ? CHECK (? 444444 EH CFFgSAN O pl Y CODES? A D 17 1 1 1 s, S , RM n4 F3 I lI FMR VFFOFANO1ryER CODES * 7 nu • °v'sieM"T 3 Nt<noN' b -1 ,c _ ]] , A- 0 NW" 0 VFA9 M M A .F DOpGF{NEV W IN RIF 0 ---a cm. ? ? °° S I FL IOA`RINOVA) STYIf I]OR CONV.) • - ? -7 Qo /uv?l?' Ce C Z ? YEAR ( {NEVI H E NpOfllO TNOVA I Y r c: r 1E c I V H. R KfNSEPN ytAtF TRAM{ER gATf NO st i H ]a . g F 1 I •uIxyy Ia.9 cA WH. COLOR [- VfNICIt OEMIfICAI ON NO. RIA1OWNFq 2-:1 rep 1 zi6i4-i 1 1 vFGIShR O UASI i VfHICIE 4N1 f1 II Nf rip "I'ST - MIDDLE HONE NO. c- j 2-Z6 O P, IS R DOWNER: L SI iIR3T -MIDDLE N NO, I] pp tiSd ONT°f4 A W n) 2 3a ?f OGIrk rL, 0/91/c4y//K - u, R OWNER -- N SI 4 AMI ADDRI35Cp INSURANCECO. ORAGINI E L AU,S. OAMAC,ED AREA AI -- IN U A OR AGENT R ]] E ' oNVINO sETOP ?°NC n°vH0°i EMU ? CHARGE OAVGro MEA ] 'm ' rG POITOU S 131. DAW,G[ ? AWAV ED REMAINED • ? A91VfN i'rDAMAGf 1 t0A a Lam.'.... WAY ?RINED fS I?,1 sI O Y °WT111 J] 0 [D C rOS 11 ? q U . AWAY DIAGRAM OF COLLISION: lu P lJ ar: S T r ,„ NFC(SG N Al RJ IN BY-PRN(YO:ITH DECRIP I ION OF COLLI SI ON MUSE SUPPLE ENTI.IETI NECESSMYI 0 IR[r I ... ._...._.._-.__ ]3 ' Vr , I eh ar n/_w,0 sE .wf_on__CU..E(Ct_L/jse S _. w?. \o ? r I . ?i rCD T I ?iY h / acct I I ? I ia.- S/ cecvwS__71u_.ntm?6,Zv.E I j .. I^' f q B e'tvt t . 7k, _ V k C 1.0:" ?rra crL? _ : trxt/L_71.e S ? _- ? P`Taw/tYrE:r.Jt"...li'c.tciL.1,11.?._vE3;.:a4. _'Y_• .1„ . __ - I I C - ?? - s oM^PICkIj C4wuw1 . lc ltl. ?_ Fr-c»r j*?? 5K ,j, I I f ° l ?B J / r V ¢r Ti•a. Faw _ ? a t I 7 .1 E _ ..__ ? I QtGTt?E rz rwE•, F„ /%•.. -rt. Fcc 7 Qw ' '2 F 1 4 1 ?. rRrr NAME, ADDRESS 5, INJURIES OF PERSONS INVOLVED + CODES 1 OCCUPANTS/ WITNESSES (USE SI»ntMENTAI SH AMIr IORADD1IN]NA NAMI N IT SI ..__. s[K AGl IAiU 2 31" _Y;i ,. r 3 I. 4 6 RTSrR. EHO AgO ., T, ,1on33 _. PI NAt oRe or .... _.. -- l •MI. • Nr 11 A ML. ? w ? ". ? Rx ? ImLo m w. . NATURE 01 ... ._._•._ 4tA.N OA MIL ° N I ° I MIL AME LL ??,L" C]C" m"(:) ' ?n° •rRwns _ .. _._. ufGr. ....._. r er ?AML. ? r:Iil ?i'irr1. ?:ix ?n;Hr X MrISNGATRrGOrr(lrf NAMIa BANE OMD firlppr AGENCY pN; EpISrA1Mt0 race YED DAIf a•fgRl Mr•OVW aY OMt f V"1 C ?? "tf ER4Y" ??? I r :. Ys ??yy I I S r r • L ,'q f r • . 1 ,I I i r > fF7 i ti I .F i ? 4? { r` y lti - i fb`a? y Y t n` ? r I fl. } F } 5 t ( I Y ? 4 '.A 4 a ?.,*?, p , ? ? I?m,? ' E t ? ?? 1,? t?' I?'l ?'r I T.? „?'? ?Y: ??? ,'„;?Ys'?'c"P7'('S`¢'153 J j ?? 'l5' ` ?q ALd ( n . 3 ? 1 ®TRAFFI CWAY .4 POLICETRAFFICCOLLIaLON REPORT 9aKf eoMIwNl Nlreafe PRIVATE WAY DA E r<a" ca Nrr ' " n ?$ / ?. a rwn m FAI . Ra. """ X ?s ]AOOAN.OUei u 3 A rf ?Q o 4 o cow+rr NO. / / Arl. u rNwA ?uee eu ON ®F c)w CIIV ORIOwN f5N0 5 MGNwAV 7 VltS O. Ow ?OF yA?socK ON fageLrklFRVAO AD gDUfFQA 3 93270 MI[RSfC11NG w11N'. 519[FI00 NDN IMtRSlCl10N CAP, T3A A Bf1WfFN -III. 5r9F[1 9MFl% 110. M11f 9051 4 I ISrAN f Dr ,CROSS 319ff1 MARF3I MAF Mnes 5 /Do Fflr o9 OAK A R D ACCIDENT MILEAGE COOS DI AM MIA eau'OT. VaveD vwxr. 0 NO. IN1 0 SNIf IAGf o N ''b sl C f wu?owoiws '?`:i:i; s %.eD IMFR Cl5 IN a al MF OR ROAD W RFfE4tNCk OIOSSSTR 09 e0AD [fi F 5 / 9RORRrv DAMAGE -Y Y O p? ? S IXFN Q VE I vlwCl! ': »t / G yTOQO I J aexcl srelA-%INAMt al oexcrslRUCA U+D awNfRS NUAFI Isr. DAMAC( s9ECw COD1NC USE S UNIT NO. I UNITNO.2 O VEHICLE 0 PEDE57RIAN 0 PEDALCYCLIST ITT.-T-1- -I 51 -.T ,1145NAMf' 11, TESL Mr DIF -? Go N244f5 /-I AG6Ie 4cE n? SIMFIADD4l5.5 1 1 £• fl i cH B ?R? FFI ADDRE55 111 CODE WgNF 910 Nco?o cl? wq 98129 g,-396'6 D R x rAlf 1190 DF F ?- NFRS UUNSFN . srAr F F A MD r N I ? Rl ENSE NO. Arf ?Mrf4Ate91x. SJ6?Q wA f /o i$ 99 V I _c UFA- F.-T-f e9NONf NO. GNI NfrGNI E -All- M NAMf 6 9NONf NO. fN5 wf GNt H GNr Z BuAT6c ZZ-Ag 6cN, NOSP W, /SS 5 ? R O CHECK (.l C, El CHECK CODES 1. 13 "r" S 1 / e CODES?' R? 1;; 51A p'"" " nR%s 'vow Jl? .j," D„ O A-A.MI O W' O bb R, ? N K ®;4 0 MN .NG O :rtl 0 bb9e. O KD ? ::'N KN. YIAR M%f p CAJ<V =I I,NOVAI 51Y0I]DR-CON. C.qR 1 D/t E IFA9 I E NEVI (DART -A) rlI R. v.l _ re Af AMa RAR NO AIF 5 H NN-m LICENSIPLATEW n No. Af cAG/C v $ 983 w4 C I A VtHKIf IDFMItICA1KN ND. L v r0F1IXNlr9r Ar NN O /z37/-IR ozS6 / RIGISRRFDOVmtR: USI F141t MIDpI( G o t? 2 t<=5 Pt! Ak.1 P M vNONI NO 3 966 W 1RR0 wN(9. 1A31 FI45r MIpIXf ENO ADO4tus owN9 N _, a wwR 51 u 1/ L`. FdTclJjjuGta Hiao?eclc E I NAw aADDnuF>rmw4ANa <D o9 AGFNr 'VOMc2 sAfTN IAAASACA AMA ? R w u AN C AMAG[D ?fA " V ]] 5 O ?oITCr lwoo .,N ISr. DANAG cNAeu A.5 41MNNID ® wW V ? cNAae( ;w?Y C] ?4fMA1N(D o µroNN u 151. UAMA- I . 1 IO?p n S OE7 ? rovnDer: ,(j IAAS CARA6F H o A, I, A'rnD s DIAGRA M OF COlLIS10N: I ' 1 KAR NO4IN 5H[iU MCl35A4r1 el'??OOw DESCRIPTION Of COLLISION: Iln(SWKIMENIAFSWITIFMCf-Y) e f /L) . L FIT Tv R/? TO /ND g iv is4.4ND I L"H_-.pv SHL:' A.ST CDN-rPOJ- D-Ae Ta ? /L,[ ON T-F ROAD-Ay. I AA ci E4 Rm, r NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED A CODES I - Z 3 a 5 6 OCCUPANTS /WITNESSES oalrlo?NU r?iAiu ii sl% Act IAI rtv. exa NAw uD AFxnss ° °' .FN4 er ?AM e [1 CA" 0 " O» O NT- ° NAME. No Z\ ADp,tsS FIE MovlD I4GM OAMe 0 OoD. O .Ni O I : ° A DDnss "1;i?"?O1 Inter OAMe 0 NI .0U. O n Hy +MSIKAI4gp9Kla>1NM1 e.AN. eADraW Af.FNCr KI DIS.AI 110 90 Y _ 1?ND Ev`en' ?oA.1` r 1 N DAIV OF%9081 OI OAI? 5 }Aiwa .- - -.. Ai S rn ox C ! LNsrw? ] s r it It f y14 ? r t I ? i I i. F w 4 1 / L L 4 ?R t Il,,t ? r 14,x. N Pl ] a E.S? 91 4n . •Im[`•••••• . _..... FRIG .RNNINWABFR DA,I pr CausO ? PRIVATE WAY v IX couNrr ` ?' a r Rnr ? v,r „w, oV,f wl f ,P 5nl r IUSf }.DDHOURI OJIM7Y NO. CIIYNO. iHNA y 7 1 ZSO/J /(v ?D AN URA l ?N Of LIN CItTOR TOWN f6 O, Sia[fTOR WGHWAY CIS - - -Es US ?w (wor I4QLD W, ON C? 2D, c3 9sz7o E2 G? 17 , n N RefC, NL VRfH. SiRlfI OaPoM NON,NrfNS[CDpJ PREFIA E MifEPOSI ?"} K BAY RD C FEvuzy RA 0.37 I, StxfFl S,Rtfi w DSlu,tf 60,4F?1 UFS F .CRO5551Rffr O4 NFAPfSi M,lE ro51 /ACCIDENT D IS e IF N 5 E w RNAP RAM MtA " ( EAGE Or JL • / 2 O O DE CIXII rvvIXVfD: Sf P,r -AI .RD ARef RRtSHE OR OFF REERENCE } •i,IULF ?H16RUN uN M NO IOI OPAlfO NO. NIURFO ( ? I" LpnFR Cle f055 5r ORPo AD 6 © (• O RO VEH,CUS / - O PNOHRIYDAAUGI ONIr 0V ?SFNCIF (yS R 4 llc S1RUCxF 111 GD ftr SIR I UCN NDOWNE45NAMEI sI DAMAGE SECUCODNG bf - 9 T D G5 ( UNIT NO.I UNIT NO.Y ?VEHICLE PEDESTRIAN 0FEDALCYCLIST RnrN"s N•MF: Frer M,Da D4N[4sNAinf D ? : IASr Roc3?ar IR C .A2K slxEFIADORFU latfr rwORESS 2 8 s 3 s. a+ti C,rY 11 IIPCODf o FNO. D IF, s1 1F A ZIPCOOf i P R DR"1-CFNSF NO . S,AIE O e H IN W. - w V IAIf SEA DAIf aeIR'N C(-A 20409 uq LUA N1 0i A (.GO g OCCUPATION MNAMF6PNONF NO t'IS T 1 E OCCUPATION {IRM NAMf6-ENO [tt5 TON, NIOHI Z X X &0X60 So? R w O CHECK (.? ^E A4$e„S .AO pmrn"I ?CHECK (?) vENCif ASAN FASNOrfFdAFFO"A°,r{PM S AN CODES ?+ w yr J r °" Z 6 s",°"1Or r CODES ? * 9 n . is 5 u E s"On ?' 2 N e tr ?r T 3 . ,.N ? ? zR.II ? r K ; ? r° ? M N t o C?L%'. o'.", ? ° IH rtAN AVMFIDDDLF CHFV I FI DA 'I . E 1 If IRD CONYI Y N ( fV.l AtlOFIIDARI"NOVAI T I R v. 10 l 75 110/JDq c8?>r m/'l? E 11 7 OR N PU trv S H F MltR 0.Arf NO S1AI[ H vEH CaDR A A - _ I A 653 5 Iae,DEN,r unoN NO vFN of DFNnN An NN 0 C BSa40rt00a L 238 ITH HGISnxIDOWN[R IAS1 FIRST MIDgI zETt? n1DLlL.(? H,ON1 NO O X RcnnaFOOw I V,51 FIRST .1-1 ENO. N W ADDaeuaowNER OX 83 u14. W?1 . 837 E A OWNER 31 w?Me anwefssa ww4uxee o4 AGErvl 14 R , U AN J} DAMAGFDAR[A r ? s I ffll[" ?L _,. 5 ???? EST. MMACA cF, oa , FIN 11-D ? CHAROI NI !N NLNnr°iN tSf ' G DAASAC ?D •RU = \\V?11 D1 • T $T IO w/D ^ ^ E] µY RfMAIN[D TowtD . DANA F ' G''orT?s O AL. Aw r ® nr. ptJ?-GTY TLIhJWCs CJ 5 ? I GRAM OF COLLISION: Iu u NN •11 QV'N N pro t -jj 1 ? ?r,?T1,'EE?1 lrr[tT I WUSS•IIYI T ' DESCRIPTIONOF COLLISION: IUS[SUPPUMINIAFSwern NI We- so. 6D.-m wE.,D r.Asr WF.JJ T- oF;' THE ROAD ALIIDHOL. LbOS rEn. [?j ' Yl w f DMOWT our0F HC'R4RQ WrO A 2E DRAWAB81 l?7iStL(!*E coNt0i?UULTD cAoi> x? sw ue?n AU51 a l X , ARgLa?• y,: _ , . .1 Ws RlGUrSIDE commr-7D RoSrc oo Tke SFioLUOtR ' TRIUER, iUr GAVEmaw c+,1$zr kkxaF t SOT" 6LgPDS AIJD A' ? ?? 20' °S IFE7J e&AKtr_V ALCA* LCAA)WG -4t%'6 p 6LooD SMM ALE)PGMG PAUGMEOT. '[RAPS. Tb 3'EFF' CZWL UN- Cekx4Ous RAP-rPaErL 7PA1.Js, -CD HAR801LULEiW" FTMAL PM I y w ? NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES 1 - Z J 4 5 6 OCCUPANTS /WITNESSES IiEAt wa,an:irM+ui ' lsi uA Acr ums '„;'" R ;' Rslx, fxcT SOSEPH D'Ah11V 'TR 5.48!3 •Drni NAME gatoR NAluat or ._? rrR er AM e OE".1A' p ;"' . OC+„ ? {?IUNV o NO.. rwsa r,UI or V N MalorxoM pAMe ?Y°?Rr OrM . 0. S ? 0 "' ' F - •c<rl+v VI Ex•r,. s arFA? KnF,c. rF ,i, :?s° srrw er ? AMe ? i:: r O'r'iwr. O H: ?': ? OJ A X Uw,.. ?„ v.ul D>(•I HID D Dena nlwl Arwovlper IVY }Fm Hes D•n ?? R A i. t; G w i J _,1 ' POP., 'm1 ?nw _ POLICE TRAFFIC COLLISION REPORT I2q TRAFFICWAY IGICFCOMp?IANI NUMB[R PRIVATE WAY ] DA EOiCpI N DAV C ITS Orv NME COUNTY IUSf ].uO NOUR I t COVNIYNO. CIfYM. NWA F J wa, r ? ?. S°t >va «N, R., IR ar ,. /30? FF?RSDr/ 7 DR ftfF( ?G ? / c . c1YOR1oNN Af1N-11RI-RNG-AY RM 45 -as La" ?1 ? N '1?Mnfs ?L ?w„?OF C D ,Hi^aAw ON R oo Ivd I RWIF ON IHlIC 3 9szoo Sf I , Nt[R YCIING Vn IN 51RIFI Ap rv pNINtFRSFC110N N PREFIX FO. MILE P0 51 ? Q EFrvIFfN SIR[fl ? J y v, y/ [ / 015rAN'f 60 Int .LRO55$IRffIOR NEAP[51 MRE POI ACCIDENT MILEAGE rtF M's 5 F t w OF CODE RAMP DIAGRAM OAIA 'O"slo" IrvvavID. sfvfgnr. H T! RUN O FITTED NO NIURFD ? sYIArf 11 NO IOIAt NO. -?- Mlusr" rungttRln I %U Cl$ IN fR CIIH iREF10RROAD09 R[(fgfNLF 0105551 PEETOR ROM '] O<VfHIClCSpNOHg1Y0AMAGf ONIY ?pEE ?SFaCIF / 6s3E3 OO ?1 . OD]ECIsIR_INAMf OF ODI[D 51gUC[ANDOV]NfRSNAMf1 fs10ANMf SPf[W CODING IISE /N? RNfCT/ON {. WAL, 'bNr'' L SAGiY-•. f %o O UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 'y r }? RIVER'S "AMf: -1 IRst .1- RNtR'--l -1 NR Mr f } 6 GY7,N GAS t'DN Tr, L /'s! / C. 51R tE1 ADOR[55 51 Rftt MDRE O °/ ,28°1 i; .N?fv C+4T/-1 / /-JVN7` (?d FpQ Olr stAlf lIP CODE PrtpNf NO. ?D„ A D Irr srAft Ipc N NF 76•Tzrlniro Dirt'`. 92?.AJ -i??o ' R {/,ecuo cl? 5„]N, y8339 '•?n7 / 6 R S "Cf" NO. A% o MY STATE oqc DA31r,Rso I V R l FN NO 37tor AIF vor DAI[O RIRIH P 30 ?? y OCCUPAU- ONE NO. MNAMf61-1 NO ?CHECKo_ Aol,R HKYN[flol:IEaM COES3 14 CODE<a MR P ? u. " ? 1"lo'nly ll1DART"ovAl Strlt l]DRCONV ? ---CI ? ?;,,tl ? ro:;l. ? El :W- N AX-- 73 I Y° ' ` E I EVI MOOFl10AR1?NOVA1 I sun stAlf H NN.caoR AE"o. At W x?yd' OR v Lo'? NNICU IaMRIUIaH NO. vENInEIOENnII tf0 N t. 3 n- 3 2 CS c' 3 9 2 7 6 1 PtGlsngfDOVmIR: WI HPSI MIpOI! PHONE NO S4,yc= AtJ[5 ? ?^ `. O W Rt I I 1-- -1 FIRsI MIDIXE f E+ I'r G e' 8f 6S0 I & A ]I Morass a omvu N A R F JF E NON? = 14 K nAM[XADDREssor rNwRANCt LD oRAOnI ' R .I IT7I6S4FSS3F iFSL77F,9 V;lnel'Alr. VS ]] DAMAGI ARIA 'MARL( H CrIAYG( gA='fDM[A y DNAAGI 10 .11- ?RIM,NNIU EoioT14 FSL lowlo ?R[MNNID 151rDIAMAGI 'YRS. l5 ?DR '" I lo rt ] t -- - oo f l e AY v D 7 ? f lvo NC' ? D ? DIAGRAMOF LIST N: SH t1?..nerll 1CAN (O I DUa Aa. SR Ah' Y DESCRIPTI Y.{NA ON OF COLLISION: IUS[SUP%IMfN1A1 sMtNF M<IS5ARY1 '" N• / IN 4S O CA IN aovN? CS/f TC 5 ?' -c- {- . O y , a R • No 7. E.A q 5 p RA= PARx / Ns. T c T v R7Y x Pti _ «'FT F'4on? s.oN RNoorpR.T'o .C'HST o n C o . Rc AJ J/ vFN• No 7, A?/r-j pt? tnco T o - - c d 7-. r [o ? ,?• PAR 1c/ N a A R [. A 4r qNp T[.RN?4 RiGr?I' r[{oM Trl•c ttf;1 - 'TV RN LA NE. t]6rap NO .11 W42% F'.Atrn -r Ljff4vc-r Ir = l?u4A 7'o Arc[CI A CALL:ASioN.r NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES I - Z 7 4 5 6 OCCUPANTS/ WITNESSES Ir°a uwua"uwHArS.uµ ii seX AG r ulu „„ , N siR NEO ; " A ? ANNL- /.4vMAN iq %+ns ?" ?I eJ! w ( ,t. "AllRI v AM e. ?£3RI ? rrr . ?C ?Caw N AMI NO [RrRFiS AIUYl01 v MOV1D rgpN ?AMR ?rtF[I ?wr a ? vwt ? Iio p AMI NU A lXwl55 IN Ih?? S fIMRY ?AMe ?< .aAr ?<'Nnr ?71T ?TA t vrvl]1K,AIrNprClR Yh[.vy{PANt ."? X .? 1 AADOF ?v w'?IMV .cam p 3'c ,I rNr ,(I OrSPf,ICMD i O 6 /,f %?«tlNRi ? K[ARy!ND n 'ruo NC DAII pRIPOPI '7'/ L ?? AIPRONDIr DAII I urn ?1, ; ??NI 17 Y JJ I,g p t, 5 8 ] ] l ? ?{ Jf I { a fi ,rat ? H J,' L'ns r1n l ?.Wr:? u. ` ? "'74 41 w r { .' E,ry I"IA g,? i s'? ,T?CVh ? ? s? r?l s y?'I ? I? 1 7! lar1J ? 'r?r ? 41?rt#MN h -, i [ I , , l s ? y r if ? 4 , ,:+J at ? t ? ? ??°? T; 1 - f y ? 5 I i{1? . I Flr``? it t ,'I f t1i sir. Y fr t^ A d tAVr ?+ 3a? 44 POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY nu. WLCf COM%AINI NMMOEY E] PRIVATE WAY Av OI C ` ON TIME C.-TY ww urt 0 r ul ITT >+ru HOUaI p,ilOf COIL qn " D ',T Fr e o t? -N" NO/. CITY NO. DuR. Y° // A, (/ IT TE OR SIRffi O OR tOWN LND ps pw ?? -..l---.--- P er RD CIS R U .3 9Sa70 Q I , ES ON t A&L- s PREfIK F MIIF WSi ?CR R CI nG VA,N. Sr E-IT WAD NONINiFRSfCDON EE,WEEN SIRtE, ° S,R(EI ACCIDENT , RAMP DIAGRAM MLA CV051STREEIOR NFARf51M if YOSr MRffLNFNCf ps cEa NI I I IN 1 ! MILEAGE [:3 Of lFf 1 ? n CODE "I'll W .RD rvlf RSfLiINGSRfftOR WAD OR R[iFREe{E Ix) S CtAUSgnI ER ivy HlD? NO. NITAT D ?sUA-E DNI,°RUN I.-rvO ? RSUL1Ip 05'O`Clf O VEN OF NO KI S © ?YWYlR,v DAMAGE OrvIr INIfIT Cls CROSS5IRIEIORWAD b??5,S7o LODIET-E OOIFCI STNUCK INAMEO10ITIE S1RUCKANDOWNERSNAMEI ESI.DAMAGE SPECLLL 5 1 UNIT NO.4 D9 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST LI UNIT NU. MIDDLE .M.SNAMf. IAS1 I D lE Q pnNlRS NAME My NNSr ?kpvON3SBP, 1 N SIRlFI ADDRESS S,Rf[, ADDRESS O I Z O 't xIVCOIX rr 'dl ? S D R Aif xl C YjAr AT pp, NO. _ 2 : vIVIRSIC Imp T STATE E, A f f .0 DArxl vN V _ MR'S UCFNS n0 I. 1 cla r:0DAlfw BrR,Y v e. I L R. S EY[5 N41GHI rf IGH1 NO ?? E Ev[5 WF GHI IlIGHI OCCUVAiI N MNAME6 rNOrvE NO. . aMFA%gNF 2- CHECK (? o AN 1 E ? CHECK (?) c.c 0 vr rw xR 5 ' CODFS? f 1A 6 win 5 -1 1 CODES' ).'::' Z IN L`w,, D w ' v{?.' ,. ?,wbvl,xO IHf D [1 : Eu- Cl LT UNiv l M w79'" p < u n,EO l YL" I. ? 64 31 O Moue IDARn.I". .IiDU.. c I _ I . Ix VEH. AR AMKf ID oo"L11f V.1 MI%,tLIpPNI.NOVAI Y' 5 E T B DR - ??zt%A z to I O 7AIE BATTIK%„I nD. STATE I 'I n VER A AIN n. OLpt L-PIAtt N I _ E IIXNxf A, N RE. vtNlLIfIMNI IICA,NON NO I L YE I 583 HTZRR&5C 's(0 z l 82 15 2 F ISIFNfU OWNEN t N0. AST 1-1 R O MIDIXI G SM1VIDOWNlR V6i NRSI Rl -111 NO O (e. S m F as A Pnv AS W - A 5 Ev 2 AWRI55d OWNER N a AMIaADORluormweANCtco wAGlN1_ • _. . • E R RdSOL:LAr?; u )x K L'C O lJ . S ?? °oY AND JAM.wIDIARI I) -_ Ai -IDARLA .1-- M _ rvflnr„I CHAVO ?- / / v I rv pAA5AE. AI l5111 P, N1U AYG[ N'-? ol?iv o,NrAN }l CH /.,A 151. DAMAOI 4Y ?R[MAINID '1L I1Ge0fleM 5 ' IlJ SWAY S A X9tM 1L J WVD Oe0n0? L o ' s ?AWnI? DY ?1 ? ^W Y... S xv H yA OJ IN M?n DESCRIPTIONOFCFUSION: 116ESUP%IMIN,Al SHIiIn N-,-) 5 Y b DIAGRAM OF COLLISION: SIRlILL N,C YI ® VEN, #R WAS W. 8ND. ON FLAGC.ER RD.lA GUALTtNG` ON SO • THE ROAowA`1 "? •Qd ;9 l , LgMpp&D YJU TRAP 6 T TO MARS. A GPf• 7URN Oj?TO JCHWARTZ VEN• I (uAS ALSO /w » RD. CIE AND 0_,D NoT Harz ,D BND, ON GLER JL( LR?L G -- /? I W4. 4*-2 SMPPep- H• 4( &k-azbE.o 11 ?/EN R . EAR of s -r. 8UORE. J7TQr-ktEvb THE tr- I SrAT*M HE SAW " / F101Z , 4. Z ORrwkA of PATE F N/c 7WrC B . y LZ THE EFT. TURN JJ:CAji9L NAME, ADDRESS 8 INJURIES OF PERSONS IUSI SLW%IMINIAI SH INVOLVED CODES 1 - 2 9 4 5 6 fII GE TAN"N Y'•1 YISIR rAc, w ADIAPGrw NAri OCCUPANTS /WITNESSES 2 SIK A SI vONSHA PGK ;?D ?E A? 2 H rr :NIOF N' AwfpraoM ?AMe ??MxL ?..I , Cl v%Ix O :D INE. o p NSS MI HG N,uoJa I er ?AMx ?:: R' O<".»11. ON OC. N All ,KA15 - -' 4YMU ,uxaw AGU.:T QKI m;P cr°D IARBnvlD D,nrnNIWRI ArrWVlDer I "? T 1820 lB4 X p tee t ? hd 4 P '? i yy ?sS L?A?'^?R sE! n 4 PC { 4 N I ?y POLICE TRAFFIC COLLISION REPORT IQ TRAFFICWAY Pa¢E Camw.um NUMBER I PRIVATE WAY ,21 ummlcaus N Dq onn oN Ui , D" couww NO arv NO. rNwq lusE E F .uuRl >iE 9sa °""tl ?? Rql p.; ?N Ot Dd N COIV OR TOWN 1 INI IXFFi OR wGwwgv s ?; ?w o. C.1I Mx4r -E ON N !-,yJ DK CIZ12 f ICICI; ROUiF 0451vfE _ 11 ??O ' N ? Ni w nc w m slNfnuR x n Enx E MRf POS Ig ? CGEYIAE.ry Rd -EEN 1-1 It -III i F NEf xD REMI. CUOSa;lNttt OR NE^uEVl m:l PUx. ww ? III ? ? OF ACCIDENT MILEAGE CODE R DgOR•M IY,Iq ..; NvaVFD rd RUN ? 10111 NO I?...) NO NluvEp_ SI plF lgGf ? ;wl „v"nnn'ix N .RD NiER Ct; NFR CI.NG;1RFfIOR ROg009 R[iFRfNCf CROSB EMD? 3R] q p [ EY ViN fw; L[J. I Iv DgM•Gl ON.v ? RF ??Z 1S Z OBxCi sleuCxINAMI [IOtlI[Ci;IVUGx NNp OWNER; NNAFI .tit pgMAO[ E SwG•ICODING U;t Is UNIT NO. I DN ER'; N UNIT NO.2 VEHICLE O PEDESTRIAN ? PEDALCYCLIST 5 , gMr N;t wN;i miUDEF Go Jld -c1.? ONwt R';i7_ :p AD N B1 qr R , SIR E EI gDDRf;S tlI ADDRESS 2 / ? n ° ZS? // vAAl (2.8 .ib a1J o qte nneoa woNENO BRnlnnon A 9 2 D R u I slgx RNONF C°?LME4ty l?fF ?/Q)3ZS 73Z-'1635- t ;NCFNY NO SE S 85- ;IAIf ;fx CJA M ^^E'I^BR1/? I wF '; EICFN NO PAD N(?'R4Z8Y13 IgIF WA SF% H DAtfaBIRIw gj Z3 53 F occu-'mNgwrq PwoNE NO Ew; vx.cwl wtawr E OccueglloN MNMnFa PRDNE NO fvf; .cwt r<ICwr 2 -'cr'0w Zc3o 6'2° R . ?CHECK(?) ^ NvN vN, ne • % rFE r NN 1rv ?CHECK(?) Egs:Nfmiovfragwol?ivq! l a I CODES P E ,,,^ ;, 5 I e "" ""-- CODES I? ' 3 6 Z N w ^S 5TAi4o ".-g RZ7- 0.-..'I,I fA4p M. tIpODG fvI MOpFI DgNI NOVg f }pR CONV am N V " 0 ' V Ford ?7 I I . .I Yiusrgn 2Dr, E w. vfAR I pGf. E I 8o Clnau A%%%FE O V I] , CA?tAro zDr 'S Y ' vw N sl P.•x NO slwrt t -11 NO S1AIE H Vfw. cao, . q nql ? f ?d YAN 86o LEA I BI K u 5-w 6io wA. v(wCEE iIXN1w A ON NO o T L 33 2.2z L vW211 ,OFNiRI A. N I P 87 L A L 5188 o 0 eEU,srtwpowNER vs. ncsl M?DDU o,ld olln ? wank NO. O Rt nxxlpowNER: !•sI n%sI mloaE ?Idr? 6 t inclA No. ' .3 , •Dpwssa O`MxR w /43r 732- q s EowNER p. 2 ?E 1?.0 . a Z S L I?RI'w uv wk N E 1 bl l 35AVfA VA II 4;met6Lj M WA ' NgmEaqunefssa.NSUR•N<fco ErrquNl , 5 NSZT . qN t2ir6y NoN6 R 1 lorttr Si-?A . P7, I t a+tst.A, t,14 Y pNMM.Ip N,u ,U";'° ' r 3So •? + ' - cat r ix • i ? gMgGf FA J G [ :'.;Y.oME cwgRU w - ij--a. otlprta.: O ' ' w o ? ,"x7. .x, agwot , mew vN ? es??ogmgce REMNNEo ? ' 9 i[.(OO _ 'n ? AE + nx w lOwto ?-11 ?gwgr tl. sl$OD-% - u ntM 1,%. c w DIAGRAMOfCOIUSION.5 E s, VOW' SW [I Ir NIClSSMr1 'N XV?AV j DESCRIPTION OF COLLISION: Lust sEWwEMFNiN Swetrn ru<es;gRrl 1 - ? I $ © UEl1 d L L){ ,T -l ftA oj N ?O C¢ I Z AC C Lf, „t".,.t 1 0 T'M V S+tt4.tY+{.+.n , wl,to 'L 1. v dl . A JAI4 ,ort.E h QECIE. ' -' Tvw s to (tAI Z. brc. ?E ?l Az UGLZ?iB. - D2 91 ST?th lh,d noT Ss.ti UE?,'?2, D ? ? b LD y, Jam- ?•E+J, l 2 L AM1Att? . W1. Q rQ.L SOP NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES 1 - 2 7 4 5 6 OCCUPANTS/ WITNESSES $I. A.1 urlr ";?" , " ; RESIR "c' 14 -1 (,tadA £ldr:dgE NO -?3Z-19/63r 2 I 1 1 _ I It 6%.4.nt_ U.t LL P.i G- L, irL.-t wk r uRe or °A. . ?"6"' ° " . ?? ?.:. y uuR - u%u n wx.1 PNUV1De. DuI -" '8i;i... '2 2 X ?Z ?, ,mac tl'7w sE?o ra ?r ti$ i? Pi I 'N I NoN H"E: o`? .T N NO No. NO Cixa ?N ?E ?IN w ?-0o, a ?,"° _ ?L4! paa ax t TLaa iff iff: N A. NNTEATN ? -' 0/SD ' E1.11, F1% [xaaiD131 11 NOT .1 0 o PWLPaAa AaalNaMLEPa! WE a,HaaL. 11 TaP aENPI,xaLANaM x aAA NOAM T A % O O -ED co I2 aN WV:o a. -OXI f si F ooue uaiEN!+aeuNO TgnNaPaNT ? eA o atNFN I ?wE osE eowo°.Ew?a e a ° N o Elo?A3=aiREE,oAHOA O JECT STRUCK ., .aaarv, u ull OWNER Of OpJE T NAMEA DAODflE55 ee eo in ?_ 9 ! _T-1L1???- i+ g xa.Alxoa,ECr PEa•E L,. DRIVEflS " MOflc THAN , F ... MIOOLE ?i„c s _ . . IRST NAME _ -. _ WOE ovEO D(iIVER'S LAST NAME NAME MIDDLE !' IF [FIflST 11 S I 9TPfET ADDRESS TE NO. AND BOX 0. PERSONS TN Two Y TF I 'Rf WERE STREET AUG.— O TE NO. ANO pOX NO. i•{ NSEPARAI SELLSE1. ( t P CODE L EA / V CiY ! ! LI ORI fly CC PATI PFPOpiN CIT STATE; ZIP ODE DflIV OGCUPAJJON f y' J a r'F 9 `w A t 11 OnIVERS LICENSE NO. T E SX ATEO.' BIgTH AG v IVER9 ILE?SEN <TA_E SE% DATE OF DBIRTH AGE Q ` ' V9CL AN ( EV. OOOOE) M pEL OVA•OAR 1 B 0 14 7 (2D .I E ICLE YR. •E, D EI M DE'L IZN VA• R BO 51YL (2.DR.) 'L LICE 5EPLATENO. ST TE _ _TRAILE4 Tf, Nf).,- STATE,-• E $ PLATE NO. ST E TR ILER PLATE NO. SATE v VEHICLE IDENTIFICATION NO. , VENT LE IDENTIFICATION NO. _ REGISTERS RRAST•FIP •MI DLE E) ORIVERS LICENSE NO. REGISTERED OWN ER ILAS -FI 5T-MIDDLE NAME) ORWIFFS LICENSE NO. ^`f?'S ADDRESS, _. MST SET. C Y NO STAT ??UU(( ' OF pIRT OWNEflS A ORES- (STP T, CITY ANO STATER GATE OF BIRTH uD D"v rq PAgTB OF VEHICLE DAMAGE Pfw tco oE?? PARTS OF VEHICLE O .AGED IiiuP ?l°niTtYe?. p, ... ,. . ?._-. 5 A LIABILITY INSURANCE IN ORMATION- HICLE NO. 1 ' - WAS THERE AUTOMOBILE LIABILITY INS NCE ?v-?/? COVERAGE IN EFFECT FOR THIS ACCIOE ON YOUR CAR ? YES I)SI No E5 OF LIABILITY INSURANCE POLICY MOLDER ///// ;.INAME OF, LIABILITY INSURANCE COMPANY .... .TE NAME ANO ADDRESS OF LIAR LIT IN 1ST INJURY NAM t?G?F 2NDINJURY I ! PATE PEPOpT IOP ADOITIONA, xluq ESl .. .... ............. TOTAL ADDRESS NATURE AND I INJUR E NAME Ir Pa. "sEx .w°EK M F AODPESS III??? NATURE AND M F ? ? EXTENT OF INJURIES ' I I INJURIES E ANJURIES GREG Y UDO DOCTORS %MINATIGN DY CTOgi O ADO ? ? D D INJUR E5 PEOU RE N MEORS AME EXAMINATION BY A DOCTOR2 b ^ TATU$,QE INJURED -,MARIE FIRST ONE TMA7 APPLIES TAI v4 Off INJURED • , ,. ? _ ?T.)gq,I F,FV O E MR. NIL - -!+_TIIATAPPLIES xox a ? ... Ps.aL?xo s.x?rvo = o°e ?" o IN V n( ro i ' i -" °" f ? rASU NO'. s H. NO ....___.. " jY NOMj N . N x PlAauxa . s o s. A Nt ? N aPY N, xr PASS[rvc[x NILLEO sfv[nil v NO OOIH[p wnn[ ? S? 111, , wan rvEtcl HOPI F COUIx. xi . __.. ?P[OF.R Ax OoI.ANFrc ?.ININ .vNT1 P, ? S MOTORCYCLE SAFETY: ? HELMET USED ? HELME T NOT USED MOTORCYCLE S ? AFETY: HELMET USED ? HELMET NOT USED SHOW NORTH BY ARROW REPELS H n"<rx,nv ne, n,..,...............-_ YmAT,IWnxrONMMa 0 O ,\ Y I i VEHICLES POSITIONS BEFORE COLLISION VEHICLE N 9 E W ON STREET OR HIGHWAY rLa[[IAL» a - 00 0LY.xx ?P. a ?roI« ?ip`cF ?"a°rioN al 1. ? ? ? El °..A„ FROM TO .yu rcuc5l nlAYUPED AL CYCLIST WAS USING: IQuo[wu. I?wuvw.v ?wwlnl _.,. PEDESTRIAWPEDA L CYCLIST CLOTHING COLOR: , ?HMN, _?????t ROAD SURFACE. fl LIGHT CONDITIONS ? TPAff10 CONTROL x0\ , j.A!i.. LIGHT i ? W!" [I I `?aMUS ?, ? 2 1M IIOP SIGN 1 (w''r ? 2 ?WtT 2 ?SLO ET ?' --"LL p ? ? S ? %LOW ? I ?ICt WING I ? FOO II D , ?DIOnNJ OH ! ? GAP. I -T L-11 01, ? 2 YI[L0610N ? ? A ? RUlnIN6 Pf 0 µ{ "' ? L ? 1 ?H FGIYI J I ?•INIfTOlgnrS OT ? [ ? ILASnINO AM.IP I 1; VFCIIY I ? IC RY ? t ? XR fIONA, /,? ?> R AY. ?1 ;,•`? , P TtN `f ?,w O ROA Ar 6UgFACa TrPE '??'I't OlOl?l El I ? Orr C[wlLAauAN ? ! ? mnlP !P[cuY qtr /,14`77 5 ?711 -MI.. L11 ?'?p?'T-. V L NO INAl11C vH 1' KA !H[ Awx1, O OHf WAY ,?? %I 2 TWO WAY P 1 ? 2 ? ' GOING STRAIGHT AHEAD OVERTAXING ANDP 55ING ? 2 ? ROAD DLf ? 2 ? MAt NO N GHT TGIIN ? E ?IIWPNA.PIf ? 4 MAKING LEFT TURN ? e ? ALLIY T O ? ! ? MAXMGU•TUnN W INAY• ? " ? LEFT TTURN ? I ? SLOWING ? 2 ? DRIVEWAY ? 1'?" STOPPED FOR TRAFFIC 110 D WARBLE ON ? t ? OIIOt10P AT SIGNAL 22 DIVIDED ? t C3 STOPP[DINROADWAY Il J lA ?' x dwf t pp s. .---.111 rwa l9a0 iw:. :o 'Lr Nsn n?aE [J?f couPIT ryo. :; craw ?r eu[ r. RI ? °f N C? OwN EtN0 /b URA[ 0 ? . Ptfr09 niGnw.KV ) C13 aWrt a5R Ivry MR<S 0 5 ? ?Or /?/ oN 50?J7? 7Ty - ? IN[!9X<IING Vnr rvtET OR PoAD wrylNit9XC10N vvt % f MIIEPO S -EN ?? sT9Elr{ Sr9t[r / DISr.NC!{DI a FvN ,[00353r9tf1 RNt.v[SrM if M q[S 3 F ACCIDENE DA 9AM pAlA I![r w p MILEAGE 71 p ; CODE COll151ONINVIXVP. f l, ""I NO wKI[Up??w.INlUEFO ?SVI ? l1AGl N116 RUN rn D IN X rI SPE agOAD09 REf[9fNCf ]3 _I OV[nlClls ? pPoRarYDM,AOE ONfY E SIIXEN IN MtP CLS CRO535]R[R09 IM ?q ? [SUliFO Vfnl[IE 6 ""CTSr9UCKINAMEOP DOI[Cr1rRUCRANpOVMFR'SNAVEI O 2 .__.. ES AMAOf Sp[CUI COD w1AE s ' UNIT NO. i 3 p9wF93NAMF'. IAfr MIO R r / / UNIT NO.Z EHICLE ' ? PEDESTRIAN ? PEDAICVCIIST 09 fP'S NAMf: Sr -3- -_ ^ J, r E ?"? slREer ADDatss C? '' 13 C Aq ? Ov/$ / 333 z> 19„i Iv fl Ap09E33 3e rr _ srA[E ["Co. ew. D PION a aJ tom! 983 J ? R ; c .. DRN . Pc y A, .j021.? t V Ir C N?iO r 3lOS ? Al. ? Mo % ? .. e aN [ ?? [s W,I HKnI E ?? F1L Ca..rrp?f/cA. po ` i R Q'C _ , l,JA l «CVVAIION NY O KS S%riDG.rEi 1 ? ? SG IONI ON ? t E v[NIn .s: ryrMpir'r A.M,orRIK l iy .?is t? / ? CHECK (?) ri l o - 2 CODES ?* s n . s D I p wnlrc•cL e a n E?w. uRl eNKle.s Ary EM ore[aA rn[a CODES ? * p ? u { ? s e%aKIN a s, -. in±:"' rrn ' ss S o H YID pry °IOOaGE.Cr'i[Y.I u1K' ° ` I.1- 0 y9?'c11 °ONV ? u odE N y Ir.rKwo..oM ? wNA,N[I ? . .^N ?CI ? Cb:rr ? •'wC0 ! I]D . Gz ?_? STAIt rqA Eq AArfw SIAtt I'I I .I of n. IX R EF15F7RTEq V Moofl[DAR . Af [ o D ? , lIv P A w? `- IaN1DKwt -- gN C vFnKlf ?aN11 I A I N N tearta[oowrxo- uar nasr r . Dae pwNew Is o eq: [ASl sr >i9ncW S N Aooalssa mYw. A uA5 T G .??sS 5?9?+1F? N SA?? NAll.DalS3 C. rNw.AN[ECO WAOWI E N ' lc A? ?Iy L- /.J S - / waste R A - ?.? sF?b .... °? ]DAMAGE Anu NN. » ?) ' N ' Cn•gOt .?. CnA1pf ? Cq'nOraiN ]AM/4!, KfA. r , 13r.'DAM? ! or pwMCe IU?OrIOii r vl E.y ?9lMMNlp p flop N 9 w,AY ?gFMAIN[D t 10 .0IlDli 0 MOPED- AIAY p v v DIAGRAMOFCOLLISION: nle.. N.l NDK nNwrn HEc[ p evA.1- DESCRIPTION OF COLLISION: IusE3vruMaN usne[Ilr rtcfssARr[ 6o?r 7 :. AFwG -. _? ?// »'/ tii1'3- ..lo2Ti>?..L?iu[?..E'D?:.¢7???jJ _ Z I B/1,.??s - vG/?. "i ,sue aaoa To .o -- I ?aP ys;,E> L.. ?- I I I I I i _ _. "TTo ?sll'..??c , •".2 ?,? /?dah/.Ic ? ? ? ?-.7 I r r- i. -17 I - NAME. ADDES 8 INJURIES OF PER50NS INVOLVED t CODES L OCCUPANTS/WITNESSES ,l's'd su.nll r 1" ApprUONµNAMI ll Z w S 6 .DO.I,?AC T r.?? _ .? aLa SI vo[D 3?.3 ?/ X% AGE IAIU 3 . D MSrq /ACT iii. .s . ]o .Days S. y'rAY_ ....? ? pNpruq a8'S-.R/Yd . . Nwl . ?O?CC MOVID I.OM ,wG wl- -. N I l,r •r..e prIK1.1NAV111.N. ?( ,?s.??yZ / _ a.0rw or yp 8f .OIryC• ?s O r0. y"'?r 9? P3L,D1.. .SC[/?.pnc.5 Weer ?St3i Ft.+clo /].00 n.3D ?•w o.rl [ a' 88 H. ?w°..,s. Awgvto o.rl r L !??e? 3' ate" h'p ' "K 1-N, . . ;?.: a.,.A;» l,s»e?r, L4$,. fin:., ..-..w_ _,,'?`:,,.. '?l .. ?..:. .. .. ,. fin x,.:s..T w:.1,_'.a?f??w5•?•>," r t) q ?? 9 it POLICE TRAFFIC COLLISION REPORT JaTRAFFIC'WAY fcoMVU?NrNUwef4 PRIVATE WAY - pA _' ?$ fV+. ISM ;ut COVNIY i lu l.oo »x1;41 cfwNrr w. onNO. _ I ? ? INl /?O ?iC`E.QSo..J ?{ we.AiN ?N ?!? rO410wN f{NOO Sr4fft0R MCyW iO1 Cl5 UR•t M1E50 3 ?W ?O OIKa4 / 9W1FO451HE O CiON Ni[RS[CilNG rN 3t4(Ft OV vOAp NO N1FR3[Cr?ON y "r ?? vvtNx f0., Milf v05r r? F,. DS ANCf {Di4 pry{ M .CF0551rq (rfN 5 F NIA (SIMILE 5 SI4t[r{ 'MET Ml'S R R w ACCIDENT Du 4AM I _ pAiq F!t n OF MILEAGE COU Sx1N NVIXVED LvE9 rY. LODE r}} TOTAL NO NO KllfO,?Np. NIUREC?' ?SV ltAOt ?Nr64UN -D ' OF VLN C[ES m SNZ- ?pFOVf4tY DAMAGEONIY TING [F ?Z Oei b4 NAOOR 4[ifvf F !! ?vFSUl1l0 ?llaf" NI[R C13 CROSSE -n TO440 10.. ECT5I-K(NAMEOFOp{[C151WCK Hap OWNfvSNAMEI "Cl[ "M • /mil{ LSr DAMAGE S4ECUl COOING IAE `E- t f To 5 N[RS NNAE: UNIT NO. - lµr UNIT NO. 2 9 ?- )E.4.) '' L l fixsr M?E D4n11 SN.M1: ?SVEHICEE ? PEDESTRIAN ? PEDALCYCEIST 51RtE1 v G? -?/ tr ACO4t55 a` s gyp. ? c ` rwr[ tipw v"ONLNO. D DRN'?"1?G? 5 33 9 £cs ?o? R 3, L R s e[nseN sut ~ _ a tL? •I? I , ! F? a?; e i?F?LJFI.SD3/ .? G".? »D'1569 V .Y l N N A FDA D. e N f OCC aN FE Rant NO r I•. 2 `r 5 GNf H Nt R 2{i .?/ ? R CuvnON M NANf { vnpNf NO. [YFS , iOnt HbNt ^ J ? CHECK . f a As •pMior"[R CODES P. CIA,°.. vrN l •{A'fwR p ? CHECK (fq •s•"sDMROrfFOFA ' l `(' I"A.w os O??s ° S l fora" w •RL CODES ?' 7 ??"' .„ 51xc1wN .D» (? [d'rifv ? vna.n n 01 a .ff Snu" C ?NrDrq? a ?? R sV VINMifA9 ? •".ulArKl ? b, ' f IN, .( 1AAKe(popee.e"ev J _I 4r.-A si+uaD4 cof4+v.r YfrywyRfro» ?*" 1 ? cMCI ? 8"". O ? :9:,,. Y ry /? OiJ% GG„!/ ?S OILTJ? E l v.l LE, A4 NDVAE cuf _ ,{ / " 51AIf fR`=1ffq. 51A`F H vl". IX R p VINKIlIIXCAtKM NO. 1 C 3'S 31 OZ L EDN, N - .w 5n4EDawN(R. wt '?s?°!O S' _ ?? ?S ?'C iDM[ 'R4JN[NO 0 wN NaSI Mi I '' ( E •O0R115p OWNIR ..!E W x Dk N n 1y,s "AML{.Datua?NwEsfac??Aw E •? ? a ? , ??^" E-slGO - S69 GE R za?TRT „ ? ?1 ' ?,"' OAMAC, •IIA DnLM ' _? • V k 5 ?? -' L idiune?• (s?, ?line."RK:»i c".. w:v" ?R(MHrxp c.A: ?awnroNO.l g•MAG 'ARU ? 7' ^Riv(N `, Y I ; lOwlpe 10- WAY ?R(Mi IS D1.R»D •f Y 5: l ( .1 r. DIAGRAM OF COLLISION. o:o wimSARI "OK ooo"O9w'" e ( , I i I -i i '?'? -.f'i'r I . 1 erO DESCRIPTION OF COLLISION, J,Esls% SHtTn Nee(SSARr(__.-__. r I I.. ..r T ?,? I C I 1_, I I 1? I I _ OCCUPANTS j55 8 INJURIES OFP^ RSONSINVOLVED « WITNESSES u CODES I _ I w.. 2 13 1 4 1 5 1 6 s[+ i Msre EIECE i uw ' KDNISf - -. _. .. ... ,.. NO ? ?L ? . ? Nw ? rui?lr r ?? 'A?N +?M4 _ NAl 1 - _ !D {.pM r f NO 1? k? 0 :21- A nr,D.r.ga a Snw({{.. e•Dplo. •c[• "Ati`?'15DE _ ?.ve t ? K• ac D sp.rcH Fus (. ? der ?.,,? "p '.. `'w? ? 1 'rt 'fi, .?:'j;?l / 7L/? "° 4JS? au.3r ??7,5? ?'/.Jd p/•(a. •p.foYlper?T: ? i y 1.00 r{f V I I" 4 '.t ,vw; i 1 n 4r?Ni vxVt, I 1.4 73T.4 ?'w' ro1T9 _'L?{ 06 POLICE TRAFFIC COLLNION REPORT LI 1RAEEICWAY vgKF nA?NINUMBtp ? PRIVATE WAY Dwll OfCq CO nM NIV p ag :. ,,? y.. "• ? U IusE HDUpI r??t? COUNIY NO ?? qrv NO oE?µ N , ' CITr WIOWN faNO ^a-3_lYF-tr?ov eiGNWAR Q O, O ?M4ES sow or TWp N D?[rL ?CLlJ VCt clj [ pW1E Op St y (? (a Of S'D INRev reRT Op 4owD NoN NR4sm on 3 nrx FD MnF TKRI sE ^^^ ??6 L fN Srv!!1 l STe![T D 3rwNCla e1M^ON FROM pITtvtNCt.CRW S3SIR[1104 nfwvfsrM lF 3 ACCIDENT _ f3 N 3 [ r1ET Or ?? MILEAGE OD OA , RwMp DIAGeAM"A I M Cg11-NVgvID NO NO t4 rv. M ? vlllO_rq .iNEU4F0 ?YIIAG! QNT6R wNOwpr" OrAt [ .'4D i 51 i p[fr O4 vDAp OQ p(RRFKt N pPFp C13 CpO3551WEt04lOAD 'ly . S of a vlN Cl[S 1(j QepDREpty DAMAGl DNIY ?NSu,". QVlN CIE ? OBACT3TeUC41NAMEd C!)fCI SIpIK•(A?ND?OVml4s NAM[r EST DAMAGI WL TO.?-1 s SpFC AI CODING ll3E UNIT NO. I UNIT N0.2 VEHICLE Q PEDESTRIAN Q PEDALCYCLIST r7 vle'3 NAwl USr n43T Mi F D4ivi4'S NAM( IAS - f ?uvr ,Q?r -I 6 ST4lt1 ADD4f33 S-z?.l?so.J ati ADp 55 9/d ?Y 3L?r 3rwrF SIr GOD[ D ( R I 31w11 1 Z ,'UN'NO 31AT1 N "° I ? IKfN3ENO l • DAR p rDl !r! P K ? ii TurFo s9 e< wA. n, I ? I r ' OC -1KIN N.M AMIan IpNI NO 1'E[3 ", E CUNTION MNAMIa-1 NO Ens K.rET I 7- ! 1rsU X ? Q CHECK( MNCwr.s:N?rt vtrA o wn QCHECK (? vNar ASANwrio O s T D?o.c.TyL, CODES ?' 13 1 nr nTN CODES ? » 1 , ^ As u B i ° C 'p > z- 1 .w _ F M p. DM ? pl° ? "b., O „xF3 ? uL r b ?;. D Q .. T O U.", OEM- »Kt ? ti I- VFN {we? a IDODC <wv r IoA41 NDVAI s1.R j- v f 1 D? Z6 E I// 1 MDg1IDU . N V?671 ?/Y- wl l A l uF sun AR4 WAR NO slAl H 3nNC •• Irl vtNKll,d rCwIRn NO 1?667 L ° .... ??A-?X68;X?'7?o,G 15)/Iz? ?? nenrt4loow..14 _ rI43r Miopt r.aw NO O I n4eD e4 IAS? esT ?IwIE N .DOwssa owwe W "T, Z N R E N.A,IaAOglssar+w4•NCF co o4AGlNr S l L R Z , ?9?EZ90 ? c .(J.CfrGQ? l C33(? D..MAGlD /F I• ?wclaru CNYa CNA4W u NMCriWN Qaf APY r b 3lS1 DAMAeID GI Awl?r ? rnN4? ?1D4 ` nMUnln ? uT F _ A, ? ?4IAwNfD iu " ' iu ,D r rov?Der Tow[Der w Aw ?? DIAGRAM OE COItIS N? yws'w yy s e< a rN 0ESCRIPTIONOFCOLL15ION: Ml3 .v NTU Wfin Nauuvl ?r ' ''?J " uLl•1AJ.l?IS'C /s+f-?JA/D -.G/G.V _ ? I i 1 1'! ??? - I) ?? L ?? '- NAME, ADDRESS 8 INJUR OF PERSONS I VOIVED ? E C ODES 1 - Z G 4 6 N IusnwnfMaw sw OCCUPANTS/ WITNESSES rD4 Anlxuonu NAMls r .MI n i ?N - i7.? NI.. _ _ ,. ._ j. ns p - I , ,. u i. I I- A.. Qi1"I Q"? Nw. ? :4LY ru NI..° .DM Q AMa pNi4I ?",..4. O O r:°;,. n 3 ? Nx?. 3 Q.Me O";x' Q?al"I. •O ? ?.,. X .E31;..r,r.c c».<I.3N.Mlae.N. e.DGT a. .cE..c. K I oiTna c.'° c-ID. o °.rlu ro. .r.wrt° wn f Y ? ? ? ? I ?d 1 'NE 8?? N-4 f t R rr, r:. POLICE TRAFFIC CC ION REPORT ?TRAFFICWAY A( ,q,yN,NDxxe ' PRIVATE WAY j DAl1aCaU MFOUY CWNIY A p?y IIrSF ]tlD NDO 3 ONlr - c G S WN O? rN+e5FCl O CI ON 4-'w SrvHr t slner ? ? / Ds+,N(IaO Vt rteflKf. CPOSSSre[[r Oe N[,vtSrM ll vOlr ACCIDENT o D DATA M l[Sf et5 f MItfA E IAGRNA f[fl W a CODE <Otl SgNrNVOIV{D S!v[%IV' lwue A pyllAGf pxrrte w+rsx M f of PWDOe p(sInNR solo NO la.w 11o rwnlD+x Mfe cts aosssrcliroopw^ avw nfs veonvn DAMmlaa. ?wsmrto O"i°ca? ?7V oencrsleucvlNAMfa Den rsseuc. ANpowNle's NAMEI ess pAMACt sffe I SK n IOr w YS tet ?. / SKr S ? 1d s Ntv sNAMt u?r UNIT NO.1 M UNIT N0.2 VEHICLE 0PEDESTRIAN 0PEDALCYCLIST t DeNfe'S NAME IASt y Sr%er ADpelU r App [Lti (Ilr ?S?os AdL srMt :ncoa D O? c? ?Tr2 rf1oNl NO dl?/0. /- 7j? `!/?l5 De e' R Il^<6-1SE ss G,J/4 ?(?rJ 8593' `i < Nf S rr NY NU ?1 /` 031n/1 i S1Mf i . l e?7/? V ?,. ?// occuvArKxl rrroNF NO s I ra?cNr v/ E R /f f/?G? ,vA[ a nqN! ND rarc111 M N iV or_fG- "y2 ?O /? p CHE K(? vfxaeASWNw v. ANO+xle ^+ COES 0. '"r" ] . ^,n a 5 r cr?o-. c ?'D^• p CHECK(.) ANUwonfaworNVA Nc CODES P * ] :,,. r!A i ie:N 5 u .w 6 ° ^? n " M „ 0- O Nx A. M, [ INJDW CNEV 01%%, ? „ r.R u M M ?- ,ne' DM 0----Om" 0m., 0 ,NY .=" , I ID,er NOVA, 1 1]1(WVI E 1 I Istlat NOV NJ T oTi9 o2 2 + SKf Arl sr. m Evn,M[NO 1-1 H vfN ov O? C ?C C ?ZS? A?AL %G?1Re100vMte rA51 Nfll Mipgl o %M]W luO ?i?C ?C O W f R MD vmfv IIRI MIDgE '??C? i/J J c? DD%uaowxv N r ne ` NAM1a,Drotua NwvA .xf co uAGlNr ),615m n oAMrao AaeA ?• ,.c ' _- fA ? CNA,ra ?yVL O MAl4 M -. + > S/ W.?e/ f wW'ii ?nAWNiD 'iv ?nAWNIp fS? - - l(J.00 ? IOM DaY Oc./N6/L Av ? IOMD AWAr 0Y t DIAGRAM Of GO1U510N' I I + a....l ? ? - ? I N 1 wr. E NovrN Inell•N{u sM ,'ie rDw I ? ( } ? ???p0?1 p ESCRIPTI NOfCIXLISION: 101[sllnf lu SHf Na1wI //G`// wA$ EA.? _o..) .JESS S CaZ+.tc2 31 incr.! vGi,? / wj+s SK /rl/ of J?a.rty- < 2a r ? - 1 L i i ;. G A lA,e ?>t7Ji?tii __ ho ay ???/ / ?? , o- r coz zL,, . AO 1 Of PERSONS I NVOLVED ' CODES I 2 9 4 5 6 PANTS /WITNESSES SSES iusls?nlARmusa OCCUPANTS Oe UDrgN,r NAMI AMI n Sr _ u. tAr -vA:. .. ___ __ n51t 111[1 ^ - . pn.l11 NAIw[a pAM . p£1' 0 ^ . pR. 0-,A'.- .. x p,Wrll .M .1,. a r.DM pAMa ptiar p..ml. p:: ,.. .x 07 b r ,w0 cxr.(Ias NAMIf IAN. DG1 t» rixr «r N ? ' X .?T /G.ee??/ ?3 .'J,5 / %(,D ; `? ?Yj?1 /1 Sd` ,f y . } 's I't G?ex ^q k ?`°J .J 4 ) s ETA I TrAP ? ?: v i 39 x?R I.x , A-11 rS F +,, rF ?? y 0, t ilk TTA ? I r? ?? ? T 1 E?+A POLICE TRAFFIC COLLISION REPORT TRAFFICWAY o•fEU au rv_ " NPRIVATE WAY N COO I[E CQNMINI NUM![R - 1 Q?S wr Vw Nf H H 41, I S[1.ODNOVRI ? V [„r I N COVNI Fp cItt NO. E-A •• .. 0 / / .. • CIr OR rOWN µ, Z QN pl QN N FlN0 aS1REElOq MGNWY RUR•4 + J S RCUrt09 c MILS s w or DON oPCR INlfRSt<r NO Vnr IT ' N S ",I ORROAD NON NrER - i% Mhf ?D+YT •Erw[tN - 11RIV a -? sorrel DiSr I {DRf • 6 f MR[S M s "I 'C;OSS SIRI OR NfMfS Mil ACCIDENT r[[t or A72lSl? MILEAGE RAM DIAGRAM Mr• c ITS- NVav[D tv[Rn CDDf o%IILD Nlueeoy Qvvi•cE Qnra RUv .uYOwo?. a vi?c 0 ? _ iryr[R [IS CADSSS1VfEr OR?RDAD ?"D??rlHNC4 l ts . Q rrDAMA. ACt ovlr ?'"LIED QvI'A. OpJtCr SrRUC%INAMI Or -- STRUCK rRUCR ANDOWN[R'S -11 ESr DAMAGE %CNI CODiNO USE UNIT NO. I DervtR'S NANt iR51 Mi ? U N1 N0.2 'SrrAMf VEHICLE Q PEDESTRIAN Q KIIALCYCLIST U ICJ JJ eE efL TU4 v Srettr ADDR155 ? ' 2 C,IL/L%vy,J QC 1RlEr A00RI55 I j r surf nPCDIX rNONe vo D r I nlRSII? u? Lvo 9S- S' " R r NT T ?! 536 3&S S eEaT °CCy°""ON ' r F II ° • V E D Ae A M AEaeerN ?` 19 38 _ I "ta NE NO A w ens ?cvr n?cNr E occuP. .w eM Ea Pnovt No Re I ? . R Ens ur r<ICn I I Q CHECK (,I " !$I I yr , ll• •HOr"ee " Q CHECK (?) w I i O w CODES ? ^ ii• s t w w p wroK. r . i ° ° ' cu. a tt[.s•HrMP orl[aAN rNe o.cyt P. CODES ^ J n.i? . °in:"? 2 S u ar. a u ' -7 /n IHE 05 Ml pM v vfN ni.R MA%t IDODG<cwEV.l tIDARI novAl srvul2DR.COnvi DM QA.a%. r Q C 0 "K`r v " S 4 DR l DfII AI a 1 " ut sr•E reMlfen•n NO sue H vw I?E?S l E T A VtNKIliIXN1D,CA1gNW C ' n A. ll? N W f? 14 b RtasminD wr sr M?Dpe nanlHO L I Ll Z ( ` D l ADDnuaoA+rf. O W w,. lASr in51 Mi [ S Yl+c. As Oti%ttA ..rt N - •Mea oaE:svlnweANa co aADENI E El?[? A S IVt S^ l T H R .. sR D•M .cl NI, l •_ S •T •rD. D"3.°,".EMr cN•.IX fA aA•p _ 4A""cES..u { Curio r to D•MACt f ;w ?l: ? •eM4NID OwE D ?yDU:.n ?YIM4H J°?a ID w ls?I rlo. i i + ? V r ? •w"'Dar = r4?Or Gi P DIAGRAM Of COL 1510N1 n+u f. nD2Ar Ho•rv aiwn ar ?.ow P DESCRIPTION OF COLLISION: IUSI SVRURRENUIS (ID ma-, 0? v ? VEµ EIB G(iz-Gecr+C,a R0. V 14KZ Pq+XPp +aG ca 1 Dl? r SI pe Ko. VeW l BeCA*11 CoNh'vup T - SexAJIr l4eADLic-"TS A03mL60 TD CPLf4 ?L b a ' Oil 0 x R . vel+ l sXIDrLD J•J T ' V4 VtO 47 U A l L H V up ? -w -1 , j ,.I4 Or r Ko?pw i wl6 ? ? n?. j oNn Q,p I• NAME, ADDRESS B INJURIES OF PERSONS INVOLVED ' CODES 1 - Z J ;r NAS„wl OCCUPANTS /WITNESSES ,w F?vD^,!aME i! , 5 6 • ? - Z. , A;I TAIV •,• " nsn I,ICI •uar++ A) ? SAO • a? .M . 051 Q "' . ?? 0110- A r,s Np r ?a nµ y Ew'nDr.wf QAMe Q.°?.rQ 0 0::;.1. 'D • Mr 1 u Dr ? ? ' '?.?vGCr{IR IRRRn• X I.DGE hit+',• "IIS ?, o; "Dfr r [ MI• CHID ?y GEt/JnD I? Q{Va QA"Ar CJ dn• D.n YngEr •AnaDr10. : Q,iirfr D.n tY'!+4mf[fT`?•.STrn-ElAx: -?.m^f.AA!a?m.-?.-? .MK 1.•v--,... ?? !P•i•4 w•:... 27 -?::. 4 4P.41. ' i a f?` y ?f v 'TH ,zy,L .. 1 I i r. ? ? N s? tom! ? + ? 7 t I y, . > t }~ AJI?`. f3 ? l` { r ` * i t r ?.a x ? X i ? r 4 ? ` ;r . mfr d 1 s d i k i i O U . M 0 J 01 O I ? `I V1 O Q1 O I rw4 ) 9 nr7!+%kl i5. L? QZ SO No. TL 0 fA 5T. .P3 L L ?.i7?Door 1 ? REr. EPO:. ?olnER r NPN 1 A "n cA?"LSSSi ?Er on r. XOR `E 3;7 yrJ B 45'aYPA1ROA?EDT r<<aoA?EE S VER'S LAST NAME rFIRST NAME MIDDLE \ Li _ c- AaWtrJ T _ iLET ADOR 5 ROUTE NO. AND BOX NO. Y STATE 211CODE DRIVERS OCCUPATION ER 'S LICENSE NO. STATE SEX DATE OF BIRTH AGE A, I '" rl D ICLE YR. MANE ICHEV. DODGEI MOOELINOVA.DAR II BODY STYLEp SR.) D' ENSE PLATE NO I LET PLATE NO. STATE STATES n ICLE IDENTIFICATION N0. I OWNER(LAST•FIRST-MIDOLE NAMEI DRIVER'S LICENSE NO. )DRESS ISTREET. CITY AND STATE) PATE OF BIRTH :HICIE DAMAGED ?fe:,AVEnic.E 1 $ ____ HIS ACCIDENT ON YOUR CAR AYES ? NO NAME OF LIABILITY INSURANCE COMPANY P FAQ Es u a. .IP LIABILITY ICY NUMBER c?.n98} ATE n[9 t08SZINJ21ES-? -- r- )USE sl AGE ? 9Elf p ' INJURIES M F ? ? Es REnE 0 O nocrORS ES IfYDwA OOCTOR+ NAME OF INJURED MART( FIRST O NE THAT APPLI ES N NO NIIIED I.rv[Nr IM?nali ar .,N ? s o 60 YCLE SAFETY: ? HELMET USED ? HELMETNOTUSEO SCRIBE ODELOW WHAT HAPPENED (REFER TO VEHICLES BY NUMBER) AS "eA- 1L.?Gs W 1:.ST. 04? o1J tT kbaa RoveJ???Jc?. "TOV,IJ ONTO "r?-\O-,AALAS Lo J+ S C. o A.rA . (J ttt T bl Tc r S \-rv. ?i l M ?T 1 0 IJ A IJ'D Ta TKE j%3sj-.,Da pG. CDJLoz \4SL W KIa-: TL<- I'VE G.L\ a 2tJT oGC.u Jt??'D. ET. D DY ?Mi?l [r ? ? Z ?n;i? .N. ? ? ? ? ? ? FROM i n.. _._? • ? I 1' .0 TYPE CF ROAD H"'. wInN J1 I ?IONE WAY wMII OI Or BEING SHIADHT AHEA D Q 1 C4 WAY ? 1 ? OYIRIAXIN0.110 P-1N0 Y ? MU?I RSIOIE R C)T J ? M-na RIN1T IURrI I y ' ?IIOOP,RAMPIE F ? ? r K APP). LEr1 TURN 7 S ? ALLEY ? 6 ? M+XIN0 UIURN + ? l? 19 WIN ? s ? RLUWIrrO ] 1 ?nnrvtw+r ? r [f slormmrpn m+r nc ROA06EPARAiIOH 10NAL I06 ? E ? UI O'J 1 N 1 Dln I 1f 1 ,O ? 0 ? ,tO IEp MROADWAY 0 ?N U I? r h ?' I ii d , ?7 14, A 9 I sl r Na 1"`:a r ? rr r?l I }, 17 II h ,i -A „s e 5 hI 4 ? r L 5t y r .,b e AI y ,R 'F,? "3333"""" w+G DATEOFCOLUSON:_D FA? 9 AY DRr. Fe • W9' 9d1 i ih -S OEDdLmOp s AM y?'?? } r aRI.I R* } ? ;' l ? 17 : d- N I'm l al PLACE .. CO?WT(Y? .::..': .;C11V.TOVlM_ trtrur M?8/(6 ®® •s.dfY. TOWN:,; ;?..? ` ? F ?y eEG1!DM; C'CYL•( ` ( /Z ®® OF SC'K7 t b Ehlt .M -..:dVENANEOF biREET:R0A00R(,HWHWAY 'l':'.i'. T3{4W7M:1 ^:r: MEfl31EC ? - auR lA Q. V?•1.74A? .J(X.?V f?1,t rso Y?•oCLa.7 ,: f/v' 'ci :'.:. .? ???ii.Gfl?f ,., `- 47 ''•:' WRINTERSECTONLMA-OF ELISION BETWEEN STREETMID STREET ®© °LR `DErwiwE"Mi`E?Pl1Owrunrarl"rivWa .AK. xRB"O0E °:: COwSpv NV0.H0 ??nCLEVEnv:tE ?vE•utEE,:CV0.E ?Dr.EA1wXIE1 .,F. N 7 Wc.E-0wECr ?v[?c[E ,.M wvE EES ?V......ST... ?IC.t0.- ?Hriu. OBJECTSTRIICK I.AEI[g08fCfMRUtq..s;,.'•9ifly{?•EY?..•i:ONN910R061ECT8NAMEANOADORE89'.. EDCAiIt]N ?DI?M? .';.WAOADH,A'/}ri/Nd.4EET ©® EWG f'Q6BP.P. pDVEAS LAST NAME ..:... F'tlL4f NAME <i.v_rvdl :.. AAOOLE 'PR e, illms THA wO LDLWMd, DPoVEASLAST NAM •...: fH3T .WOOLS .'. Luvo? .SRmu STREET A0011ESS -:110LAENMAN080RIq( IIDm mAV lv.0 9THEETADO@FAs J.ti•Y^;:„u fgUfE NO:ANDBO%ND.- I F; 2 IA 7 ,, 63 S Aarisr dTY ;s. 'A,:+i; ;BfATRArWS.YIii.e"?A!.f.0{6:: 4/^ . ?y dTY 1; %:c:.' LY F.A J)F CON, u;i? VWERBOCCIPA I10M,m : 1 1 ? ? !], p ?1 /? f? ELY I I I OJCL el ?.? 1 ?l.E .S FrYaf! I p]? ?) pno y P /l O..it/lS y np R? I S/? v,l? ONVERSMCR/BGNW....:,? ETATE..9EK. M TE OF. AOE ". O1eVE11SUCENSE NUMBER BTAIE 8EK MTE OFBwTN ApE - v sezo? W z ` a 40 WIN Lu NA59A883si i if " '7 VENICLEYR.- MAKEIdIEV.-0ODOEI 47 a r MODELwDVAOMTI f ? > r BOOYSfYLE(S DR7.. V VEHICLE YR- g NAKEN%HEY: OODOEI MOOELINOVAOARTI BOOYBTYLEISDN) 1 o., c nnc ne 9r an l n3 nca ENSE PLATEIEA. STATE MNLERPLATEN0. STATE....,. 1 11rl ?b? gT? TPAILER PIATENO. -/ STATE E VFLfICl OE1EfIRtATIDNNO. oBmMODELSiNEWERI r ODOMETER IMILEAOEI VfHK;EE IDENi1FxATgNNO. IIBBB MOOEL8INEWERI nAn cuu Sa ?.Bas?o ' 7 18 F8 IEdSIFAEO D+LSf iRAST A100.E NAMEI OWVFA911CENSENO,, .-.. ?? nEdSTFAFAOYMEIE -TiRiS T MOdENAMEI /? l dpVER9 LICENSE NO. 02 PdT,Pse!/?r 21 E Q h ? T a (? ULR.I e /IMAM P87y OWNERSAOdEA9, ... ISITiEET,CRYMO9iATE1 ?:.:•::;... 1 Fi' PI RT, W.4 ?183r?' OATE018MIX OWFR NBAOdE8.9 . (SDEET,CT•MOSTATE) !0 3 S son OATEOF9RiH PM11SOF VENK:LE OAMA/OE?D(=,1 Dwx Y' L.I!('fAC ?eR f PMi180'F VEHICLE 6WMED 1--AL rTL1 `?•. "'?., ... b,oz LIABILITY INSURANCEINFORMAT WAS THERE AU ION•VEHICLE NO. 1• COVERME w E TOMOBILEUARIUTYTN-ANCE ? FFECT FOR THIS AOOOENT ON roUI1CM Rd YES ?NO NAMEMDADOgESBOPUABe.RYBIDUnANCE POIICY HIOIOER -^^_.:;: -.:- -. ;.".. _•:,NAMEOPUA®UfYw5tI11ANCE COMPMY ? ?e a., ' a 85 °?.A>7,s,A?"'uaa, 48sIa5? rltF'?I.L..C "?e.+ d ?Anp ?Y?/EL?w? r /?lfL?7 ,?:,.?"• ?JT'`. aTATe ,;,.? ?L.. f.:;;' NMMeEN ISr ••i:^;, .. ., .;-,'.. .• .... .. ...'.a?; ,,,. rAGE SRp"AM. T?",' ID¢ _ RR[PPIRfONApp,KINALwAAtel ADE NAME ADORE89 IOfK NAME .AIwFAAp _ _...._ ..-... _.- EfNNI011tAAV[0! ?. w?f ADDRESS ALIT AAO.- .••??.?-.--•___?_..___ _ f.x N.ME. .BEY ?M r El rtW` 4J Fro ` ` " 9TATUSOF WAIREO ?aVKn fl MBE, ? KILLED MMNiRibi DeAnf+w IxvEK4 CNE iE41T APPLIE ALNY ARA)IE S ro5..1KE '.P I STATUS IX WlMEO ?nTmR w.VElY44fr ?P'? KILLED MARL TONE THAT 11PLIE ate .trl de"n "lefvEnl MEWN? 8 " PasswLE aouNPUxr ?p aR`,,.; ? 50 80 ae i 70 yp ?E[ ::,. .. ?o ? I 5 8 ? ? 7 Ertl ? SnOW NDRfNW NUgWwGRCE " N°CMEa,MJ°M.NI ? j .tw p? ? ,.f,.ID W „r.1 "° Dn ]tD.1 H ? DEBC?HIOE BEL1A_WwHAT DIIEFEn TO YEHMAES evTMBER ?hL.olcA ?k l.-kuw•-1?.. sSo uY?1? OM1 ?1$tpJ'C (2ecuR_ xt• aAfta 36-d5 (hPh w3 M- hekd IFS G ? """ IC. Na n DNDW J 011 1?oi??ed Jel?ct?c ?IrZ Inc °" , Jefc Z ors saccb Tri llc¢ i2ta lt d ` ? ? A -? I z ?- lk k . c .>.±gL F b lowed 0.n1 •(DCerded yFTtxsln ? A.gbml Z S . P " ' VeLyu Ic -21 brzL Ices k:Y.E! 1 I ?atab m Uuc?d ® d cFw Yc .} i- ?t, ncl co f (i.? ecl jyLJer Ueh;cle -02- -1vld deice2n6 DDr VEHICLES POSITIONS BEFORE COLLISION MD°`""E D a [:vn: . uv e cu n '"?DO ° "w R u a , Hn. Y. ,TD W D ? a c c YLIKLE N 3 F W ON SIR(frDRNM)NWAY NAMFDR110 fsYCIKAV vpC1 13 „?. ? ®o ? A c0 o a o a o o ?DKH ®ooMl ,.. .. ??W? b 1 RuL, 1 ? ? ? ? ? ? ?A.I.! ? Q Q ? N"4 ?"' - " M- ,. MOM DIRECTION To DIRECTION ? ROFeIRAN WA1 u].IO E?SDEWMK S?WMKWAY ]0l10LI0[R 1?u-?teNf a?ptyAw4A a OTHER .raclq/CE.i•. A1 4T.rL?lil1 A,. 4.1.t10MIGal?(ilOWr.. d1EY[II/W/11CAEACf10N8 ,w d9•METf!QCANRnIFYI.!PSUDW ryP[OFIgAO l.. AS?I VeiYf HHtLR M { NMGR K?.LA O.fT AtlN[I yr rt r 1 1 pI cp-? ? DAVL .,HT l ?Sg1143 ? , ?ONE WAY® ® 1 MIM6IRAIONi Al1EAD Hly ir[.1'I?t iilr ,yM ? rl ?EfMY JQA-4 i DAWN ? 7 ®/fOP 11JN J TNO WAY ? S ? OV[IIIA.w ANOPkS3 ? J ? WEr ] Q ]Now w J Q mu ? J ? wf 0 ] DN ? ] ? WM I E ? ] Q 4Axwa NIONT TURN ? ] ? SMOW ? F00 1 ? IMTI ON [T ? 1 ? IlA3MID no ? 4 C3 TRT A M ? 4 [j MAKIIO LEFT TURN R DM. 11.11 DOOPIflAEMI OI 8.1s ' IT. H( 3 ri 3 ?lKWl1 p1 ? 1 Q IW AMIIER ? I Qul[Y ? e ? uA..OU TURN DTrfN 0 H ?I ? M1AC.r e ? °311.11 OHIS ? 0 Q m'O k ? A ? Lin W A Q rdOWYN) 'UR"I 10 IIfASOH ORNOT IF WEw E-o[R r''T OTHER lf]IY ? I ? OIFICER,fIADAAW LMU ? F ? uc0 rD FoA IAAFFC e WV(w N,A..IAw1IKr 1 ?6l ? / ? OM(N. 4lIdIY ? I ? YP 10 ? I Q s'Iwr yT DDNAL OR 5- 0 ? I ? Bldi[DwIgADWAY Q ] .. ® ? ONO IRMfIC ® ] ®lAdNO[D ? 10 ? atNfIPCIOL. ` ??I. ?3,k'&M?; °?, ?1 ?!'r"""'T' ??tx_., ? r?-?+ _- «iK,NIrI,rE 1,?,. ?'?^"- .I"'?".? er.wnarlC[ -r, C ? ° Hd Y ?v ?I ? li o / !i ?1.• I .. , f ' I? ri N??tl kSy9 ' tr ? } Y ,. Y w RA x M,n Fn 9Y WJ ^? f ? • ? °U NO GTX NO ' ?"i ..? s i '/ 5 ®u `L? ?P!' /•C /' 8 T 4 3 ?n r{wcE ., ? ?" ? E N I [ [ No 11 STREET O i ? 7 77, V-[... Iw n ca R{ - AwaNT,l s ?s ?w?D.I ?./ oa/ ON 7 - , G.&Z xOwR Cil` , H'!R E! (R NOAO ? x H![RSECTIOx L , T M: - O• n?' AO NA[NS! _ (` RNlxanp Er,3oSOIN_oS, OR oENl i. HO [AxDwxx. ["'Rx OO[ ? 0 .1 0 1 EI 0 0 o : ?[D L W [ADD M MT, m To. ? ` °° "" n Ex .T [. b o`? ? ?'E 8< DR B AM B ; ? :091Y5A9 LAST NAME...-. „..: '.. FIRST NAME':. +,' ate. iI.Q?', MORCARS [o wTRE AB1YEf3&N8T<NAkA .i :¢J;( FJflGEI rJY. xa M 1'rrJ.. ?o,fns?n /% ?n.rTes IN IN'. COLLISION DR ° fPy'!3'os/el lPa/[ G IAEET.ADDflEdd .. „ ROUTE NP, ANQAWINQ(< /3L A / L ?isTanc/s ,?ri ?r• 0,(? //7S' " E SEPA T $(!EE7 A09flEe?: ,1;(, _.se ^1 .: -:ia ?v ,gQ. P? ,A' l..... STATE ??.??. ,: 21P,. OE: ° VERS. F AT ON 00 LS .OII.r: a ;.rcSIA7E r men' .-..IP:SIQQE. .?X 0 FORM Q ec Q 93179 DRIVERS LICENSE NO. Tat SE% ?D/i/Vf ./Bvr.PP DATE OF dI TH AGE a 6y DRIVER'S LICENSE NO. STATE 5 % 04 11.01,61 :A MG A i9YY j?o,,;?a , MC/ sw Alt-A . St? x . .:4 1 cILT LICENSE PLATE NO,?S/TA?TE TRAILED PLATE .NO„;': %.: STATE. :LIC€NSE.PMT,E?O ;':.,/T??T,'AWT6!y4F$-P,f.AIE.BQ? :.`?:.".$TAL:a: i; Z Y6GD .. -.•..^ ? : .?. YEHlG4E_IDENTIFI JDNno....:.::_.: A...i L.:.:.:...... ..., . . .1111 IFF8€B4 I'19111u_S.T-FIRST-N.IDER. ME1 ,^:,; 99h'EN,s upENS?N°. .?. ::.?? . ftEWA.T€9f.R.Q4YNRB.14kgL-F.!R$L•ML4 ..tlr]EE?LS: ?€ H(eTdPR@?+ ua. OWNER'SADDRESS(STREET. CITY AND STATEI;.,:ia'd' .; OATEOPEI . :.OWNEflS;ADORESS:,,;,:;;'u:ISTAFET. CILYANR-EIASEL'1L'0..aCJY "J.JJ.JWT .QF..BIdTH_; TS OF VEHICLE DAMAGED . /i v . t ro• r 9': f- IN L r ... , , a fda is LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- WAS THEREAUTOrnOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR © YES ? NO NAMEAN°.AQNESSOF LIABILITY.WSVRANCE POLICY 'ru iii •1':+:dwfc- .vs i:t.:.: ", ?'.:Y',?,,NAME.Of?{+. ILIIYJ Ef.AI(P •Mi^ •.,. °xEi ?o/in son . % mfS pi/Ly.-v-r• NAME AND ARORE55 OF LNBIL{T?,I,NSOHANCE AOENT,';LliZ' d?y{uErA.?9w:Y. :..' :. •:3R.IUd§? - +CS:: s AlifH.nYn•En? Gr 9YJ« :O'?-d9-o 5'x978 _;L tiClf-?:si.]:YY..u4A / ?.•: •:•'.,. 'LL4i.]'...?IE?EBV y / l C O AM /V ?y mm NAME OIT • R1'Z?. ADDR S ' ADDRESS F. M F M NATURE AND 1? ?[ NAT E N EFYEW OF INJURIES ? ? 1 .snl E%T OF INJURIES ? ? DID IES CRAM NAt ON BYOA IDOC.TOR+ ? ? NOMTOB S 1 % 11 OXO ?NNgR ION aEDA IDOG_ 0 2 °OCTORE NAME "'?:,MM!KFIR87 QNR2WL _: • • wo= ? NILLFD t?nu?rWionl Co nA IJ RAf1[ND[R NILLFD 11,V RuhOn •ctun. "ON NO " , .. NO. 1., 11 -DI,. ? S? 60 w7?° 0n1 wn.1 lr ? S? 6? «7 ?a MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SHONLOyRpTCH? BY ARROW N CIRCLE \ ? '•. \ I SC?iSE L ? 9itAY.SASSARIIALHMAIS.:. f rm Dunwl rnxr R ?i _!// /S^f7YY[n^ ? 4[M'4 _ ??Gt? """ 04 ? -- [ [ AND : 1 .. _... ... • 4 I w xrA[ VEHICLFrS POSITIONS BEFORE COLLISION INVESTIGATED dY [K l[OULrRMa p WIw¢[ L[aA[ OVn[ Try V( N 3 E W ON SIREEI OR HIGHWAY NAME OR NO D .[ r[S NO •[[ No ° ?TN ?IOIWAILi l.?C1:0 ? rr :; ....., a;?Jrc . C1.?;O. ,O.'. s 0- NA- ?d"DN.r. IS_ I 11 ? ? ? i ? ? ? ? ? ? ?wMRRn ? ALOfq '!A ?'"',i= a? ..TA. 1 •Bi 11'?L?,44. ';;E ., PEDE I PEDAL CYCLIST WAS USING.0._... ..[ r ?uAwA . ? = . ? r w. [ [:I.,_ r ? M4ONR11O E ?ro. R PEDESTRIA PEDAL CYCLIST CLOTHING COLOR. ?- 101- .?w. ?Rrr l?°u%M [D . RoRUI[erw[ Mi,i:?r[i°.iirMU4 ^?.":r •,..NWR. d?ti ?'%LIM/ ?GAQ?'3Ti'dL E I[.+c. ox.l T ?OAruanr IE%RU wI ?,y.pR.°Y• Y"R°w[ IFAMGIaw w•RM[I WWttI [ I .Or r ®A.w.rR [ ?OAWN ? r n nml4[ O ONF WAY © E ? 001NG STRAIGHT AEEFAD 'c' ® r ?DIIY [ ?RMMINU S ®OU3% T OE SIGN [ TWOWAY ? [ ? OVERTA%IN° AND PASSING ? T ? WR S ? woWlNa f ? LIC=ON[T S vNLDSION J IV[RSIS ! ? S ED "'"'S '"C"TTININ ? 1 ? 6- S ? r ? Lianr4011 R[0 00 f IIµHINO ILRCHArgL ? % [] MARIrq LFR TURN ? R ? ? 1 C-] 100NRA V A I ? [ ?IC[ [ ?yrlt,l.1 A ? STPI [. IG.... ? f ? rI -'NO AMR.R ? S C] AlL[r ? [ El YARIND UPTURN ? [ ? SR61/T [ ? _CIl ? [ ? .-AL ? S ? l[AT TUIIN ? S ? RaWNG LAN" - ? t ? O.INA-LAOMAN ? I ? MNCWAT ? / ? ROM(D FOR TRAFFIC or [R. [A[L FY a . lTOAFlo AT slodu ? ? O O ? [ ? ? F ? DR 610'.... ° " n ? ,ti ? ( ? d D(D ? S ? STOPP[D W ROADWAY ".}•'' ND T rro k 7Iy''?' 1,Q +.1.+', c n. „ur?4R1r1[F6°.[af?P i rM"4 ?hF {. x D(DA D [TARNNG MF ?. p ? a rem _ , r E OF D ^^II . - 4 STAT WASHINGTON 'A. y POLICE TRAFFIC COLLIft REPORT ©TR PFIAY ?- KEc iN PRIVATE . rcal o• ?' cal A LIME Wx A. 11 COVNEY ••/ 1 - , C n o rw 1.y1 (US[ 1.OO HOU4) COl%J1Y rq. CItt NO. IHVIA A ??I I J / lD W (/ ?N ?E IN C[^???O'4 tO/w?Ny LANE6 Or5r4[E OR WD.- MILES ?5 OR, pOi I1lJ ' ONTN?55 ?? U4Al .. RWIE 51 • ,? S f, ' ? 4 Wl .E IN1fRkCHNG Wr1H. StR[tE OR ROAD fRNC110N C ,s 1' C pRfPl%. [ MRf POST 151 CE6 IRKIrII F Uc • .CROS55rRFf EIREE N SrREEId SIRfEE DA yB /'? If51 5 [ NFARE51 MILf ACCIVE w • ?A# e X:. rf rLEr OR causaNlNVavED; tOlAl NO NO k llEp ?/ NO INJUR[ 1 ? SPIIIAOf ? H r 6 R NE • f • UN OVLH CIFS (? PRORREYDAMAGEONEY 4f ?V a ?? ? IMER CAS RFEF yI E OfO51SmuoR IEW, OR E ?- ' - ? SUIiFD f CIE %P OB1Ki5LRUCk IN 1fR5rRUCR PNDOWNFRS NMIEI ? .. [Sl DM1A( F 37TH 1'•: !/- ? 1 .? V? . •KCNECOpN0 U5E ???? ',. E UNIT NO.I'- UNIT NO. rl ?i VEHICLE s DRNERS NAME. IASr ' ? PEDESTRIAN ? PEDlLLCVCUEST DRIV[R'5NAmE y +?.. . ?t ?i? E T I C..E?1 SrPLtE ADpgf55 I C _r 'A: b Y?r.1 ? ? ?. S?-. X28 EREfI YnoD2Es YYb a? ole - Id z ? 3 ? ?, x7 r„ - Sy srw E 1 :IPCOOE w.oNF NO. D xc) ^? ?; Tr' SrAIF DR eRSlu?HO srA.E 5 R PHONE R R r Y IIfEN Wick 9 3?? 5 Q$ ; O >? a_.-, • Ek W1NCa h1$ ? 1tJ19 (''? ` D.. ? v AtE sf% D•rf aalRlH v'?`nv l` =UPATI e AME.PN , A4 RG / LhbC4 F S EIGHt H O : E OCcD ( 1 ?? 5& , ' z % 4M N RNOHE NO { ?N NE; '1kmd I-, .s,1,s Fns ZONE i ? CHECK (1I 4l I 69 R U.S. Nl9 IS. RTtIY, 3 a aJU ANA°s YET NOrN 5 s _ y F ?CHECK (E.J S CODES 2 IN ?* D O S E w e groz N<LF 45AN LMROYFF 'ANOrrvfv w[s Ais R °:sw.e .er sum xe CODES * 7 a e °15nMH 5 eA to .ul E/ r H 27 r r D ss e qH 7n1 s ? .M A E? I ors R. ? ru 3 M E orf< T I, YEAR MARE ?DODGt CNFV.I IDARI NOV 1 O H?K;1 ? CR°.'RS. (]DR.CONV.I I FCrvF1. C C. " aRI NOVAI l^? 8 ?I?' Yl 1) 9 v I E H 1 .l d L I 2 8 ?f1 ? 1HSE 1-1 N SIAM IaA ItRR [ NO rt H vE CgOR N ? BC.L •o v7- P _ . J pI FELT R 7?3 GLJl4 Ilve? " "° A F y V NK E IDEN Ir CAER]N ? ` 38z W ? ? ?. ( 1 vENICIL IDENI IU F REO -DOWNE4! FIII51/ I ?Y/, ?P' i n N 14 , IpaE' PIEONFNO. ? g' I I D VMFN N I • I O : {,RSr NRS o MID l N ADDRE53 CY OVmtR ?/L(A z N f?R N No. ' Le ADDRI INUM-1eco OR AGENE E All, y7 R ? ? ` ?: ?. ? c re •vb '. n' sg???? fArn Ew ,?wh n..vM oAMMw--A s Imo`-?!J o-s.. D CNMG! CNARO! Esc Lwnwee I°sww IIfMA Eo ? ? :,9 1'l EON'!D I?'. ____ ?:u,N: n4EA1UINED rNi: wi ESE DAMA 'E 1 lf OMAAOED AP[A ?'?? ,K I x??' ?I. : . y MI, a. • ub .. m'?dnl armWMen "-. x,i R,- 7-14 2 CASE NO. '} ' OF COLLISION ? FATALITY INJURY ? PROPERTY DAMAGE ONLY ?vw .?. v Mo ^DAY ?yYgRR GCOUNTY ?-fryJ1 ?^-CCITTYY1 /t STRREE,E`T. RO'?.0?1ADD/N/ULMBERCOR' "LISION ?R /OI /lYJ IOCAtION ?'•rGL? Qz ..._ .!.' -U\V?+\ NAME p? NAME \\ DRIVERS C?WIIJ t?1C.?0 N rn• vs { F__ vs ,. .,.. IIAA? .: -?_;;,'' 1PT10 O¢ ICOLLISIOP,?;' 1.7RF }NA DITIONAI INFORMAtION WHEN SPACE IS NOT ADEWATE ON ORIGINAL REPORT OR AS A SUPPIEMENIARY INFORMATION SHFET 10 CORKER D R'S NAME. OCCUPANt? (USE FOR AO LOCATION OR ANY DATA NOT KNOWN A7 THE IIMf THE ORIGINAL REPORT WAS COMPLETED.) the driver, of the motorcycle ; and she--believed he began. Driver 1 stated she saw - -_ . - - to go left, intending to go around he vehicle. She said she had thought she had giv_en kQ__driver 2 room to go left Driver 2 was taken to Jefferson Geneeal Hospital by aide car. Z contacted driver 2, ' -- Corner -- ---- and he stated`he"wasn't -clear of the-accident; he knew-he wason Ness when he noticed Vehicle 1 pull out from the stop sign at Cedar Street. Rd . - - ---Driver 2-said-he tried to-brake down -and-go left, around the other vehicle, but d and ' Corner Roa he thought it kept coming, continueing to turn left onto Ness '- he was unable'-to-avoidthe -collisionx' Reporting officer feels the accident was caused due to driver of vehicle 1 failing _ to grant right-of-way__to oncoming vehicle before entering the traffic lanes of intersection th d e Ness' Corner Road. There is ample view of oncoming traffic at ffi a c. and allow the oncoming vehicles right-of-way prior „to_entering tra ,.- b ? % ? ? % ? T u m C2RAWsQ.F,COLLISION, _; a ?u a k1: :?' f DRAW DIAGRAM OF COLLISION SCENE IN REASONABLE PROPORTIONS, PROPERLY IDENTIFY VEHICLES AND HIGHWAYS SHOW SKID MARKS AND OTHER MEASUREMENTS wrO I 5 I 7.1 µI I i ? r 3 ? r s I 1 I`"Hllf '? ?. nNFSIIGAiING dI WAN ANK BADGE FA rAGFNC ,UNIT3151 DLl- APRROV[D BY DAII OF REPORT SS II, t??,II ?a --- 01 1 Nfnt4+rL 4 YLT ctM :IrG? Jq ^? R?))xkl? unlW T w.. ?b I 4 i I 1 ? r ? ?XJf. ?IfjJ1 L -A J 1'"' ' r ? F_ q Iy IA ? t s ? I;I I !_ ? . t Th T 3ti, I i E1?a?Il r I 5,. r - ?t'I +' LID n{rF, 4 s ?r I 11 I _ 11 I 17W FFI AY,? POLICE TRAFFIC COc°?'+r COMMON REPORT D!g TR RaK?'•? T" - ?• R ? ? PRIVATE W,4 w EOrCIXV IImE <OUNIR N I I Iv rs N,• ,. 5F]?NDUR: ? w c?l]N yo. arr (/ r"v'. Dlw .? ?f ?. urvoe lov,N Amt•ND . T RloR wcNr ?N us Rwno+s G9/oo MIltS DS W o IteS[CTivG VAIN Sr ",-ROAD NON ANT v51 <IIOV sTRFtr E StREFI B0 'EN NtNll t MRf PO51 v O? CPG -1 DISIAN. RllvtNG 555TRIf1 RvtAPFSlP 51 FMRl51RON S I W ACCIDENT MILEAGE RAMMA R /. tP Or C O ? I ffrE ] - CO111510NINVOIVfD fvtvlrr. NIISRUN NpINrvRjD? ?SVnIAGt ? FD ? ?? ff ?a:?°rlDi.s IM[R %R CIS CAO355TR[ROR f.0A0 '?- NO.III ?? OT.NO \\ D iMIRf LIED ?STIXtN P 0 VINl,l[5 ® ? ROPf RTr -.10- ?7SO ' I', CBIECt SIPKRIN EECI UCK AND OWNER'S NAMEI ES .DAMAGE SROW COpNG IE[ q --? 5 UNIT NO. I UNIT NO.2 SNAmE iA11 ".1 1 I l O VEHICLE ? PEDESTRIAN ? PEDALCYCLIST S -? ervtR'S NAME K,T rIRST w lE , ']lJ STViFT Appvl55 rRfEl p 5 ° 1 10 T? 2 . O ssA,F SIVCODE v ON[NCvB,Vb Tr D c PNONt cil, STAIE I 12 , 4 ?%s R Wrv!'S IICENSf NO SInII t RI N I IV -511 FN.N TAT[ DA FV•. ,? S W . 1° D V OCCU+ATION AMt nl O [rES IGNT N[IG", E DccuPAlla: Fa PNONENO III FvfS WIIGNT NEIONt 2 eS l R DC CKI?I 'vtNlnt A5AI-1-0 2Ar-aNteA' IAI ?CHECK I?) Al AN EMPtovFf DrAroft Vl- M0 ?] 7 n S l t 6;° CODES " n I •5n 6 CODES ?` D n N. I? (lN K v1 lts N]l R ti 2,L' O <8;". ? : ;i ? :°', 79' ? ? D y..l S:nVA O H O :° Kus D vl e °°" vtN rEAR e"evl moon lD%vT.NOVA, vnn]DR coNVI A , I .cNtv.I IDA . I , E OR UCE P A 1 S1Atf R 0.Arf NO "AT' H N O 0R V T I A AI ". `- So vfNKltIpNTRIGrgNNO i vFNIOEIDFN % N I ? ? I !3'5:1;315'Z'llo!oit! i8i I . ; ' I i 1 i MI Rf,5lsrtvFOOw++fR Ksr Rsr mIDDU R„oNfN o8? W o ER. 1 rl sr w. ] -. ADDRESSa ovmt% ?u SIC -11 N E a •" . , oe ACtNr ? tAmf a%DORnsa INSU+ANa co R DAM_-A. . ' gAMAGt ' !A• DNAR o M.DNGr .rD ? 15t w%u ? ?W?W ?REMNNED IbioTi:? i ? 1Rlvl A, ?R[MAINED f51 DAMAGE IG:OT10 s ovn TD •. Tow D f Ar a lz V $ Aw Rr . , DIAGRAM OF COLLISION. u^ A' ev ?Teo;,°„"I" swtRn aussurl .? N D CRIPIION OF COll1510N: IOStswntMENrAI Sr,[eru NECnv.+rl \ ES : ?fMEA %Cl S = 0 YU A3 . . . . . W A t .C= . eF Mem -,6E%kL5,3Wre m Cu,RVE .LEFT 'IT. 4AGflF;? ?'H ? . "? M? .,. ? . ._. ..{... .. .- u.1 PadEMGwT FWa SKIDD MgRtt ou .f?PfMcl?. 35E.\n? 6RAVeL_?3EFo?E tICCCtraC.._ -' _ • - A EPEE. • .... __.__ . ' L '• NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 -3 - 4 5 6 OCCUPANTS WITNESSES wo'i.o?,.:;:i:w: ii? :(, wvR u¢t ?. .M 7T L s-1y'10 s t . S wts czc?tu w ADMI„ pRE a ?.mR ?re^I ?r . ?a D Amt p .roNS, h I„+fa t8 1,R M ?Ame ?A ll0 , ? n ? : ° mr p - ,) ` ra ...fv.?°u Haul ? e._Gro .;r.c. .... ,?.I m:... c.,m : .? r:IC n ,. _ •?? .., ,ti Dom. 1T H•r5k.k r-:,+NY"• t.= , :v1?5i+1 .raTp,: ]RT`,l....,, ,? - ,].•^mw ti :? 1..: f 7 fiA '?ffl? 3vLu)L'M 5 C C hLSP; ,. r E v k s ?r A . E '::41 I I V ,l / 3 • 1 x? ? rSa: , 1 "?Y 43 ?? v Ati .A . 'y f???,yb.?r M a a • _ ?n r 1y-6?6.•n- --i`?Yi.', - -? ._wRYrCL.... _ .. jilk ?'?°`ar.,sa?ar , ,c. .r d SR ISV IR(V. ,B01 A" k 14• O SPATE OF WA INGTON rwE 1 OF 1 No. ?A E? 2 ? i afs A_oY ?. ?' .tiz • D k r s ,?( S 5 4 41; A I I B POLICE TRAFFIC COL ON REPORT QTFFI(?AY comrt,u IN z ? PRIVATE WA ]I ? m N W - COUNiv MIf11fY NO. ry FMVA 2 16 85 0 I X' 1240hrs Jefferson Ra c ON Of 01- OR,OwN NANFSNOO 519Et, 09,uONWAV CS ROVF 1 1 Mrlfs ps w orpt. Townsend ONHastin s Ave 1v?'InG {b INTIRYCT NO WTTN. STR[E,OV ROAD NON NIIRSECI ON NS Jacob Miller Rd 519[[ -L." -Ill IF KEN f MRf Poel . /O D1IIANCF SOr MIIFS 9om Rf SR f C.OSS STPEF rvFA9(31 M11f 1 NN N W OF MILE ENT F , DATA _ COlll$Y]N NVOIV[p SfvFR,r (? Nr69UN lNjURID par 1AGF p ? {uvRLI l IMFR CIS I NLt TOSSSl11F[10R 90Ap 1 Si-N OFYA ClF3 O ? PRONRIY DAMAOf ONEY ? -ITIp p VFN CII \?`__\\//,, a13:4/ R^ 7 UOJEC1519UCK IN- I OB1fC13TRUCY AND OWNER'S WVnEI FSI.DANnOf S SHCIN COMNO USE UNIT NO.I UNIT NO.2 'T I VEHICLE 0PEDESTRIAN 0PEDALCYCLIST 9 Ov1v193 NA«I U T N 31 ml E -Y-NAME U3, 1 I LANDRY, Barbara E. SMITH, Christine L. e stxueDDRtsS 561 Arabian lane v9Etr wDR(u 45 Victoria st(Towne Pt) ••J Z -ll ]1PCOD[ PNONINO CII D nY -11 IP Y Townsend, W 368 385-2484 R Pt Townsend, Wa 98368 1385-Z582 pvrvtv'Sl1CtN5t NO Stv.tF I., A I r 9' ll ENS( NO. A [ • p B Ptn 2 LANDRBE537PI Wa ; I F n '47 V SMITHCL508J2 We F 04:22 !TO DccuPAllw mN--ENO. Ens Ic rNllcn, E acaPANOrv r19m NAmfa P-NE NO s `` ' ` e Z ited Airlines bl 130 506 R u t To b j 6 D Maria Grouj Aome 160 50 p CHECK( aaA olNFO•` A_N p CHECK(,) X"clN AS AN LMVlovlla ANo,NFRAI CODES ?' 3 11 5 1 CODES ?{ 3 ,; 1 14 1 s f1 N 1 a 2- rNli.RS ? .»N,,- ? uf" p Eb.,l. p ?.. I p D•Ny u sor 0--OM", 0 ,86. p w "K I 0%1'_ ?O En ?r AN YFAR MA[E ItOW[CNtv.l MOOR IOAYt rvOVAI -LEl]D -CONVI HYLAR 1 nEV,S MOCfyDAI NOVAI l]p vl 7 FORD Tempo 4dr E.; 85 FORD TEMPO 4dr ]B ' •, Nu PIA sun AnfRM1I NO un }I. vEn Ca 9 A l Ae . red LM0005 Wa blue LFM578 We vENKLeIaNnFlulloN NO. i l l I I I I I I ! `.. v[N CU plNDrl 1 N I i' IN ! i 1 l i d ` Rw1srt9lDOwrrcRuat rlRV M1pw[ rNONf NO. D 1 powN[9 IASI rwv mrp E same 1 App9I53OF OV?lE9 _ F WN(R , ? •?'? NAf Y ADEKISS OI .N5U9ANC1 CO. Oo AOlNt Homer Smith Ag. Pt Townsend, Wa Homer Smith ag. Pt Townsend, We DAMw! MIA LA. Y iOreiN CHAROf • A CNA9GF w<tlquN ' DA.wOt ? B N ?R1-D S fo ICIOlrO? ' DAM t I s RAW:Y MA1N[D IS? M E AWAY Y ' IOWED r Sd000=- -. DI A iRMOFCf UISIN „ v:TOYNO.`'9v e TION OF COL LLISIONS IuseswNemf rN SMEr tetssA9rl D - s h H, to ? I fl„rj icle-#Z-wa s slowing-.for aleft-turn onto- - eh d t i11 d hi 1 #1 ll t 1 P 1 I ou . _S.-Jacob M er_R ._.Ve c e. gu e o l t3f h ,_; ( -} ?._ ? h .. __ _ ic es ae _Psl&s #Z in the intersection ,.The ve - - p1 0 5 -colided in.tha Sntersaction._ righ he observed vehidle #2 stated that Dr #l y _ - -s , . i i de _ te on and nothing on the left s turn l chocked lites_on #2 and found the left 8>rak turn lite out - - - - - -- - NAME, ADDRESS B INJURIES OF PERSONS INVOLVED CODES 1 - 2 3 4 5 6 OCCUPANTS/ WITNESSES 'm _11ION. r`A5Mb i1i 'Al. Y NSIR lJ A«1 N Y ... u ° ._.. -_. _.._.. _---_.. ._.. .. -_.. AIRIRni m.ra-. _ . IN, Br ? AM B p G 3 aL?z p Lg'- N w Kq .? - -- ..... pro'°I nD1 o.n„Y YR. 0 Y 0 T.ws. RD I:o ? _ il * _ DAN SApO1M AO1 N!r nr• + rA tl Dr;AA•(NIL I•UIK[AK?r1D D/O NION .._..__ ., .. _.._-.. ......... :Dd'O •ren 1:r_.'1'• 19A 3] 1955 Q Q/16/45 •/W O 1 1 k JI L'. y: Jr -" y a . 4.?1.'°rcyY' MS .?°'fk+?'s T?.t K r UAF` L }'3 ?1 .? ?'f ULa11?/^?rl -p t?Y4 r V. 1 fl F ?I +}^r ( Y df 'I 1 F (?' r ? f I Ll r,? rr r , tr J,. orb d ? 1 I lu E `f ( i? ? k I I it a ? r r 4? 1 J r 'I'vrfiy r 111k l I 7Y 11 r ?,?3 ? ?, ? ???`[??F y?y ??,?? {??S?o ryY7}?l;K?hn?? ?,.? ?+i? vgy,f?},??,f7?? ?`"x?'i r???'trd ?5 ?u,y,?r wr6c,??f?.9 ? ?;JVt b'? i?r,`E ,t1h1?? ?9? ,t a?a?i ?.i?a? r ? ???r? V?? wit.. 1 ? ??v;??l ??ir.. '7„?ilr ? ,firs( ,p_ +i.??.r, V ?3?.?d ?d?1?, ,r?,. ?, ? i'?,?C. ? ?,r. ? !n^Prc ? ??'.+? P; r ? d. ?K POLICE TRAFFIC COLLISION REPORT L/{I TRAFFICWAY - 7N.-n CwNr . 4 - - T IL J\ PRIVATE WAY DpAt F a . D4'4 71 01 rml.Fi 1N f.-. E.... wr ?R I IUSEDbO HOURI L n CouN V r7?'' ?tCx s COUHfT NO. CITY NO. ?4 iMV O Ru ON OF 0N CITY OG_wN NOO rR TO4-.-AI . 5 NILES O5 12W OOi ,- rA ?lv fCTQ ?) RWTf 5 -j PRLII. -3 4-INGVRTN'. 5TREEt OR ROAD NON rNfERSFCIION • Y ET-IN STRFFI6 5T4Eft v4tiU[ f /AIt nJSt OQ OAS ANC TI Mfi 4f .C40555rvEE OR NfnvFSf MILf ST EMI(ts 5 F ACCIDENT MILEAGE RAMP DIA RAM DATA R Dr CODE COLL1NVdv[D. SEVER tr: lOIAL NO NO VLE[D_NO INNRED_ O54LIAGE ?Nn6vD N wrvDwRTw "// / 4D IryTfN CIS F 4Efi 4 OR OifRENCE CROSSSt4F/Ei0 44oID -1 ?? l- pVlNICLFS 04 OOKRTYDAMAGEONLY Oa5`UITFD ?VFOiE'CINE e Q EO/IDO CTIACESTRUCK (NAMf OE CBIfC151RUC4 AN0OWNER'S NAME) Fs10 F ?t.n <•i W'h tV' ov S 6?AW SPECWCOOINOLAE UNIT NO.1 UNIT NO.Y ?VEHICLE 0PEDES7RIAN 0PEDALCYCLIST S DvrvtR'S NM.E rA51 NvST MIDDY 2 / RNERSNAME: UST EIR - -D-E_ \ Yq VY\q _ a Sivltt ADORt55 \ 5?e?\v a ffFT ADORl Ss ? rt St AI F II4 CODt vNONF NO D Y I STATE IRC t . \\ , ^ ? tY'? W Ym YVh- (fj;3 l6 R suctNFN FF4 ?? s AT VM. F r l r? 1 V Iv E N IIAII 1 1. IT el _r CKCD4A_ ITIM a- N E NO. Gtit " ' FS J f E occ-- " I. PNONE NO. EYES IGNT ItIGNT .E h l E I . OI i\ ' `C\f 7J R CHECK ,4 FMwY'v A o veN,tlf As:N ? CHECK (.0 vFNKI(AS AN U.nEiYFFd R A` ` s CODES ?3 e CODES 1. * o 15E, a 5"'.° ro t ?} w alts 0-- 'cR` ? ?5m. 171 h ,; O v15. O AR•„ I..KE ? . ? C&N. O P°,°, :Kit O "W- VFN.YGM MARE IDODGt{NEV.1 t L+ C ...1 EIfDAVt.NOVA) 511 lv D4 CONV 5 Vh H E Y.r INAAL I Ntv.) MOD[L(DART. VA) v 1 .) - I l 1\? W KN I W!1 \ `14 SLAT! W I.. AnFR 0.A ENO. STATE ?.. 4 vfN.C A A 3 tNKlll"[ IKATgNRA. AI o X61 i VNrIt IDENII I I I I I I RID,sRR[DOWNt4. IAST `nRSI MIDDLE / ngNt NO O IN, wry R. LASE i,RSI MIDIX J I?YVVSQ- Y? h? W ADDRESS d owryE4 - Ir s2?(?Y\..rcn ??v1 nr :ri ?Lf?! E _ Ave a.DD.essdINw4ANCt CO oe Aeem R DAM.WDARIA C A- ' Z AX D CNA4(/ CN.4Gl• , IP AR EA S 9 ITOY a DAMAGO BI A [?4eM.vN[D ITA=, O4tMAweD .DIWAVN ?e U 1-1. A*lI 11 O A.Al er s DIAGRAM Of COLLISION >.W ? I--I ! {ER Ia -1 _ IIA., DESCRIPTION OF COLLISION ILdt SU4ntmE SreeE N[CtssA ) I r . .. FT ? ? 4 ? _- [L So?W S > ? `.{Qv SYC N. ?h aI I - _ 1 I I I v I } -y I... r .?. I _ 1 1 ?.._ _ y... Q..? Q ?{ .YS4S ?r\ d,i.C as YYSi k?n?... -( f o r - i4 c 1I7--f I NAME. ADDRESS 8 INJURIES OF P ERSONS I NVOLVED CODES 1 - T 9 5 J OCCUPANTS /WITNESSES -; Hof uius 'HR D ..I . elfri Intl .MI .. .. ...... ..__ _..... .. Mln N.mn or _. ........_ .-0 Is N•er O•M e OF+f' ?'" . OH ? :`2L,. Nwt .q p _ _........ ... ... .... ,.. .m.ns NAT •Id --.. _._. _. _. `L •.•OVID,.OM ?AMe ? :"Or", 0 M., 0-11.1 AD AMI N t F - Owe ? , ?..? ?.... No/ ••• vn??. n•.w wFG A.t A. elos c.n D nx L DAEd Ero •ovloe. D.n n 1 ?n 5FI 5 l gI H t ;) - E1u yy??IEE L L JII / I I I • I 1 4 IfS _ ti 11 I _ .. y_ I T ???, I.Z I I 1 I>? E `?? E Ph / 1 Y POLICE TRAFFIC COLMON REPORT aJ TRAfFICWAY roux " ,uINtN Ee z E PRNATE WAY ] COUNTY j o.r I / p-11u15 w1 w IUSET-HOUR COUNry pp CItt NO, ? I . 0. (, osoa -ate flµ ° REEL CN ?F 0. CItYGRIGWN FeNOOS1vfETORHGHwpY w ps Z w - - 5 gWlf df Si B us Ix1Gp T ^ ON ,NILPS[<IrNG VnIH SiPfEI OR qAO NON IMF4S[CIION Ffl t W y BE1WF[N SIREFI6 E6 EIIT MILE— - Oi DD g5iprv(f 6D afCM111 MPfE v N f CR05551R[FI OR NtpRfSI MIIF 5 ACCIDENT SE 3 [ MILEAGE iF[1 w AMP DI RAM DATA Of SpNINVOIVfD: >> YcODE COUI SEVER iY lOIAI NO NO KILLED ??NO.INIURFO-y ? Sp IIAGE ?HIB RUN WNDnoiH m 9D r CII E RgOAD R[EfRfr4 1MER CLS CROS -["WEECAD ] dVFH CltS ?PROPFRIV DAMAGE ONLY ?gS?ITIO ?vFpCl[ OB1fCT 51-X IN- 01 OB1FCI STRUCK ANDOWNtRS NgMII fSI DAMAGE / 10 ??00 SPFCV4 COpNG f 1 ?/ - UNIT NO. 1 _ D4n[Rs NAME: Ntr wsT MI IXf UNIT NO. a tR- ? VEHICLE 0 PEDESTRIAN ? PEDALCYCLIST -I T : AME - A IKU1 ADOeESS s1etE, bDRfu fr it WAIL IIpp'. PHONE W. D Rr SIAIE (y lJ 3?t O R IPC E , _ NlR'S UCtNSf NO SIAIE A H I vF lCtNSFNO. i O glf DATE IT- OCCUPATION MNAMEaRgNt NO. FYfS IWIIN H E OCCUpAIIDN NRM NAME a PHONE NO Sys So R . EYES GHI IE GH I? ?CHECK (?) CLEAS Aw IMRO ANOIHF CODESSH ? ,(,? ] 5 I a ?CMECK (/) 11 vFH ttf ASANUAP iort[agnorHE4A` CODES 1? t 3 I D'lv ? .M.MAN(I ? .(l0 M. ? T1a I pM M wUOr qP, ? MI ? h ? u VFN. lAR MAKE IDODGF CHFV.I IL (-1. SrYIF 13 DR.C vl WAE - I H {HfV ) NOp[L ORS i Cy a 6 5/v - E . NOVgI Y L y 1 OR IICEN PLA FN SIAIE E[e RAIL NO SIAIE H 11H. Cl ???.? yi9l $?/ LJ4 . I N . VEH It IIXMI1ICA1gH pE0 I io Y RtG15RRFDOwIRtR ' i vFHllflgrvl ilCAl i 9? L _ : LATI f1951 MlDplt pHON[NO O of f0 wrvf4: LAST fIRSI MIDgF ?? .]? ADDRt530{OMiRlR W wrvt 3 N AMFago E oxessdlNwRANet w. oe AUNr Dg?_. R ,q2 DAMFA f;;'" 235$ Itiv.u CNMGI DAMAOI IARG _ _ r. C.A.GI EsI?DAMAee ?Dwrw ?RMAIN[D esi DCe DP ' R o o s IS ??W ?REMNrvtD Av Iniorr5? 5 o W sD f.SSD a iw:v°er . .;. ? ? ? ^ er: DIAGRAM Of COt SION: ID w urq m DESCRIPTION Of COLLISION: Ilnf SLRWWN1Al $H[FI Ir MC[SSggr) fR NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ODES I OCCUPANTS/WITNESSES jUOS`p bdirONAI N•M SI N•Mt - 2 stx v. i? J _ R 4 5- R•6 t51R fx[t Z d, [r?c/4 PD a/.r - G 3 7 •rrr. . i '- - ..."s .R, -i frw er ? AMe ? ?•cI ? NII r, $ i?Y ? ::In. ... _._.._-.._.-. ..__.._.._..-. •q+Rm _...___.._ NAI P .. . p fd HMO ?IOrROM ?.Me ?u"?o.?.Hi ?".° w .. ... • I^. .uv.G bICIR1N.wl H•a. q C41 OR •GI NC? vYVpror __._.___ r wgG.Me pq I?7a ?: .I. .Y. • ? S u l /° A21 OSP•I(MC D 4 z ? IOIKI rvED GC3 ? DADdPI POer 8? An OvlDer DArI ? 0 , //03 / k? I 'e t - Y t? ew;' ? I u a f +3 ?4'y7y ?q . P AR 5 s' ? I 'h MW 'A ,i } . 1 T L I F,• Ifu I IT „fi ?? A?°?11 ddt) A Ai1l+ ( ,kxa ?k Y 7P ? .. ti.,a,w h Y ' ? .? ?Ys. `? o ? },) ) L7?}?? V r ° , 1 ?l?'SbI? I AM'. OTOR VEHICLE COLLISION RE T ` A "o. " ? ? x NO - cIT Ff u`T S I? 2 IbN?.o ? " ab ? l , w E - ?a t 1 / » ?E 0. ? gN,gw» .TPI[TgN GT. c N. L . AgYr[q».,N[[T?gq[ ®W ? ., o G ON - n 68340 L NI Ln [CT- ...... , Dq,D.80 0 o P l gAq?q,,.»R Kn[? + n.EHI?q[. , anml»nm»gLN.g NH M q M N 11-111110. ®O I[r -1510NlNV ?s? ®p NAEASOSIW TEgglAtlPla .N-AVl::i _ - GFVEHICtl. q`Y ? ? e ,, a e ? [" Nr[ N,IA ?, x,ER,EgENa.rzEETgRRDAqqR ? NEI ?? D ?o.TNEEr aR RqA _ _ OBJEC BTR,UCK qM T„ ,,,0 mr3 010 :. ,.,-OWNEHOf O&ECTSNAIAEAN4mo9F.s .?gN,j??p , e,EgcoosusE • • - .. 11 "HE THAI Two CARS ..em .'?'.. ,:' WFAE » ' - . u ri:gAL Al u YgVEO IN THIS COLL. LISION OR fLa -1' /kUL?F uO THAx ........ E35 .. _.,-90UTB PE ' O U / /` NQ.ARO p4!S.tl4.. jfffljSpg9 $__-;.; "` .... gOUTE M0. AND EPA 1.0 p NlUgsq us sEPARArE CITY.:..... ,. ,..STATE ..SIP.CORE. M11VE9B OCCUPAT.ION,._i Cbu slox 41 Y RlPOxr •'T.•v'-"'•::.•:•::,3++i?T.A?J:i .,-:w::I.IP_000E, RA.IYS9S.RS.F.UPATION.; L nG.C? WA. ,y33 E T/ ,Q T?... ?.v ' Dg1YEq S LICENSE NO. TATE .SEX, ,. DATEOFBIgTH,.AGE ORIVER'S STATE SE% •,gATE OF, I'll", AGE., i LM E/1 t Y2 f A'.5 u EHICLE Yq. MAKE (CHEY. DOOOE) MODEL (NOVA-0Aq) OY BTY ,(7 VEHICLE. YR. MAKE (CNEV..OAWE) .MO N VA-,,ART) „BODY STYLE 12 OR.) h/ P2 L v /A LICENSE PLATE NO. STATE 11AILEH PLATE NO. ."TAT E„-,,. cNm?83 xv' . LIOEN$E PLATE NO.. _ _..STATE :... ATE NO... .. STATE F7 VEHICLE IDENTIFICATION NO. 3 '?ccz- VENIDLE IDENTIFICATION.NO,s_. ,. REGISTEREDOWNER(LAST-FIRST-MIDDLENAME) DRIVERS LICENSE NO LO ) /LNl E/Z fa P /aD j RFLQWIRjE4 pWNMJLASTTF,IR T,.M 4QLE NAME), ... DflIVER'9 LICENSE NO. .. OWNER'S ADDRESS ,.ISTq CITY AND STATE).. DATE OF OIRT111- , ? ! GIGO r 7 '? a? NEN'5,AQPR9SS_ ... ISTREET.CITY.AND STATE) DATE OF BIRTH ? / / r> ! Lcc/1 R MITS OF VEHICLE DAMAGED - - SOF VEHICLE DANAOED • LIABILITY INSURANCE INFPRMATION-VEHICLE NO. I. WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON 'OUR CAR YES El NO NAME ANO ADDfl OF LIABILITY. 9URAHCE PODGY HOLDER' - .,,:e;:. .;?ryrNAYE OF,LIABIMTY. INSUFAMCE. COMPANY ?... M ? I crr sr C ? ' ? , O G-.$ O? LU2 4.?- ,'3 .ff) CJ Cl7 NAME AND ADDRESS Of LIABILITY;INGU9ANCE AOENL ,,,,,,,,,;,;; £dT!?„??.. _.V ..-:fie*t,,,..a,?IEIiY POLICY NUMBFA D Ek > •Ty E1?le?A2vct? FGroe . Y??T? LK'T 9?YG 1ST INJURY YV ./ YS dG•T ?/ .. . ... ._.... ... :..... -.._.::.:-:.__._-_.. _...L /?.GE 1N?DINJURY IuSF 6FPAMTEA PO fOq AOW 0 AGE .._... __.___. _.._.. _..: _,.. NAM IIlNgEO NAME ADDRESS ADDR -S' ESS NATURE AND M F r NATURE AND E%T ENT OF INJURIES ? ? EXTENT OF INJURIES Li Li N R CX DID I JU IES REQUIRE D O CT OR' S OIO INJURIES REQUIRE EXAMAi I ON BY A DOC10flY ? ? ?O NAME NAME EXAMINAT I ON BY A DOCTOR, DOCTOR'S 6TACUS Of.IN URED MARK FIRST ONE THAT AP.MIE4., El Hsu 7a »u» q _ :.;.t•,?$IAIVi4 QEINJUREp ;I, a.);.;J• -MARK FIRST ONE THAT APPLIES . N ""' lu ?ni iu w p ` : V"] n pq E u ?vs En NO ... KILLF¢ s[v[ni 2.1 NO I uriox . or " el I [ ' ?T ?c 1? ? 5 ? 6 El 7 ? O a ewnnE Ul ? 5 ? 8 . 0 MOTORCYCLE SAFETY: ? HELMET USED El HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED 13 HELMET NOT USED SHOW NORTH BY ARROW N C C E •1411[%• pW1M1 '.. ' ' ', 9E T ¢ O. ERIC Y MUMpER ® \ .l:M1A[MMS'?uaL ? ;. ? ?,\ ' _..._ .-_ _._ _ ?1_( .Gt?Tv?-_garos?J ?ctD?.?ze 1zt,?t?sF Ay2 _ St?f Q ?!t ? nlgTlo,.w, r[L..AIr•gW '? r -?? Qf- gnNla ? i Y._2 A reat C.et _.. ZZLz Ivy-- + ti - .. ( - I T - -d.Y1.L _?ytF_G•G 1'+?GS?-- (?.1?•-T.wt._ . , • - ? .' : I1 -->nt/(i'I?LLJ? _a_Jf! L LFLSEaL ?Li' 461. .. a tr f c L ?4LG t z _.__ ... Jw _A ._ i g VEHICLES POSITIONS BE FORE COLLISION NlR ,s I dVESTIGATEDOY VEHICLE N S E W ON STREET OR HIGHWAY NAME DR NO. w , F 0011 13 ? ? 13 ?wlnur ? ? ? ? EING u 1066.16 FROM TO PEOESTRIAWPEDAL CYCLIST WAS USING, I?„P, r?nN +? ? .u • u ?a . 0.1.. ,?t 1. r [?•q PEDESTRIAWPEDAL CYCLIST CLOTHING COLOR . I?I,q„ 1?N ?q,A • r „ I?ne [o rnonHllcrxl r.Nn nHUC+w, .•.An 1?A°,AN 'L s ..rcwY ere . _POAD SURFACE... ....WEATHER-... ..,. LHMILg4N4!11DNS .-., -TMIFIG-&QR.C9R4,.,.-_,_ KNn w, C ' . ORIYLN,Y&HW ACTIONS " cA1 Icwa ow, H..a[ I ®oA,LIOxT " I v[wcl? wWO:[?1 I y[NCI Kwaaw oP YO•[I 1 ??' 1 F ?DAWH ? , .??'T Slawus S?P,wAgr 1 ? [I01'SIaN ? S ? 1 ? ONE WAY f f ® TW¢WAY p ?r 1 ? GOING STRAIGHT AHUO ? F IWtT Y OAR?STRIIT ? i ?'If106gN C3 1 ?61'QW 1 ? D?A 1 N[ . FIEVEA O?61B1! ? S ?g ? ] ? OVIRIAKING AND PASSING ? S ? MAKING MI.1 Tl++N A I 3 ll ? uaH130II r_] • ? IASH•q Rlb ? A ? ct ,0- ? A ? NT" =,6,,' ? [ pl " "G LEFT 1U.N W I 1 1 ?11K M,I 6 =? IINLET 1..'$ ? 1 ? ILASHNO-0111 ? 1 ? ? 0 ? "'t, ::. ? S ? MAKIHD U•fURN SPIC I, I ?SPICI(, ? 6 ? RR 6IGMAL ? ? t ? L! tTUNM ? S ? 6lOWIND A AOWAY T? HOAOWAr WR?YJFLLAC$$EJJTYNE. ? I ?MIN:Lq;ILADMAN F3.81-z. LI?I LJ ? ? • E] OT-, -CITY ?? IG ? ? 0 ?, ?y{.I+t.,I ? S ? 1 ?pgWlW1Y .IgA¢tVAF1A u ? A ? Oly O p E] I STOPPED FOR TRAFFIC E] f/I STOPPED AT SIGNAL 6 W ORSTOPSIGN ? t ? ITOPP(0 W ROAbWAY ST RANG N I ;I ?I ,I I 4 .?a7rw[ PRIVATE WAY D.rt of conlslon cool n DAI CO i / - IUSf ] ioD?OU I ?E LOONEY CIIY NO. MyA RM L O TOWN p ?t ? SrRFFl04«GHWgY itt Cll ROVEEOIE t 1 n oc r 677' o , ??` ° ° ''? o'' ° N EREFLr RFF q NON NrfvHCi ON PREN% f Mllt •OS? N BETWEEN SNOT d STREET / D?SrgNCF SU aFMr, NEa MRfIEafNC[ CvOS51ER[fi OV rvfARFSi rn uYO ACCIDENT AMP DIA eAM DAEA S N S MILEAGE R iFff ` W OP Co. coo sloN Nvavm sfvfa n: N afE RROAp Rifv[YJCE TOiAl rvO ORIIfFD?NO. NJUV[p_ ?sP ItAG[ ?Hr6 RUN wnogolw IMFR Cl3 CROSS Sl i ] 2 / q]( O Cf VEn<l[S © ?OROYEeEYOM1AOF ONLY ?cF ?vlatlE 00J[Cr SIRU RINAMf Of OBJFCi51vUCx ND OWNEe S.YMfI sI DM qGF SYEC LLCO OWGUf s ,^ S UNIT NO.1 UNIT NO.] ?VEHICLE PEDESTRIAN AME 1 MIDDI[ DR VfR SNgMf: ? PEDNCVCl15T rIR " 9 0 e G /? /' T sreFFigooa , TREEr paE15 C nw b O Ae Am inlf ZIPL IX D S O vnONE NO. N l f CENHN VAIF Tnff 0 El H .° Rq. ?6 c` y E DAEFa BI rH TO!? ? Ko SL M ' AAZ OCCURA[dt INq ENO. frE1 wEIGHI RIGHT ? tY?pR l 35 5/ E R M OCCVP•IION hMF6R ENO. EYES WEIGHT HIOHI e2 ? v ? CHECK (?) vFHIai. AS+ EM FFa+NOr«fv•l CODES ?+ ? n ?.. . fs'° ! Nee, DN 6'"Or'6 s nn ' ECK(11 A lM?norFFa AN"W'orNCR+' CODES?+ ] ?.,ve. --II AnN v 5fx N A ?° °e?e.:'i ' ,ro .ss . s:vr '?'"" ? N uarFS R M E v[MZnR M MOIDODGF Fl?j DDnR816. E.NOV•O 1111.1.2 ?`1wCu I v 'pN I --NCII ? ? O H D Iz I]D ONV.I Y?v7iG G ti '.?-d?2 E H fA .I MODEl1 a NOVAI (o6 /n?TC ?, r , oR / ? Ice N' Si r IFe axrz ND sr+rF H . vEH <aoe l ,? (• G•/ ' I 1 y / 7 /7 /J C keg UE&rlas Gh4 - V(«ICIEIDENTill LAEOCIN v101SEFV N i Fe. fIR LIf IDENI i. ?i0 sH;597!31671 1 i l ? ? MIOpt ?av T A ell OWNS .HONE NO 3P?L?ii w IS DOWNF9. ASE fIRSE MIDDLE Q C?ovaS ? - l? !e I ,, E AMeAADDetxiolNSUeANCe eo Aewr R i(Jpn1u Z DAMw-IA ,wNoNM C«ARGt l CHAOGI 6 ' 0 1 C] S7'REMMNID AWAYN W s 000 WAI61? w AI R Ie DIAGRAMOFCOLL15ION. 1 u NAE INDLAII Np r er ARR H DESCRIPTIONOF COtLIS1ON IuH Slrvne Mf rM SwtrP NteesSARrE . _i I 1- :.. ( I... 1_ 5,11! WUFSAR S.. 1 . NAME. ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES I Z 3 a 5 6 OCCUPANTS/ WITNESSES II-All-IN1.1- MDO!ON+I N•W +MF 11 SI _ ... sl. Au urns I ., , nsER o u'0r I WO •MI R N love r ?qM e ?;y1'0 "' . El ? ]D P iO? v . 4',5 J. a[,MVID IVdn OAM A'cl ? .?' .0? .... I. '• ? ? v MYlss Egnet e. w1NC. 'S • • YlMf e. " " O.WS p 011.11 ? ' x ..n•.___ _- _ µ 11 • y „r ?q!Yf «.J, re .u r,D .2, 3, wna•Tan I? AY fe F . _ n+n 86 . - 1 , i d I L d y?;-u2; DER fin.' ux`i 1 Jf ,. mR g „• > F. ' n ?I t -{.WIP n ef?'$YUi E.: I/. vb., } is f I iFw /Yi t t i yl I t v?. I 7 , I 1, r Ji iC ti. I 1 1 ' - M Ir I'7 t `t I.f 'pl POLICE TRAFFIC COLLISION REPORT LKTRAFFIC-Y Roucfcaneuwrr+ BER' ', PRIVATE WAY Daeorcous N •r Ar u rv nmE c IuSf ].DO »OVRI ourvn muElrr urvno. iNwA ?URBAN URA ?N ?f ? N C O Owrv Nun 6N0 SrefEr p9»GNWAV iCIU pdElE lEs ?s Ww NO' A ON r rF95ECr N NG WVr»SER[tt 04 Rpap rvON rvrFRS[CrION ? RREfI% E MITE POS D / ` BFlwEfN?- SrR[Ftf ?_ STREET ? ?? I pISIANCEBDRECRrI nr40m Uf eErv F.CPo555rRffl Oe rvEARf3r MILE ROS! E ACCIDENT lF5 S MILEAGE rtfr W Or CODE M DI RAM DAEA col rsroN Nvav[D vER r DIAI NO NO.%ILFD NO. NIVRfp ? SvIIIAOf ?»lSaUN om ® s "` OR RffEM IMEq C% f° 'c"IlOyyy ,„,.. / "' R OvI,Rc. RRORRr DAMAGE ON1' ? pESUIi[D ? FO1clF D Jam ^ L o"Cisio IEINANEOi OB,E<r STRUCK AND OWN[R'Sr=EI E3r p =AGE $ SRECIN CODING LLEE 3 UNIT NO.I UNIT NO.4 ? VE HICLE ? PEDESTRIAN ? PEDALCYCLIST DRN[e NAME .r r R" 114 MIDDLE ?µ _ Sr RvfR'SNGHf: U 1 ' ^' RI l SrRIfIApp [ SrRFfr ADDafSy r ? raiF NE NO. COIX RO D E r 1Y Lry 'K LA Cn R C LMA - ?r O[ DRNE?SI NO . yintf f% BI n I ,v fN5f N0, ya % pAlCw RIN l I l r` VI(? ?= ° . ir/ ' .cup-0,1 NE o fr s wc ur a c»r "'V•' S M E uRanorv AMf 5 RNONF rv0. rE5 WEI »r IE G 1 a Q, i R 61 i R ? CHEC K (? »aE AS:N wovr[EO ANOr»fR: L 3 'IT ,e oxyL CODES ?' ? CHECK(?) »RE AS AN XROVFFO ANO1MRAl ' ° y° I a s e AVRIIS CODES ? y, 5 N e wen'Su ?i Msgrro C.MB. Mr ?ELK' OES F. H:K`! IMSEIDODCE.c»fMI FLIDARt.NOVAI /Strl[ IRDO anv l DN -c 0 ?N° A MM O V ?GI?vOI%l Rlv a v " 5 , :3e oR Nu l H .I p ( N) 11 I I TYU2D-C ? VW I.IU?/ ' E a l sere R0.AlF AI -" » aoR u[FR$F7ITFR N l A 1 - (? 1 C a 1 ' W p V[»Kl[ D[NrNUtgN NO 16-1 vEGRrfRlDOWNFR µ5r 11451 Mlpplf MgN NO L vfn Clf OFn r N R SgRD - E . O W 1A31 flRir MIDpI -NE NO ?R1JfR 14 ADORESSaormlR e 1 Z N S VRrd om NAM[4 ADD/USOrINSURANC[ CO OR eGENr T - ifiTfSS9 Ra I Ih2h Coffin OI A R L r DAMwtpweA 1 Nwcior°iu pq rp ' CNARGt L `,_ CMA9G[• -_ .SA 1 ' gAMAGf ,vIA : 5 A t]r .1 IDEW N RfMNN[ MD ?rvFN E9 p?m? rt,; r $ EOI Br W ? TOWED A-1 1 $ re, . / DIAGRAM OF COLLISION: ,iEUfruwctssN.q I,,, ;N puNRO/r» T. . _ _, T DESC TI 11 ON OF N11 COLLISION W 5 M[Nru uA rE t f - i Veff R 1Te%fio ) a-i= A? fl a ? CeDAIZ _ . _ oP Ness• CoAr C2 RAi VeI? w 2 _ w l l! . (?1e51 Ca3NQ1C IiD Vew* I Tuf NQO LFY _ Igj ?I ' ... OL?Io Ed8 Nc?s-cnrE?Pa 4 Dam ?TZ ? v _ I .__ o> X14 2. Vew* 2- AT .,,givo, m Avo,•D mJ gI IL Ll ?7 A ILS RIF , 1i ^ SsoP ) e 0 ?¢}? e 1 WITH Ti12 SE Da 6 F NfR Ve)4;,L. LI IJ li NAME. ADDRESS 81N1URIE5 OF PERSONS INVOLVED ' CODES 1 2 3 4 5 6 1 OCCUPANTS WITNESSES 1Pa:ooro.::ivA+ .MI vii sex Act r:rm '"" 11 .11, Reelo ?ter A oaa, •96°' ? A.AB ? FY'." C ^ . ? ^I C :YL, B ppRt55 Avl N+rwt or , MOrsp,ROM ?, ?."C"1 C" . C : ? 74, rA . EN,.r„ ;Gr 5 r„rrB. ? mB ? ? •l. ?^: ? ::N. w r ~ ? • wc.l In N.w aR. N. rc• a F ¢"I, wl1•u 1 ID n Irn o ED e. X ?.krT-n 1 ?? tr !R N r rn W? f wr' M? i `q ?TRAFFICWAV POLICE TRAFFIC COLLISION REPORT If?•`? PO IC 2 PRIVATE WAY [] f CUMPIAIN(NUMB .. : 1A . DA F9 GgLI . _ _ Dql p nvE muNrY i r. w„. I rul1 n (UIE-HOUR) CDuNr ND GIEV ND. { / ? iB I ' Z I I/ 2 O .?EiPSOAt BAN ? DIN Qf ?IN Ctv OR rGwrv NAMF6N0 OE fEt OV NIGHw•Y fCrU gOUrf ONSr(Eff AL MLfS ?S ?w ®pr e c ON C - NI RSfer NO.1. I9CEt09 SOn o G 3 Rio Y IaN mregseer oN • ? `IV II"'L/ - C Y rWFfN 11RFEr E IME, OSIANCF60 IMr M 4091 F9fN EC90s551vtfi RNtARFSrMI 5 v9ef E .MRe rosr f5 f ACCIDENT S f MILEAGE {fE w O{ CODE 9 0 GRAM (MIA CIXIrSONINVIXVfO NO rv IOrAINO ^ O[LIEO?-NO.NIUREO_? O59LLAGE ?„rr59U „rNOerOi. N , IN 0 N N 11 SrRff( R9MpOq aE{FRFNCE INif9 US CROSSSiR[Ei i If?• U VfNrClfS PROHRIY-AGES ONLY ? pE UI(f0 ?vEaCIE 0e1(v..... 41N•MEOF OBIFCr SIPUCS NUD O ' 5 OR ROAp 6lrA.j c=O /.? WNC S-I, [Sf.OPMAGF SPECNI CODrNG l6E " s vtNS UNIT NO.IE NAMES usr nvo LE UNIT NO.2 VEa De s NAME: ?VEHICLE PERSTRIAN El PEDALCYCUST usr sweernooaESS PL ? • fl (] U G?{ t C CG L ? '- 0,3 <rIY sraEFr AoD9ESs - ZSC? dJ G-v??Li --. AIE ZrP CODf ONE NO. / W wrr- 3G SiT -46,34 D R r , _ . a P l ? ? o ' 09 vf4511 N SIAEF A . f o f ?d L L? w f &3 d7 /P? S L o w C ?e ?7e ?? N ?OcFC L sr E MD°?22 ? 9 OC<UPAt ON INAMf69raNE Np. vE5 GHI NEIO t E ?? CUPAI IX+ MNAM(6P NF NO. YES WOGHI fE GN Q r i. ? CHECK(,') vtH LIES A unPEOrfE CP •.MiorHE4"' ? CHECK(, M.. o CODES w* D? . 5 r 6 ' Au nu +Kr ' ° E ? EH CIE PSArv DMa vEEO CODE * { N 3 E , N r NOm f 5 S ? I D n .L N N uerr?rc t r R x YI DM ? Mw ,Al ? utir' o za'm, ? E ? U - icl ? f NfE ? u , K,t ? rs airt9 ? ? A d IDOx1 GNfVI MOO(11DA9f NOVAI StvlflRO9.C VI ' o . tfA I EV.1 MODfI 0Yl A, 10 v 1 (72 l V T 'L g M 0 IXDO U lrv5FPU1EN AIE E FR2- lw 2 S4 '° a•tIFR Mtf NO. SIAtf Z ?? H Mt„.<«D9 N I w ? VWICI[IMrvrIIIUraN NO. C 1? FH ?OfNiE A ? m!2u c /IZ I !y! 1017 3!7;29/Iv Rfasre9foowNeR. lASr sr MlottF PHON(NO L fi•o181 III I Z IffS I I esrtam wN 3 . pa t Q 1/1 YN / O E9 w1E Nasl MIOIXF $ NE 3S 13 •oD9fssa Nt9 W r4 I 5WN-1. M A m Z N A! 1 4 LeC N•M E(ADD9f sua ee eo o9ACENr E AA 2 R -7-1V A DANADIDAe[• ? 4 "° o•inAee u c? a„A9u cHA9eE fro rwPD, y ?- ??rm?N ? ` ? E ...- .- s m. D.n+•c( g[-yiw?e? ?vEM.uNfo ryD9nw fsr.rounACS E IDfO OR .N Z AWAY 9EM•INfD • 5 ? - 5900 rd `T O1 ° ' a ?ew?r er SS?YJ•CL/ `er M DIAGR?M"Fr_OLL1510N lu N- NOr+."N- DESCRIPTION OF CCILU5111N Ilrs[su ruM[NrAx sHfelrE rv(e[uARr1 1-L?D ! ' N °"t J?loreTff ?%- c Er1 - - I 1 t- ? 6nvr r -i I PHST azo_P s1 G-? L/T - - - ? E , -- - -- •- t __+_ Y?'l d ?1 j-4-dm cii Y G ?L TO I I f ., f . I i ! r -. - 1 NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED r 5 ??? 2 4 OCCUPANTS/ WITNESSES 'I u` "o.liur?i:Ae 11 ^ R r 3 ._ , _ S 6 ' N •Mr ,E q SIN Gf IAfU1 ' v r , E [iA1 9(511 NICI ? Cv Arlr. A ..... ...... ... -11 ra " Nr`er ?AM e ? YC" ? ? . ?N r ?mll Al DDarSS _. ... .. ' ... NA( 9(Or ... h V E U 0 atV?0 r9OM ?Awe ?Rnwl wlr •ll ? n r Q r ? ri b A io r IY.•M ,., e•xf v» . ? 3 L C•n CID1PArC?tC klu0'd D All fl, AngvlOer .1 All w?? D WS t; 3v rVi/nQs / ° nf??? µ Y Y ?., n?v?Cv i. ,. ,?' ?.,. ..?; n Jy ? _'?L r I C •J'.. I h ..Yna y yrr` -ta - ? M .: T ,. R ?{Sf? ?. tt ? E.. N 1 1 5 T N ' eF ?? •K ?M Elfa r3? 95.'5 ? ?r r -? yR! (m» 9 !v- Z 2 1?1 rl'41`Ui4,,1°E" l' -'A ""lJlllJ ea"N E jIM' bC 4 I .i1 ? 1 tr _11 Iry ( F Y ? ix I + , V?} i A I. . t? F. Ilx FFFF Jr is ? E 6. SE POLICE TRAFFIC COLM%N REPORT [I4 TRAFVWAYJ rouc IM eFR ?. t PRIVATE WAY _OrJ4r` p•?. rlMf O, ?p IU] o ?usut w:, `X'e?aai! anN. couNlr ??v prA u IDV l I ERGHWAY 10R O SI¢ff O OU1f OR tRFF iCfC U¢ SECT '.f pN cp Mnfs s pw for '? . O -N . ,, . " ON BJ TB? F? _ , ?? 9?? r11 1" . [FI 11 111 NON NIFRS[CIION t' RB/ 1,Ay?y.1(x 4. .1-IN S,PF[1 6 WHIT PRfil% t MILE POST DISIANCf6 RfD OM Rf EVN [ CROSS STRtf111 NIAIIII IE POST MILES 5 F N W ACCIDENT MILEAGE 9AMP D RNADATA ' Or r[FI MODE I E I STREET 4¢OA00R 4[(ERFNCf NFV[v lr. COII.I.NNVIXV[0'. NO. INIURED ?SPIIU•GF ?Hn6RUN O KIItO qo DK ?N ¢D IM[9 Cl5 CROSSS1NfR0¢BOAD ?- T1- NO NP[I,FD OrvEHClfl PRORtRIr DAMAGF ONIY p p".1., N -777 e ?- °x. Oel[CI STRIKKINAMIaoaIfC1519UCK ANDOWN[RSNAM[I t51.D AOF SHCIAL COD ING UNIT NO.1 UNITNO.Y VEHICLE ?PEDESTRIAN OPEDALCYCUST b $ ORIV14 t: LAST IIRST if $uF?Aot.E GAY L. o D9AR5NAMf TWOMP SW IQtctfftRD 40. 514! !1 ADJVE55 o I? iRFFr ADDRESS , oA - Ave. Si 9cQ 4, No (? C11 /O r SIAIf IIP CODE NO ' pLoCK Lt IA CQ?3 PJe o/2Q R . 't y? jMUI+IA aA Q6592„ g3-47 12 vS MINSEN naru? isa SIAT[ u,(? M B n M I + I V v CtN NO f TN6MPRD333 BS ur?l _ M OATFOfB4 td n 5 2 O?C?pAr MrvAMt6 NgNf NO f S HIGNt j1, 1? 7 E R 6 PHONE NO, 5 GHI NIGHI OCCUPAI ON IFIRMNAPIE [ei?Aautwt cc . R u. D. Btl IYs ' p CHECK(? As AN M on A orHEau AN p CHECKW vIHInF AS AN MnorFFa ArvomrQAL MN, x S r r?on "'D CODES 1, ? : ° A Tin < i:sn`M'? 5 lxnwN 6 iDnr v° CODES W- * 9 c-%,,' n 2 . R I M d o IN MI DI F oo O AM. I. KL ?u ? b"p I, ? , N M MD' DI DM B. O MB%.N I O " O ZS;_ O -M, p .T- , M ANK?FIp? I MOD[! (DA91.NOVA1 Str D CONV.1 vfn vFAa ?7 WIAof} 70 -C E EAR 1 V.I MO [(DA9I?NOVAI ( V.I WjO We%/ ? 7ay1 ?(K-B, -;I. clad SF PIA SlAiF 1¢AiIfR MIE NO. SIArt i4A +,"s6 u?A c H rt a ?tec L1 Fa l6b6 lu 5e9? l CIF ICEMI(IUIgN NO c;r-1oS?0 ?f L DENIM 14101Z-i ?3b q 171 n_ vEGi5 1ta1D tR - ? m a; E PHONr NO. W VIEGISTIRLDOWMI )-i ?k t IRSI IDL%E t' n 48?a0i1R d?M ?A4??ot?C N E A6 Z _ rv lBADD.t uMON rv' R 11fECO /*Awv?Kce nJ G6' M d :3' MG, f . x,clon,u cHARCr '. CNARGf rn.I.B„o BID. •IDr v B ISI 1DAMAGI ? ADMr !MAIN! AWwVN ?R-INFD E31 UAMA _ 14 O o 0 3 ,oxortU OwiD w f ? s, 'p f0 ? WAr Br: Ar B IPTION OF COLLISION: IlA[SWPIIMEN1Al5Hrtl li nfc[s5ARr1 EN DIAGRAM OF COLLISION 1 -n-7 1 P 1 - 2vt _ tn -?cy7?6 ?N1?o7 mzm N? e re_ _J _ r -- - - . NAME, A DD RESS 8 INJUR IES OF PERSONS INVOLVED 'CODES I - 4 3 5 A xsl ur0 , NANF ° .DD.I s nw n: p•kB 011"' N.NE o „ 0n. v O M1 INr B. 1 E.ANI No .real ulwbi' OAMe ? :.'O?d.,t. O, AII G a.{la s, .I..?1??? __ •`E5?4.?.s,f X K .r? AG ?-I /,Q?c?EC /}IEfiKryS] POS.e3D 1 hr`/-_ D.IIa!Iiwl 7I// K.'RDB. D tG o-? .; ;i v. 1 7 . r k YK ?D ; ?- M4 ' ". TLI L . l U r, {. SF ° 4 .'-', a ° I ti i IDIMIa NEPORT " ° (AUNTY CITY LJu "AR a,i noNG _??° K?1ry c°°N JQ? w IrOrJ "ts °"wr " ./ A b 'N ''?1 X31 S NO. 3 0 q 9 ? ?• °," . cL F?%T X. PO`. 't`r Whse? 1114 S?n1a °?e f' °w O. ? . Nw .. 0 o a aX° . D ?` °" ? `° °" ° ? ERL°s3A °°""° ® "°" PTNDaihEf,D?aDADD El T- ? ? e??,; .,Nl? e.?LDarLa a r b a of%OENCEOWOwsiXEEiONNOA OQJ?CT P7gUCKy?, ;_'::rr!NA4f?IDwE=rmwau .:..OWNER Of RPJ?r75yNLtf/E ANQA E9Sr fR°ae F.P $ ec°oea ????OO N?, ??''S''?? E ON STREET OR 0? ? ? ? aN E1t.. I J ? ? ? ALONG lL CYCLIST WAS USING '. r ??L -L CYCLIST CLOTHIN13 COLOR y`v?6,' L?11 C -1!C I J° CE. `G 1 I`- R?4 $ ?4 ' _ ?` DFllVERB LA$T NAM6 .:;i. _; ".:T?dsT.dnrs€ i Yro Tw"s •t4 +i Tc, '?. _. N EP-•EIRgT.tl4l1Z•, :::SS;.?.,:,.L?1PP6§..`::.:. Y,? '. a N t; l J. G C L co o rvI i o11a•t..?5 ? e e- M- TWO 'r? E` T rW. ."piT?,ri2,.dtl.Rk41SdQ? swEnE rd&E?hP.BR€5.5_.,x:'• ., o oA DBQx D i•r.& ,?, ??C So JA ?IGsa . sLt.c ?-t- E A n_? ._ -.r s s,ol T1l 1• ?A Ed?? ? r, 'f' D w L.S+MCIL v?l.? `f $3dY }J vl ri ¢. E aT MLR r JMFOPF DR!)IE s Qccupnrlon L .DRWERB.LICENSE NQ N,o TE pO?.F? DIRTH :AGE. ORIYERB LICENSE $JATE SE%. ;,DATE OF, BIRTH., ABE. IAN, p ',, 1 , TIJ SS4?FF 0.M L Y , 11 " , M AY s .:.q: ;ZL : r I"rYr .. AAEJf.IEY.WPQAI .MQPAANQY?-BHL[L Q.o2 Y4..1 .YEtU.G4ln.Y8 MAKEIQ7EY,.QRP9€1 :.MOD_ (ND A-DA T ° vh l 7 ?? L S pnl-T 1 j)P? R.1 .BODY slr?yLE Ix.oRq ' {£'.?{'..' LICENSE PLATE NO. ST TE TRAILERPLATE NO.. I M? SI?RI Ll1 > 7L 6 STATE p $ ?/7" ENPE.F1hTE110. T .. AIE - - , 11 IO --. S LRAILEfl PLATE NO STATE .. >•t:: VEH104fr_RLENTITLCATION.yOe... .. ... ?L LL?I C S f 3q _____ _ xEtlQLE1QEnllFJQATWlLNO L r G- 3 9 s l u HEG4T_FP, OWNEP.(I.A$T?fTNST MfO`D'LEj1MAEf. -,• URIYEgS LICENSE NO. .W,_ _ S14t}IAS j [iQWN€51W, IR T•-10 AME I ?L G4 ?I JDLC` JET SuP rI?YSSgg ?PflIVEP'&LIQEN$E NO.: DWNEH AQUEiES$ /-L9 EET..OITY ANQ fJ . PATE R.PA h Tll:. A4YtlEd6AD ,__...... 0'#'31 .orFS i't` DA sar-e tLo 0.101 r1L DAY eE55._._..ISTPEEL.OIlY.ANG+9TATEL ..p0.TEOF PIHrq• P,WµTC9 OF,V`EaIICLE DAMA_OEO _ _ _ F I r PART$ Of YEI{ICLE OAMApEO. }} N LIABILITY INSURANCE INFORMATION-VEHICLE NO. I. WAS THERE AUTO4oPILE LIABILITY INSURANCE $ COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ? NO NAM EAND,AQRRESS QE4AB14TYINSURANCE PDLIQY.MOLLEA_ :. ,,,, ??:..?NEAf,LIA914RY1NSUgANCE,COMPANY P°hEU ITK . ,.:, iy M E .AQP.NESS-. _41. !!•!TY.INSkHAdS Lr=::: K G_0.• ?0.4" hSurNv?w q u.? s Q '•'`'?? FLQI?LRL E `r' '-:. .Lb b Or LJ JI•GJrt)Y slr ?'^"'-"^"-----••--?•--??- +.---•-..-......_-.•_J.,_,,,,`- A- GCE tN0 NJ flY IUa¢a?AAAT?E -R[POPT IO?AOBT?Wt NJURILLI AGE ,a NAM I'I Ai.I wAxleO NAME AOOi1E55 NATURE AND RIE$ ..STX, M F ? r "'INJURIES RE 1 E. NJURIES REQUIRE I--I DOCTOR'S ? EkAMINATION RY A DOCTOnI P:J AME ?,? `` .STATUS QF INJURED M ARK fIRST ONE fMAr APPLIES r4 - : C3= _ NO. .. ... xALLO nwLn M W rw P ]DI1 L NNE r,r ? S? °?O s? MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SHOW NORTH BY ARROW IN CIRCLE k l %l NR l M" \ -. wrrlQ ?. - 11 {. i; MAOL S-t O 1?: ? rnPyy,. 111 4 O ! ILA rt H%.L t y??"' alll.w "I ` I ,' L ?? EOESTRIA c. o"Ir Y° a i n l Ter OAY Y V t T I •4 t? wtT 06- • ,? f • ", ? f(? ? I {PlGl1 ?4 4f A L t I tt '" ' CONDIT* ??..?? 1 14'p?LtiV°" 1 OArl10H1 i ? DAMN t ? aAwrNO ? w. t ?•Nr'b N ? grrra ONlT I ?loD { ? Da.mlXUr O nu ND. .. KILLED B=- 0 uH ? 6 ? MOTORCYCLE SAFETY: ? HELMET USED VAY NAME ORNO. DWCi 70 l"T c ? J? ?w°u .?du w". .?a TRA(a IQMTfloll L?wTLAONQAq ?I 1 ? ap 4S ?r ? ON[ "N? ? i Gesm MON ? J ? -LO {ION O C) VN[aS DL[ ? . ? IIAaH . SFX: u M F ?? IN N7APRLI Ea' _ "IN.JMri I s ? °. c 70 31 ? HELMET NOT USED LE80Y NU48ER? , I rA?.hLnS LILIIi.?! WYID«L°I?. ? FROM TO ? ?Iw? OO NO aTNIOIIr ILAO YSAn ? 1 ? O (AtA NOANOPAa{,NO ? T ? MAN NO NIOIIT YUHN I. Y Yan L f t 111 r 1 L } OT D.AA NOI I wU hl0 ? l I?OOPrnAwlL ? 1 YANINO LLIT 1UNN I, J , •?I:P[L?IrI ? • ?aiRllrLpnT. ? 1 ?IL•LRNO •YaER ? 1 ?.IIfY a NO U•rURN I w0 w.r. i ? Miff IY ? ! ? RR 1.- { ? ? YAK, ? ? `[µr fUw ? { ? 6LOWINO =, gOADWAT{URfACE TYP[. l3 p ? ?jr('f ..,, I 0 DINCLmn,nM"" ? ROA'D?aEVA AiAroM.., .. ? • ? ? o nior°on nNALflc Q Ornl TC rr I 1 y r U ? [1 D ? ?DV0[R ? { [] STOPPID IN ROADWAY l ;, V -?• ---.L19riLvliL.[, sa.oi.YCC.?:t'.?_ ?,:?n. _ _ I.?. _ .. an _ '3.. _ - w we MOTOR VEHIC OE COLLISION REPORT mLln coon, µ couNrr yL Aro ows No Ng, T ,T t(PUn. y[?wu[w? w YSFBn®w ?e 2y3c...() rJ .3 ry a Ng3 ?n ?L ? n s MM arI n.°HnAY .? [ °A[I°[ °wGwIRIII ° 0, 0.0.NPu t•Tow' ONT.!`• b //?R ° _J °G2»%c` Dnea M.IXT .1 -T E p p NL °[,6w oD ?R M° iA l? ToT, r ? ro+awL[?,L ?E ?`0 ? ® ? [ ? an e II[Ru e:uwor°i,? BRA°:OIC ? Non EFFAF[ycEOf.X069 a IET Oq Hai. DB•IEGT AmucX .,. ; I EnFVwecF[wal.. D 15 ?I ?oOI,S'C [ tt - WHEN OF PBJECT$NAME AADDRE`? ?? La ?, cc° E 'K}.: LL Y,, S o-t Y; T -E .LABT _ .. FL._T N. uE ...YI)?LE•. W Wo 4 AlI'YU2'. - -N-- WVIV EAR F '-BS$i NAME -•;I YIR4LE...c _.. a COLLISION ill nE Fns c F .luE EA . $Lq(Ei AOOflE59 ?-' , L SEPARATE h pTY.<:itir,•T.,.:::'..;.@Td7@.?;:: CP64?E<,EIflWEfl9 PGcufSTlr m:: wusoN ITY. ,.,: `..... TATE I FAR ?g000E ggIYuFR6.OCPQPATIPN,,.; I X51: 9fr'36S ?+?? REPORT ?" flH'ER'e LICENSE N0._ STATE 5" DATE OF BIRTH _A L SIYFRSL U1SE,N0.+[+-+.•r_?..........STATE SE DATECOF BIRTH AGE_ • ?A1Q u ? 2 3! vR `. a - u Mo vR 1 YEHIPLE ft .MAXE.LPGIAY, DOPPEI Moo€L IHQM-PRAR L .W Pr sr L g ,L KELtlfim mmklcmy,,pgw._M 6 .D[?.l!IPYRgAfl 1. 9Qgr s[nE.IT oR,l T che? O-AIL U V !O N _ ^ •^ uCEN;E.PLATE .NO,. - STATE I„ I - LR LEfl-PLATENO STA?g„_•?- _L1P4N@EP1AT@NP.. _,:TRAILER PLATE NO. ...:. STATE ,: -YfC1Pk&jpEmTIFlGAIl9N.NO?...l•./-?,.? Ct 8 ?/ /?L.IOL.. . e IfFiJISLEJGEriTIEI?ATl?N.R?.,.,',,.,.;W„ ... .. .T I.BP4E .._ .. ?: • Y+ IIEAMERPQ QJ!(HEI114A5T-FIFIST.41QQ.LFv[(AME)..:. QjIIVEFIS LICENSE. IaQ tl a& - fY01$TERED OWNER (L/y(Tfl IjAMF,J_?. ONIVFRSLCEN¢NOF-,y? ak[V C'? E.)u ?WtlER'$AD fl .,.(ST EEi. CI.TYAN YAN .SIAIEI _.;..,_ ?DO7Eo0y- I T .?riNE3:@.ADARESS-i..J1vSTREEf?I[YJV(?,BTATEI,..: .u..:..:.'.: 'DATE.OF,.@IxTN,, ` Ar + "J PMTS OF VEHIC. ,_LE OAMq `OED,,. - ... ..- RIvN•v°FE i° .°FSPARTS OF VENI_ lE OAMAOED 4 , - $ LIABILITY INSURANCE INFORMATION VEHICLE NO 1- WAS THERE AUroBILE LIABILITY INSURANCE ee w COVERAGE IN EFFfAECOT FOR THIS ACCIDENT ON YOUR CAR rRT IG].YES El NO N,1µ1 DAOLD /REa50F.,41A@IL]T?Ys INS/MFMdGEPOUGY.tlOLPEA -,-?-•, v.? A-- n _..::. ;._.. • ShoR c GN T! ?- a E E DELIABILITY INSUAANCE,GOMPpNY .. tt tel. : NAME,ARD A9990 F LIA I 1 SV Pb ? T ? 1 QyN •C"'i WZf [Fb ?'? '? [ 'R t` fi ', ._. J3!??:INSPN.- EFR --.. .. G?Y,:....r...+:`. r ?__:. .. .. ' P.- LIArF@ILI'T,Y/P ICY NUMB ' ,BTI I?Y? YJ SA t l 60 -.Io L?CL' ?LC....t / 0 M T .2 .x,11' / N' q - ._?.::..'?n':I. _ 1•:::....'iw.:.ss. . O AND INJURY / •?' -FL :. 1_ a EP PORT fO 0 0 E91.._ _.. -..__ ?' NAM INNHEp NAME - ADDRESS $ -/ L NATURE AND M F ADDRESS ,SEX, EXTENT OF INJURIES ? NATURE EXTENT Of D M F DID INJURIES REQUIRE Ir '7I INJURIES JA yy?yE AM NATION BY A DOCTOR' 9 Q DOCTOR 5 {?1 D O INJ ;'`,?kT,?,• ...SIALN$ . ...._ NAME EXAM N ARIES pEO1 UDROE CTORI ?? NAMEAENMHED ORS N v j A fN?"°"k - ° Xlu[n ___mAl1a.FlOSIL ?tlE.I/N?. I..Wj,. '-?.:.bLJln[I6R9F1N]NREq ? ?,NENLEIR$L-oNE,iNATMPLIES._: ° O Rll( NO. I I vowaA ? P[0An NO _ i MILLED IStv[nt u.r? co t5: Ate NOT, ? 50 6 ? °', ool ° OTHER wnHF rl ? 5 6? °'7 E t ^? `"ahl" MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED { ??tll::MM Y L E CW NOFT-ARROW IN [IR[I C ? i T.P. ' XLF 2 -wo!f re oN tN[ u+wu•- - v` •••wn.1 .. In TA Tp MCLP.S BY NUMEBut,.I.. i•.:L "N .$^Th :l1^Fw? ?S "?`° O Z_i altnkliuTlwt?11._DY? Tacb6_/?11/e?•_? _ F ] t Ar, •°" """`"'°" ??r..y'f°L' -?°QPsc?_[i?`lt(e??top_.Sis J tL?J2/L° b MZttr,4.._ 6 :? y Lc?^ ?' _1?4?;?cs_lir d y. hCs[ d-d_NC R r3a_-Dlsee. 1. r3 -- -___J +ai-L'AQ;,L?Gl4R__'Ve_7'LI Cr_.!.?•?v7J?,Z'S.YxY.LJ.. l I n" ?'1 -__--L'1scn1,[- g , -Z-hel]ad.?/n(A?.lun r__AsA1 ?'le{N'di?(??,-,,Sh.a?C.__ 3 ' VEHICLES POSITIONS BEFORE COLLISION h - 'o VEHICLE An I.Owv°A10 YL?:4r•o•[nc1° INVESTIGATED BY 0 o•yJl N W ° I + S E STREET ON HIGHWAY NAME ON NO. : ,j• '•L YI 0_- YTS ON •? DSMI ..w..'.. m...?.?.? • ?',A uL ? ? ® D?iCsd -'Z?•-_:? ®._ ?.?? _?...I?. ? uCe ?9analll a ?Li M' nDLlrl. n " ? ? ? ALOw ? ? ? ? ? ? ? w[ PEOESTRIAWPEDAL CYCL FNE3 I IST WAS USING °" OY TD ;- PEOESTflNLWPEDAL CYCLIST CLOTHING COLOR w"V? ? °?°?•]?O°,°°" ? °1°rN? ,QAFwaalw ?O1 ••?? ? I{ 1 f? _BRJ1?.EkINM'd? WEAIN.ER.,... ,_:,.NQHL fAN41LWtN . _1861`1146Gt1I!!Qk ?i.[?.i??-A • •.rc 51'I I,. ,(_ n [ I aruanr Y[w1 ao.Nl Y •.IYfgKENl4LE nct?ogson I w I I I.`r ] ? awN ? , ? YaNALa ' I °oNE wara I .. WIT ® I ?GAY ? ? M S- DOING STRAIGHT AH10 S,, ]((????nA.ryNG l ?GUM, ® ] ?S1oP 816N ] IwOwAY ? ] ? w[r ]NOwING • ? GA.. IIFIlT ? ] ? 'I"D SIGN ? ? W ® ] 0 A,-SIW [ ? ] ? OVEfliAXINO AND NA901110 .f ? ] ? aN01° O n r I[T DID ? ] ? MIXING RIGHT TURN ? ° ? K[ ° ? OIP [ ? OMIIrN011 ? I ? IIASHMO nC0 13 • ? I1I001R1[ ? L ? YAMINO I[IT IURN ?11 ??.,@7 I 1 13 [ ? n.1[rr S ? ISPICI/YI [ ? OT. L-IS ? L ? IIASH.0 ASFtA ? [ ? ILL" ? I ? MIXING U.TURN N• L' 1' 6 Y. T I ? r -ICNY ? S ? MIIGNK ? [ ? IA'll NE811RN C3 L ? SLOWING f II )i•, F[WOWAYAWACIL TYPL ? r ? OIICLAIIAOMAN •o-r l r l • { w ' [I ] ? DRry[WAY I [IOPP[O FOR TRAFFIC . ?I?P+I ..-I.RQ.AQ,II{f/VIA]I{y1_ ? I ? OSTO"InIAT 6NAL I .. STOP 0 0 DIV.- IF ???... }?Y[n?•unv AI''4 r t1)AN,__._. 1.1 ?'n?..a... f-I l._ __ (1 . /-1 ND InAI IIC n n ? ?6TOP[G IH ROADWAY A" "1 ? b _qqpp? 1?T e ?R.u. r x POLICE TRAFFIC COLLISION REPORT LSj TRAFOtWAS YalcfeoMPIwINT A-4 9 4 PRIVATE WAY DA1F OrCIXU A O O co y .. w.. " ,,?.,. 1.1 I?s?.ooti b o c" -"y. ?5 ouRl Z Jf'?'? couryrr?? cnr no. EmvA OUR <Ary Of ?N GIrY091DWN FF fdNO -11111-1-Al KT 4S - I ITRI f u TION MIlE3 o S w ESpE RALy.oc.K I NIF45tCt NG VnIH. S,R[Er O94pAD NON NIE4SF<i ON ON Kd-55E cao,&ta RD. 11 1v.3300 e--Wb LOR AV , BETWEEN '-- srRlFr d valn PRF F MIlf POST O/ H8 / DSfAN<t6DRtMNN M40F9FN<F CR055519(fTOP NFA9FSTM If v05T EES 'a 5 _? rlFf N E w pE ACCIDENT CODEG MILEAE RAMY DIAGRAM DATA <OIDSroN NVOIVlD. SfvtR 1T EED O[ I?NO. INJURED_ ? 54llAGF ? rv T d RUN .76110.l iOfAI NO CP VfH IES - L ® PROPER FY DAMAGE ONLY FIRE k?RO In R C i F IOa 90AO CW at1ERNCE ' IMER Ct5 CROSSSiRFji / R.1 ? FO ?vfaC F OBJECT SfRUC[IN- O108-1111- ANDDWNE95 NA.WEI FSi DUAAGf ??/O C O SPECV4CODING USE I 5 UNITNO.I UNIT NO.4 VEHICLE ?PEDESTRIAN ?PEDALCYCLIST s? D9WlRa NAMt. IAV _- Nasr MIDDIE D9m[Rs NAMe wsr Pw MI Dl V o G. ? STNS L ?"? Lr EyrL A LV I/J T- Sr9(ttADD4ISS vftT ADDRESS 470 c-ff ,- a R -rRL IK7- Poi X14/ - D S-1 IPC P.pnE 39 l3z-ylzb `?g?u R Ik+%A 4 32 AA ' S' ?? ?A ? 2 vFRSlcw?` D p . STAIf % DATE B R H ( n\ - • Ull-NO I 6 IAIf 5 % A pBIRTH p o c6? Lai o/ SAPo M 91 I 69 V }fIRS<19R6746 I.17 WA x1 g z r ?3 Z STV «f Fd_ 'HONt NO. ETFS GHI IGHr l?0 6 E R O CV-=AIION RM Nf NU ?? EYfS GH1 HfIGHT r NW ACS WJ Iby S,r ' R ? CHECK(,) ' FH CIE AS:-11-- -.-L wo1HE4 A` CODES " ? CHECK(. yFrv CIF AS AN DMYIOVFE Or+NOTrvEYAI iw?M ? D 14 J 3 r <T s%. a Ti:D " CODES 11 ;63 nn/ + I 5 Ntc N J e Mo'ox.csE?" H1Y RE r4 IN w Is L oNl Ci' 0- 7g °° ? . N . r p , ? 811111. ? r.H 4 H YEAS • IDODGfMFV.I Al tyDA4T.NOV11-IRDR ONV I ? MM ."Er ? v a:° 11 C"&.. ? ?. 5 ®P _ , ?? NL us<•J? R L STATf IL L' T O? UO+ar n TIn 6F`ICA 3Z.K cAR-1-77 1RA tF4 RAIE SIn1f a:4 - I E I_ C // R, "3 7 oSN ! 1fla?5ol R[G SRRfDOwNf4UST Sr MIp01l? PrpNF NO L ICE - R -m:A o d ,s`6 Ii'A i t4(D h'IEt -As o/ctvcr' I M9 lASt r15T MIDDtE Nf gPantP AS OnLL,ti'h ? Is2 ADD4(ssu DwN(9 N A e owNIR Ipl T N 7 SY1rnCT AS pRLV?? \ E S'q AS gnL1/idlL NAMId+DOVtssalNSURANCI<o c4 AGENT . I? ?1otN.Lrr<d sw+ LP"N R AYimlS T 5. DAM+Gm ARU p ? , Is eHARee ,r ? , • o-;',c:?•M Io.A., C.LO58e DAMAeeD wu w?m?N l cHAVee ?- r° s: E11 ! IG ?OriO? ° iw?vN REMAINED ? D f lD DAMAG[ P ?4tMAINtD I5T AWT S S 7?sD TOW[0 ? wAr er Y ? I-D S 7aa 14 ioitoii AWAI er Id u ` AM 1L1510N Noelc 1I NORTH ? IM9 SJR 1 40W cLrogti DE5CRIPTIONOFCOLUSION: IUSIS tM[NIAIS mIFN[CESSARY) .... _ Jte N I c e t! I r u t LOw NS- l - d As, 3 . AY ?! _ I _ a ,.. OEJ N6SS LoRNI{'.R P0?1. V'Li•417c.LLi- SlT Sp QP1D SsbpQ Wb 'rC Tv 2rJ N cSS cust..sLf-rl tip Ljd--r ', VN-Ai IL Lhf- ?+'I cOV.E..p Nv?r- S"gip ANp 5?flfRVti'D 7z? R\Gtl•1'T.__. x NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES I E S - Z 4 5 6 OCCUPANTS/ WITNESSES "' sE% AGf ums "M„" D F ' wu4 ?mr L w o Y ens Da t A'' 3 -7- Z?7 7 1 + eDRrssPA .Dx a4g LILA ; DPEOr N u .A ?. ?AM e?ph"? "' . ?H ?:' N . onwss ?RIO1 4Lw?vrDIRD.. 0- e ?"?<I?m .?' ?"n° 'D R , near v a ..,. evrdR +cnc +T , r pr :. I T i.E..ra. ?.oe p.? I D:S;:.I. ?.? ?" " D c w u l?t% rortDe Al X fl Av?,rRS? TfZP 6 W` P 8 ? _ m 5 F / ?Y :ter ?yL:;:C ? n , r 4rrv+^ 10 ?#l 1 1 ? I S'r' If L ? "' I - ?? r ljl' I 4 ;? j I -da f ?Y1: m f>'a}y P r, wr? _ y P OLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY Ia-l-PIAINTNLIMBER PRIVATE WAY atE OECIXIS N pAV ll N DMF COUNTY r aI n r9 fux u4n N6 wi4 IIrvN fE sM IG$f abO HOU.I COUNTY NO. CITY NO. QFURBAN ?N QF ?I C ICIFI.wN NAME6N0. Oi SIRFFTOR HIGHWAY ECT CLS 9WTE0951 EFT SfCtION Auus B pw DF? ON N![93fCt NG VAIM. SIRffTOR WAO ryOry NI[RSFCiION 3 (o0/ZO BETWEEN STREET, STFUET DSIANCEaD FMI IvONp 9NCF.CR035 SIPFfIOR -POST ACCIDENT f5 B E W rFEt pr MILEAGE CODE PREf1% F MAEPoST /,33 DIAGRAM ¢AfA Coll SgNINVIXVFO: 5 vF91 r O III, NO. INlURFO_.J_ ?SPLLIAGE ?HIS4UN ru»RnDM1eSNI" IOIAI NO. -L.L. 6V1 HICIfs 0 E fR CI E%: STR[El09 ROap OR REFERENCE ?N / INSER Cl5 CROSSSTRffiOR ROAD /a0 P90N-CAMAGEONLY ?PFS ULIED ?vF°CF OB i 1FC STRUCK INMAEOi OB1fCl STRUCK AND.-IF'S NUAFI ESf OAMAGF SPECIASCODING TAE T S UNIT NO, 1 pv vE4 NAME: F14sr m LAST UNIT NO. ] ? VEHICLE PEDESTRIAN ? KDALCYCLIST a . IpDLF p DprvFRS NAME, Insr IIe m DL STREET pef 11 l i4EET PDD9f55 SlAtf -Co. P.CUENO D y . Loo R BTAIE LIPC E Nf rvER'S U-SE NO. STATE E% MCA D.1 11 1 V IvEPEU NSENO. SAIF E% 0AIECIFBpM 9 B CUPAVON MNA.Mf6RgNE NO. EvF IGHT UP- P E OCCUPAUON MNAMF6PHONE NO R . EYES WEIGHT HEIGHT ?• O CHECK (4 vEHKlf.s:N NAnv:EE °a aryorHEeAI L _ ? CHECK(/) O CODES ?+ 0 G"ii I.Aw 5 i cI w n ?.olD.c.c r RM n nn a vfH f AS AN fMROYEE OraNTr°ERn CODES ? + D n,u9. .s I.A I . srsnM" 5 Neel » d sAV?N°C.<u z Iwt of Cl 10- IMP M 9 0- ? ? x O ?C- ?vl ? P vtH.vGR IDOOGf CHEVI MCOFL (DART NOVA) 3IrlEIaDR.CGNV.) v fpp H mAK I HFV.I moofl lDARI NOVA) r CV Ia oNV °O^• Y E I s H. 09 U .NU PLATE S ult ARF9 RATE NO. AIF H nH.cao9 L A AE ro ? I v[HN:IE IDFNr rKAUUNIRO. RtG SIEVfDOwNE9 4 i vtHICIF DENTII'll UI N 11 .1 av ( : 1931 MI- PHONE NO. O RFG131 RLUO-IT IASi FILE, MIC.L N NO -+ ID DORESSOFOANER W N A CA -IT DI E AMEaADDelSSO Ufw9NRCl <O IW GfNr IN DAMGE A9u ' ' avw»D R r" N rn CHA DU CHn9G( VI, o-AGEDIArtIA ' pAMAG( S EST -AIN FD D ^WIAVN R[MNN[D EST. OAM GE S B ? 1 ? Awviv 1 $ P DI FCOLLISION: ID PItmEN AL INmcAR NO9IH SUt[I Ii NEClSU9Y1 Br A9epW ?" ? DESCRIPTIONOF COLL ISION: (USE SUPPLEMENTAL SHEET IF NECESSARY) R - W wl, .,0 La ul. mri a CET- O,irb I? lid 1rowl R Y uE R CON l zc ?? 1 l E A IVEi? Wf 1wJ1b 9d 5 x /4r.7 ???rr??D//i??reJE., 1ZvCUL? x ? ' „ r s c4 Et V 1 r/ C.R/ ? ? E. NAME, ADDRESS 8 INJURIES OF PER50NS INVOLVED CODES I - 2 3 4 OCCUPANTS/ WITNESSES L-u`$U+HIMtmuS OR ADDINO A = I 5 6 N N I NAME AME S) SI% AG/ TATV yV'" V NSIR. E11C1 A N1 91 wlff 1 U p N n•nr ?AM e ?u9" O "' 1 0H ?Y2HL. A • rq N M' Sf A NA Ip;l OF H 9 MOVID i90M CAME I] ruAl ?m; 0 N ?» r I " .r AD ?? A •Ir ? x! J5 { / k Y ? AKryi % 4 n ?d 1 j? I .LIE ? . ' Sf Y I Yj 7! r ?L c ?r tl. ..3 } f lu ,? ? l L ,1?....4 4sX viPOLICE TRAFFIC COWSION REPORT I2Q TRAFFICWAY xRL¢E.wANUwr NEUnaf9 ` Z PRIVATE WAY ' ? DAIF OiC01 N Di is ?6 N r INyIlMf nOU91 1 X tr FL=E.2SOn 1c ?i COUNf'NO. / /V CItY NO. {MWA ?U90AN [,9A[ ?N ?f ?I ' Mlfs ? s ?w tloF ?' CIV OR TOWN N NO CF SI9ffl ORn G»WAY ro I? ON 6 CazFnE? -Cl 1E09 -3 10,3,300 tF93'FCI-NG wtl»1151`9ff/Ii C9 eppD VW W/ NON 1111111TIl" Mt[N VR[f13 Sie[EI NRE- E M¢E NOSI O•? t ?' 1 l Dr3tprvCf6OV lON Mef F9FN .C9035StREEtOV NFAVf31MrfFN051 ,n f3 3 F ACCIDENT MILEAGE N -DATA FF[I ? OF CODE COIF SONIN-ED 3fvFRllr 101•[NO O"ILE rq. 11U9F0_ GSVtIpGF ?»Ia NUN +mvgol. D IMER CLS 59fF1 ROAD049ffER[NCE C90333iy?FtORPoAp _ ' OFVf»ICLf3 © ®v90RRIVDAMAGFONLY ?vEu[IFD ?V Ic. ySZOD ? ODIFCI SIRUC%INaVF OF OBE[C1519UC%NlD DWNF9'S rvAMEI S 131. DAMAGE SRCIM CODING 45E UNIT NO. I - UNIT N0.2 ? VEHICLE ? PEDESTRIAN G PEDALCYCLIST ,z Dvrvfv S NAME: LNI NvSI MIDDI n ? R C9rvf95rvAMF: I E St L 9 - StREFI ApUR F55 tRFF[pOD9E53 R yKS Sm6od Rte{ LI'II-,,A , Z Z GIIY U 31 3GS Irv 11Z? Dv 1 UCtNYNO SIAIF - R ?OcIC CJf} `TUU3 col Pm ?22L31 ? titan H p tip I E RScRE-39IRIB ??I E CJfI DAIfO B9t» r1 l2 l9 66 I Z a ? «<? DN G»I wIGnt S?uD lK0 Sa6 R I « STUN flu ZVo Exo ? CHECK b'1 viN aE •s: M yr"r[aANOr»EVAL G CHECK (,I V`- AS pN [MttOYFE OF ANOI»FRAL R C ODES?+ D C", " n 5 r IoN a's;;o CODES ? 5 ?,ii I 9 is 5 uee N y s.n?n ,cu 3 i Z I R ES 5O bAc-V El D MCI vln rfA9pM AU EI DODG(<nfV MODFl OA91-A t u?w,eD r?cii v • 1 I .l ) S,rff IR D9 COrvv l GKC -71 ??? E l] 9 1 V) NOVAI (U MODf I C "?? 6 3 I LCtN OF HH M?? SIAIf ? Allfv 1- NO SIAIF H I 9 ??? ` A NG ?1 varnel Iru1wN i v rv .g 3 I! U I 14' 9! 5: Z-2, 1 8' 91 11,! 1 1 ', 7 x' 313 51 i i RfGr IOOWN[v II931 Mrpptf N„ON[rW U3t ![. K L O W f S b wrvf RA31 rIRSi MIDDI[ I 11 FI?C.?L. ?!^?^^I I) 2 App9t Sap Ow,+1e cSl?f L'C f?S ?r N E A f ZZ 31 I'Z NANt f ADp9[SS OF INSURANCI CO OR A-1 R rI CtA S n `F' C, (YLSt:? ?? .AMAGlD A." "" c»A9rA DAMAGfo AREA cn•vcl e ' -? Idi'oEiB? + .11 . rMINI nc ?REMMNIp 5 ?q?o lowm Y'"wwN ?4EMpINfD es o M. Ibiorib: r BYS ZOCS}" ' wA I DIAGRAM OF COLLISION s»lNL I+", < c?NOwM .. , . l {Fa4swrs . B 11 DESCRIPTION OF COLLISION INt3uvnlMl t 1-11lH I.- I , , ., .!: I .. . . VE.L.?Z Wr1T _STc C 5'TeP Sus f1 ?. IJ LS4LS 6A.,u! . P O.. _ 8 2tb3) ?f, I`(.?g ?. CIGH A t TO hiCCE . _ Uel."al AQ1Jo ?NFOr %L" a'Z f( 570.VCk ? JB 19 5n3r Sr1? I 1 S'TY1:C0 1-?E ?DLa+.SIA.Cld ? uPL_;,le L?2 ? r F.SL.iA:?,o R Slid ? 1R. A Z, NAME,AD RE5581NJU IES OF PERSONSI NVOLVED 'CODES I - 2 3 4 5 G OCCUPANTS / WITNESSES ',?: 1 Cvt -11-1 L. l, AG! AI U3 . . 1314 llCl .Ml u5T1C L L. oy LL ' "D"' 731- a//zb H 2 U 1 ?l F?sdlOr.,r..._SiR- ;;y 3 9 F.vn "• ' I,:r: ?M G AM B G ?tc' G ";'.. ? :" G :::,•. N ogL R, NtrS q' 8S-zuS I 1 1 . x?F3: 3 knE.b o u4 NI ^' uMti I,OMG,MB G.w<IG?, ?.. ?.,,? , a MdfK S. EAKE i95 3zty I6 Z I 1 -' 31 la, nT Flnll C ?1 ?f el ;[ ? `mwr? a-• 5?i4 ? , s,?.,I, NN.r. ,yam.„Nn +r?'v?, rvl°5 '? ???.Yi,?S'*"'I?P'""`n. ?? ? SRI' ? n, r. w, r, 11 a? vl 1: t? al a ??d I?r 4 Ak Is r3` Z ?:.{ ?'`i rIStE r.. ' _ kl tLI _ .; sw ?I? 1 n U. STATE OF WA INGTON w5°I?E°E I.RpI P.Gf a DP E k •' POLICE TRAFFIC COLLISION REPORT ® TRItFICw fRx KECO '.. ,. , r . - ( nAi M UMB o <a is? N PRIVATE WAY l.. DMf CO g l ge¢i a v t3 i(cu f. I's aonoual UNiv murvn 11 NO, FHW m ?N F Cn Op tDWN ? ? NAME6 NO OI 5N < I u2 ?UPpgry . A ? r•?': f ?D I'?f?DLoC ffvSfCiN ? E ? L S S R ORHGwgr ?S ON ,?Sg+ 3 RoutEOa toE RAE l ,.? ,x y+ ' } O WRt H pEFt S 09 NOrvlNtfastcnoN -? /oR3300 PpEf Mll[ IO51 N 1 n . t D1 EA<E AD tMt nr40M9FrfpfNC ,CROSSSr4[ElfO NApfStM 51RFFiy . It POS SiRFFt O.7S Ifs 5 F Y - P MILEA E Dm R if[r OP MILEAGE 'O't DAiq R 7 y?Sr. J f , - y 3R COIt SroN NVOIV[D ES Ety CODE LOEAI NO O[IIFD??NO IN -,-3-3 ?SV I'lAGf ?w1ARON IvMNaafR?. I Cf VDaCLES ® ?PVO-Y DAMAGE ONIy gESUlrFO ?vFpC ? j OBl[Ci Stv [ O IN r aROAp Oq RFEEREPICE pJ INTER IXS CROSSS rRf FrORROb ra E .: I l IKKINAMf OPOB,fCt 51RUCV a100WNFR'5 NAmFl fS / E?S?9F? F _? 1 C r.OMngGF SPECIAICOWNG IbE F 'E wfRSrv E UNIT NO.I 5 19 Oa '? t Nasr pRIl SNwME? ?VEHICLE ?PEDESTRIAN ?PEDALC CLIST ' .? .s1 ?T L C? StvtFtbORE35 ? O5 r F?, rpFFr ADpR[SS ? I °z _ 'f?is. URY S-, tiPOppE PHONE NO. D rr DRNfR3UCFN.YN? ? W? INS:RucT fk 3 i surf A E p G ] 5 F l ppC P NE NO. 3VS ?UF/p R WA I _ R)./ RM L I Arf 4 4 E% ? e. ?uPgrw nvm NAMEa PIRO IA.J? 3 I sCCU l ? D iE? 0RM Mo. r IY° 'a ;? !? r NFNO. e J z$JZ xErHE E P qM rvgMF 6 PHONE NO ?i A L.1:7/} I _ ' n , . FYFS WFIGHr rE GHt ? CHECK (.? w f3w 17.i /.?E.+3 R 'if?nE.?` CNt.vlfieu.E.E N; y v[H nfA AN F.°aorFF AHOrH[a l I 6 ? CHECKI°?) CODES?? a o H CIE g54N DAnOV[E OP ANOiHEe 11-ON RZ N,? E5 fw s s e,r .EI coDES? ^t 3M , E -7 z I Nc45: Cozuea- , Rty NAME• ADDRESS IL INJURIES OF PE OCCUPANTS /WITNESSES !mf suan C I.?RN I yr`lH-i' •SI wn I L vfHitl[iDtNr- ?oi8 RE ,IwIwIIl ISiz cit 2101 o 19 I I i l O Sr fNSt IDIXf W -? A LQ ` .v r V f .tJ H No. zo 1 N E r ,8s ?????k W .ry . RN u cNARGF ~J wC iOrpiN ??e AGIOM?[A. ;WAY f6 DAM T?1 iowEn CO W' ?R[mAINFD VVV CFF IV E AC fV CL 1?1e.. i ?DI;«c L-.?,c3r??EHIa_L 2-CAS-• ?FN?c4?. ii• RVJQ.E.,?u AyI C?? .1_.W.vE...,VeptK.Lx_ 06fRfl?, L.LiFT• TO TaUGT.O.. VEHtct.?_(,. UzHt?LF I THfg.? J?fi?G+VE_.EIf1CK..7-N?O.__.__._ Vz.4w+? W 43?.A v L_ 17AJ >? -?IfcSLLL?E(?5. UCH?GLF._I-"- i'V fil Ni hlo?r ?.? ?• . I 9 t 66 w.iTm -s I rac.ti.r ?'.??° 28 CODES I .sa I .m r..... Rr r , , i i ? ?M? Jl,;vs +11 - • `.: 'jv? , Isi • , . ,? ., L : t ,Sj ; } _ ,1. y ., s` ,? , s I t ,r / I n : r ti 1 . l MOTOfl VEHICLE COLLISION REPORT HouN J£_,J .4ior [?nun,L 5 81? en La a to : od o M e? NUJ. 2 I 7 0 3 • ; k ,tnLLroR?o ?W ?e.H?O ?rv n ? N LreRrvanWA. r.F`a J a F nG99o/nDE ? ? o .A. .'A E n O C7 nneAe nea e.ylL.e ,enretnrr.nel.nne,n to nnneL Hn ? ? z? TFR, olri. "s o?LP aEr ?`[ °? 8 oe? n[w.oy?'.nErHe,RnNDs;e Bv. n: ?e, 'o N, '99si?S6TREETOR DA R OOJECT STRUCK Aut ar atnVCA1 n OWNER OF OBJECTS NAME AND ADORESS {5 lu[n sPSC Ceps ls.,.,. - TT?x 1 ..'.r e Y DRIVER'S LAST NAME - FIRST NAME MIDDLE WE..--- UflIVER S LAST NAME FIRST NAME. MIDDLE 7 rna < L eH DR , D J #.w ov? STREET OGRESS iOUTE NO. AND BOX NO ED STR AOORESS O I?r ?? ROUTE NO.BOX N0. LL TY STATE ZIP CODE DRIVERS OCCUPATION J G,Lpn ¢, J CITY S1ATE 21P CODE ORIVENS OCCUPATION V' J W? ??,?R 9g FDRN Pm? 1_`C f L ReaB__Qu_aRTtk Yahelz_1$ I$.,"".`""`• LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- WAS THEREAUTOMOBRE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR D? YES El NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY NAMr12.-L....y cJt _ aTAtL - 9TATU5 OF INJURED - Y . 1 ? AMV HICLE ? D O r[e 3rR An ? IILE ? MAR N FIRST +II D rs[r[w[ 5 ? ONE THAT APP nos.u uxou 6? LIES o snL court r, r?7r?`nt STATUS OF INJUREDy ? IN VEHI L ? NO Op ctn NMARN FIRST KILLED rs nLn s[v[xt ? 5^?r NET HAT APPLI rvP S,nL SlO nR urvon ES rosuL `rr r^un? - 'or 7?El 6 ^ MOTORCYCLE SAFETY: ? y _ HELMET USED ? HELMET NOT USED --_?---_ . MOTORCYCLE SAFETY: ? HELMET USED ? IIELMET NOT USED ' arlOw NORin DY ARNOw R C HCIE r Wn? rLO r?a? R TNEe 1 rA.AY rnE Berl nr tn,?M ?4 YL ; _ OESCn DE DEL WWIIAT MAPPEHEO: REFER TO VEHICLES DY NUMBER) I k •S p e - r w? a ..?, ar si p na Rq rrAtn t.?n vtna,t ne I ?, e? ? el e 2 'L h ?2 c a R r-v,. ~? ?~ T?www>,g5' _ o: Y? r I p VEHICLES POSITIONS BEFORE COLLISION w rtn I wv[snpnrw Ur VENCLE H S L W ON STREET On HIGHWAY NAME OR NO tR.llr inn vt L rru WASO ?P.rPq ?Hl I JI{N Irtlwl ? ? ? nnt1 ran rrsi?M l.arr r?Qu vt'?toccOt M O [L w ? ? ? ? ? ? u r nn L I I,y t r'L r r or.xn, ? ? ? ? ? n Y1 I.aN`P. 'r'7'v A'? Nasr A,? ? ? ? ? ALDHD Y FROM TOnr l ti } 4?} PEOESTRIAW PEDAL CYCLIST WAS USING' r ?r,l>r y ?wy n ?,,r„A , ? re'.o?iw . ??wninwi?. r ? crHNr r ? nt t`L f 'S`+?N fU L ISI CLOTHING COLON. wy _ •w,. ntr y, e,mA.irr s?unAlm,r err i PCOCSTRIANIPEDAL CYC Tim rR It y t ,?lu.. .El r.:,.r .?uHO ,Ir.rxm Ii IV ' ROAD SUnFACE WEATHER r?.Hxn xlN to vs r? u.ats rr IA I LI .y r ,s?rr LIGHT CONDITIONS TRAFFIC CONTROL TYIPfi OF ROAD OIIIVCNVEH CLE ACTIOND 1 h+ c.xc 1 ?G GHI ''w c..rc. enr r? rr«cr nt Onuo lF t?F1 .1 k ,. Hr.c (sue rln ?I IlI ,1 r}1 L11'I -?? }p ?yrl L•-??Y J Nr?? 1 rr? Y 0 1 rM0 SrGNAIS ?r l??IONF WAY WwL L Or i l?J GO NO BIRA OHT AHEAD r { r f M02 0 TWO WAY ? ) ?OVLIIIAX HD ANOPAD8 N0 1 r TY AN 10I U { l?aNOW n4 r El U ?'ul[I ?St0Va0N 11 a ? POAO STALE ? i ^ ? a ? a110W 1 ? r00 ? J ? Y tLD -N ,? ? MAXVIO NIOII! TURN i 1' -yI f C ! ? 1 ?Ic[ 61HrN a ?D IDO .11 LF ? r ? Il Avn HO RED ? 1 ?IN?Pg1Ma1T MA ? Ob of,?1 ? L[ a X an runty 1 Y ?1 Lcnn F ? 1 IEr p„n ? a ? ruaHrnn A.1111. ALLn 0 C] An r f a 1tR ? ? 6 60114UHN r) ll 1Y [$y, fi E TI hI ? 6RtG1Y I ? O A ? L ? RR ar4NAl ? A ? l11-1 WUNN ? 6 ? r1 OWINn N jT Fh ?1'!' ??I V 11 OWAY CrupAGIER ROADWAY SURFACE TYPE ? ! ? OI IIGI N.IlA4MAlr LANt! 1kF 7? ?` No ?t? ? i ?DIIWLWAY ? 1 ? 57OPPED IOn InAFlO Il'Ly'?Tfi}y, «' ?+ + ?`?bYx 'r ?. ti, N? ?•[]r... ? F? ROAD BEPAnAT10N ? [ ?Oll l1?1D610N pNAL ?i I, . J ` U ? ,. [].?m.. ? t 1--] DIYrO[D ?a ? SIOPPEn N/IDADW.IY { 1 f I - i C-Y C, Ill • ? r E Nnirri i4 a uvrnWDm T (, 1 nEASON TOR Iqi SEL po oANa[R ? ? ? ? 'D ? iiAi 1:11 A" I t 4 ` A r ?' A HA T rAm Nnr IBM }- r a'?,f? t -'r I I I , J i',-l3,'h ' { , NAt tlr?y s yl.!n wd? ?. { ,; I ? 1 ry K 1 4 a 1 t°L r I- Y Zkk I STATE OF WA INGTON nI L .19 IT POLICE TRAFFIC COLLISION REPORT ® TRAFFICWAY ?. ? PIXKtCOMRNMNUAlBfR Al_ PRIVATE WAY ?1 S 1 ?r0 cola ' i G I`i x.I1µl,1 CI2,iN jul. (USE JWDNOURI COUNEY COUN11 N0. CNNd A 8 ?u9eAN '?'ypl I OOO TdF t.rSarFJ 4/1 ?N ?E O'N CIY09 iowN E6N00519FfrOR nIGNWAY qWT MIE ?s pw 0. Loc ON Tffers i2` 3 la.3S9D - r`S IN,IRSEC, NG 519FE 09ROAD NON Ni[RSfCi ON ^ ,U ?t.. NiFI% E My[EOyI 1?J' OISiANCEI RE ON e(RV(fN S,R[E,6 S,REL, Dr"/?p ry ,??y 6 Mlf3 FRN °f Fe RfnE CRO-11 EIOR NFARE51M IlR0 ACCIDENT AM . A RAM MTA F[Fi MILEAGE COIIIS ON NVIXVfD. F _R: OF CODE lOIA[NO NO ARIfD-ENO. INJURED? W-RILAGE ?nra RUN M, rv 'N IMFR CIfFEyeR(ET 09 RUEREN ?J - OV[nKlf3 ?pRORFRTYDAMAGE30. Y FRE CIS ROAD ?VF?'<t"E wN DI" Iv/ RO OBIFCI S r9UCAINAMEO o IECI e,R C9 AND-'IR NAMFI 7g0 3.. 1 9; Esr DAM cES srFClu coDlNC USE ?', , s .-w SNAMI. ?? UNIT NO. I IL R N- MI. E ? PEDESTRIAN ? FEDALCYCIIST sNAME: s, _ STRE11ADORE?/OfFLD £u EN fpw _ l REEF ADDRfss - urY 90 ror7` .0 e SIAff IIp COa eiA E Ip ,? c pnoNf NO. D Y - ORIV[R'S UCENSF ?? S s'd ti ?'•. 3AR % 78S-7y R W DEN No. X,' n 237 R.• I ?^ V Alf DA,F R i )/ p mcu.- FIRM fa NF NO ERS ?GJn^iiFEE'iGCn'r E URA,ION ^'D o,Y A I1,- 4 T I O?? r NRM NM f 6 RHONE NO. F ES IGnI E GM' SYffvGO £ Av4 B/1t lSvdml R' ?¢sy ? CHECK (.1 NC, AS:N rMnY'rcEa ANOrnfR. ? CHECK(?) _ y CODES ?* J ?; .iris crlEw [waf AS AN lMnonEOF ANOrnfRA "' O e [ e sMO?r .cu CODES ? + 7 ci M ' N?R os W /PL.}sN r ? ?: ? a "in;,1"' s w roN e , xloK.cD .? Rl ; ? ' . s vD1 EAR M MAAE IDODGf.GMfV.I ' ??' ? -EULANII ?MCI ?'g' ? K OIDARrNOVw ,. $ 1 self 1]D CON n v.l Ri ? 9 v -',jTf Y.1 . R 1 Mc,Dtl IDARI. VA1 y? /1G7 4nf c E FC.iT88o >??cc.EC n Pl^1 E V" l 31AIt IRARE.-INO. VAI H vEH. C. -? j D 3 WIfG?Z L.r1/ (sU W/J- I' l A N - E ?y 'yy Y-t vlnKlE aNDNCAIKN NO. C vfn ClFtaNi Fl [ %vyl? MIf ?I I IGIOIo VI?ICI/ zo17 I L i I - I I 2 , IF FGRRRfDOWN[R U51 43i IDDIF iwpNl NO. RF ISRRO WN T'*' ? S/?DLQ ?Xt: V N 8S-O Ytl _ ER. ,uv n9sr mloaF F ._ ' ,? s h a . ADDRESS 0-1, W c owNjR Olaae w¢, 3 f - NAMta AOwtssa wwR.wce co --IN E wMAC[o `° •? ' F , ARIA. CnARGO CNARU - V Favyc N DAMAC'?ARU I .yir' "' fsl.?w.wee IaAv rTYG? S ? ? 9tMNNtD ? DWAYN ?9f N [D lEl. D • F I R J. s, s O ®;ReD ? °w"?fDerl6 DIAGRAMO COLLISION I eY u ? eAOE? DESCRIPTION OF COLLISION IDeF SUppIFm[N}µ SM[II NFCISSARY) OiOirnii .1 r , ?- " lcL. !'+tSLB.!w.?p QnL?!/?,J sow ??? r ?? ~ .?? ? '??-? 11_ ??????-- ?? E•sFttr?.v ? .s?r_F4taetT L?eFtru v ?.Ges r--- b ! v ?! ILJ ., aN J tcP7t_7tz, !w YR oN _ SAbwr40r.Q A tY,'' --+-?- I + + \` I ;. 1 I I 1_I.. ovF?e c>'.f.TS.e tr,yt_.A,ve._Re[[ f" ! I 1 TD/.•_SiL'/G.. /!?!A4/r!S J.F1f?1J ?EhytcB. ?y .v?q .? ?- ... 1- I !?!A• b!'?'//L. Bf1A/_.0 t?tAQ ?7E.C L/!!!t a f / , W. eo.t- L s( t_1 1 f r r OStcTidltTTtNN!!.t4:_N4?tJBLiaFtL a?? 1 ,I " I j C 7fwc.9rtTr .. ?.. AttvC 2 ; '4T NAME, ADDRESS B INJURIES OF PERSONS INVOLVED SI OCCUPANTS /WITNESSES ';?RO.`.arrv`AiA'iii -CODES I - 2 3 / 5 6 ' Will Y ' 4' ? Alw.us w si :cj- alas v°w ?D•1- Nr eiir. f,[cr ,". ??E???? •r, r R _ ?A p .. v. ?Rl or ul.w e. ?AMe ?721"' ?^ F ? i ?,",q!n. .4 R ?t 1 [ ?-.a? owns- N ? ? w [ .°F GF *-D 190M r'r QAMe ,11.111 . .v116 rNGVICb " 4,F,OF ? J :111 x .N. G AM. ?o NO 1, ,Olr.<p IAJRr ?n:NSp ` Ios.,K"IC aac??Y no DoFR ?`s ?u ?MO.R. ?L?.3 r, 'a SO N Z I D7 8 s Y :vl ? ,- ... ? ..I.... '"'"''. 1R+W 4. .. Ai LCIh7:.. w.?.. r -, :":RT."'S@lR"Y"19f51tJllme?•+?i.- -_... rra..a •, „-.. ,.. - ,??, .. s ..., ,r ? fa , . ? •? ?r?iC ? ? ??, f ? "? - ? ? ? ? ? a ?..?. ? -a. ,:j ,; 9v j cn 0 F- d w o ? o ,zo '"^ ? o o? o 1 ? ? o o !?o -% -:. f-, ? i ?? 9 ?/ h o" 1 ;ttP Y N" p {of ?'?h'f?6 4 Na ?'`..e fc. ? ?? ,??. ? . r E ??„ i ? ? , ? ? ? h ni1?}Y?' qA? ? ' c ?t . 'N ?rcl S 1 ? 0. t 1 ?v4 r POLICE TRAFFIC COLLISION REPORT TRAFFICWAY POEV:, coMnAlm NUm{r9 I PRIVATE WAY bAl DAl i au I Imt .. w ?.m...w . u7. EustiObual cour+rr ?./? L'/? [LvJ couNrr NO ci NO. r"wA ?uaeµ t it 09 iOVm C AVtFl 05 °ow oDr Gx: O 51RtEt 09 HIGH/WAY ON obt DZ/? rCt Cll 1 ROUtl09 1 t 3 9 2 k I .tee RxaloN CI NO Vn1H 31vE(109 NpIINrz IN Il Vx rvFN% [ M9F rOiI ? ?? - l I /SUSS S CCJ - &MStN 519![1 { 5N1 r / DIS ANCt{D?1 I a0A3 Rli .C905]1lvlltOV MARl11MIlt vO . mn[S N 3 f w en p ACCIDENT MILEAGE CODE RAMP 9AM wrA D COtIISgN1NVIXV[D vFR 1r /? IOIAt NO NO RIEttD?NO. INNII{OV ?YIIAGI ?HI{9UN pVIHCI[5 ?rROn9noAMACt oNtY ?gSUIRD ?VtaGl[ wHDnD?H - 3 },. ? t4 1 'RD Cli x s9[N 9gpAppE VIiFRtNCf 1 QO55 S19[[10RaDAp ?'J 0? ?D L? { OelfCt Stv«91NAM[p OeltCi 3lv«[AND OWNEV'1 NAM[I l51.-AGF 3KCIAt CODING 1 , UNIT NO.I - 3m- UNIT NO.2 VEHICLE ?PEDESTRIAN ?PEDALCYCLIST s1 rI •'? s 9 . 9rvt9's N.Mt. 1AS1 19s1 - z,2 - - e sN u R cLa c j - C? r taauoovem RIN ADDRtss - otr surf nr eolx rnoee NO. aa? 3 D R /r?J9Cu.> ?/ 9s31S' J /i? WF9s upNxN D >1.nicTi?i9?/7 8? i At s ?1 F 1H D.. S3 I GLG? / % A E /, A! eeH S? ' _ «eurAN «aNt NO. ns IGH1 ?eH1 E « larHO"e NO. n Wi GN1 .9LAJ s' v 0 CHECK (4 „IA :N fmNV'r c A, o AN 1 ?CHECK I/1 v[H tt[ASANfMNOn[pAUi . a MO .c'cJl- 5 CODES P' J VNI, i in ? " ] ODE111- p ? ;?, „r w" ? ?x o ? ?m a ? 0 0 „ a+. 9: o M;- o M Z! ^• V[ " rtA GGV AMVt 1DODOt?CrH?FV.1 UGi G/?!? MODfIIDAVI_NOVAI 31nF1 CONVI /' J {7Ji2 E 1 v.l /? / MODtt I>DAe?AI ??G J/O 1 l.J LtJv se I f H s1An wI[a wAtt NO vn H nH C« ST I Jc lJBia CJ?? - - C _ FR7 nHlaupm ncAllw NO /? G 3' 3 o g/ L vlH uum A S Imo, 5 ?T - ---- I uenn9toovmu IAS1 Nast mlwlt rraNe NO ° wNl9 1 N9s1 i ADDR{SSpOWNia N "•S/?i?C «AMt a ss p INSUTANCf co A..?% ? ? Ij u ` /-G ? SiG????L -r-? `? s ??? / 1 s osu»w? fIAIAAG AaIA 3 E • /l0 / - cHAA i i C.AtGI '--? . m = M.9 gAmAG[ AREA 3 r + f. C iOnOii ? Awrn.: ? n mo i+w':r" ?auuwtD J u . ' 10 ?oT10 E V'?•`'' 1 6MDaY - ?? Yl?y? ?AWADIr: - Z s 0 ,MHAI u DIAORAMOFCOLLISION: Wt N1 Ssup e..?.a+Npv?i 1M 31lnfruEnM Yetln rRttsYAr1 DESCRIPTION OF COLLISION: I" ?. ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED 'CODES I - 2 3 , 5 6 , OCCUPANTS / WITNESSES iw ADOmowu °iwM" 'ii sf. AG, ulul '""" ° cl. nsu ten .w b Aram °' •ms R?' Ow' .OCI ?WHV wt ' io >u ADDrl 45 r rw p . MDV DIa ?Am{ p.CAKI Owe r0?irD b AMf .Dn.l„ w;w?a se1Nl :. QAmf ?E"°..''O,"o:n. a? O:°,? o n .. vcA?".Gprat I ,. 7 X 7 QCI D"rA? "IC rq Cl Ar. u ?oa A;na.' d,iion SUS //?"js? DAn O, nrw1 Arr.p.m e. ? ul iti ?.I : hr V .Sh! 7 , a5r91I:T?/ f 5 ,, t1 LL `{ 49; r ' IA r 1 s ? V: J ? ?, T? j?',it EL i h 4 I L 1i % f ?. I oil" _ ? ? ..-...... a .. r..,?.......... ...,. ? N. ? d g ' N0. ?' 7 r r7 / l TRAPFICWAY POLICE TRAFFIC COLLISION REPORT ' ? PRIVATE WAY Pa¢tcomnw? Nu q DA(F al,s N 13 !t _ $ e ,. 11 f r MF D? CUUNrv G/` COUNTY NO. 1 aura. ?it(WA RAt / AM 6N005fef [OwN ?N Of N Y04 / ' ?S ?W SS H ff s[CINO r9F 4 -AD " 5r4EEi 6 6 1 Ou vAm DAu RAMP COI1-IN-VED "' U rOU[NO. NC ll[D_NO. NIUREO' ?SV IUOF ? CIF vEN ats ?. 4onRir DAMADE ON(r O visu ?ItHICE 111 D - iN \ RD Cl3 I IMfe i<i SvFEt04 WAp 040fERENCF ,- tt3rREflO4POb 5790 t t/, /'/ CBEECi Sr4UC9INAMF Of 1111C12tRVt%DOwNE42 NAMEI i_?Of E E3 SGFCW COOING USE - UNIT NO.1 UNIT N0.4 HICLE ?PEDESTRIAN ?PEDALCYCLIST •Z 9 D4W(e SNAMF -1 NvSi -.1 ell, 0, si 71; -s ,? a1 Sit s MSt n4 Mi G?i1 G?Lc- L? e 3rvEEfADDRt55 7 A/. /??GT D SrRFF1 ADDRF33 ?s ty?. ?i??5 ?G?i7 atY 3rAlE IiPCODE fp. i9 Lvc,? /t 8'33 9° ?N?,577G R i StA f LiP E ?/I''Lr..?u? P / ? ? 's( fNSfN Tw3o8 i surf lz °° I I D u fnSf NO. tAf f% t OPe RiN GG 3/? GSA l2l%9 e IXCUPAI aN NRM NONE s Tr+?-^'/ GNr/l?cr.?! S_ u wT CNr 1 $ S E R acuPAl aN 4mN /1?o. Nf NO. Ens t4 cNr d f G/s'?ACdr1 / CHECK (?) EN Ci DnaOrEFO/ANOmfq^( N ?CHECK(?) vENcIEAS AN DMnor[EOf AParNIR•t 5 e ,cr4%. 6 ?;;i°n°c'c"-' CODES ?" ] n: . CODES ? * ] <.u i:in+.»I 5 u[c n 6 "1i4 I' „, ?° 3 .a .N Ugl f -3 o M a. ° ? AMN A ? U 0- ? a u u :;I DM ? e .nfl ? 0 'a' ? %. ? a ^ I[ ^ nN rtAR fIDODOtCNfVI rjG ?o? FIDyy??1 r ItCONVI vY. l 0 3t -TWO E vN.ruq I CNfV,) /`?G ? c mODEl IDA9rNOVA1 70 Y I Nv1 ?? J '? v W UCt Pur SrAIF rvA ltR nAlf ta SIAIE I"I O4 aN it A NO. . nn le if ulroNra. t 1/17!3171 1s , L En of .Tr 1I? I/IST91 USi N42t MiOaE fG34vID ON++[4? /liS5 . JS? ???/ 5/Z PNONF NO. as s:7 0 9 SIFR (A5t NRSt MiDCt I WNE4: CL/?,.? ?? s Q IF ADDRlssaowr:e4 d lZV?? /r / N E _R. O v ne(/ i33 ? oL /.o v?l?5 i3L ??J N ! { DRt53C DAMAGID M[A CI % Crn • . ?. ?? DAMAGtO ?U i 3 IG?Orioii r • ?4[MNNID .AY ?REMAINED [Sr. DAmw - S OU ? lovno er rovno w•r er. S ?.J IF DIAGRAM OF COIIISI N. 1 u IMNA ocAfw4 l l DESCRIPTION OF CO ISION lose 3uv E FNrAI SNIEri eesv.er) _ { G. I } 1- L f j f f .. i _. I . I ( cAj/ /J?+'.?T.ya T4 r;v o - _ -- - --- ------- _ S 9 rfJc 12? I } D1 /?i?/??? /3// rS SGi D???G /_7/ esf ? 1t NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES I - 2 J 4 S 6 'uu suvnfMlNUUw OCCUPANTS WITNESSES a ADD?Da,m N.M n UI --% Aa u -- u us r "; 1" +w+v - I r. ------- Mra wsrr Ulcr , .. rr 177 7 •DDR[3s O 6 L /Z;7 ?o^+G: 4 ?A nu er Me O 7A"' ? ' N. . ? H Nwl „ ° ...._-_---......_.__-__....-.....----..-._._...__.... ._. Dress Amero/..... __. ..----- u 9MnDE4cvA s? ..rf ?AMe ?;'c' (] n . ? N ? r:° /0 M NA f .a ^DC.n{ ..__ .. NAY AT / N ,(s tw er OAMe ? " ' Om ? X +,u 'v Fn^". Dao 1,Cr f wnaeFroel .4onD D•n ' . 1. o-0.0.pp F m T? .1 ?I ",EE l nx, vlMe4.Y.. I. .fr ) 1 " S P+vrr? 1 I I I1 ' l . , ? I ) I I I' .. s.? a r.r' nu POLICE TRAFFIC COF.. ION REPORT ?TRAFFICWAV roL, ewwrvuMUR ?k - ? PRIVATE WAY OIL N N wwJn ND. nttra. rEnvq 23 m9 A ,? couNrr O? I f M I IFr YT ? O UMl A? ?. IO I r•. W, v ' (USFRrlmE MO nOURI ON Of 0NA1p CIYOR 10wN NAMEl NO 0i 3LVtEl ORnGnwgY 65 RWIE Oe r YC q i I(.hFS 5 ?W" Or O1QT IourNSt ON ?-'O` 126 RRfil% E MllF roar ZZ 0 I - IrvT( C4NG VntN. Sle[[T Oe A NDN INIf¢SF[t ON iVO BfiMfrv SiR{Fl[ SDEN V ?' } OrSrANtF ID OF 4 OMV fef CvOS55TRF[i OR NtMEStM 4405 ACCIDENT ITAIP D -TA DE mrt[5 3 F w MIOo? e ffEr Of runrCi?iw R ,. 1]3 •ff CIXlI3KIrv INVdvLO: vfR iv. 16 RU r J .K II[D_NONJURED- ?SVII•GL ?nl _ IMFR CIS CrO555rRffl OR ROM TOTAL NO p{FIiFD ?5tO1C[N dVIv[N CliS NO v.-11DAMAGE GNEY ? -- FSr. DPMAG[ SRECI•L CODING USf ORALT STRUCK IN— OSJCT STRUCK NID -1- - '-"' I E UNIT NO. T UN IT NO.2 O VEHICLE O PEDESTRIAN 0 PE%CYCLIST S aA--1. rRST 'R SIAI{ NO D NO R ITr SIAIE 6 rI N1R I 4lNSF NO. qrF D F vBr vR FIR E T M MD?is a M F6vMOrv[N0. EYESI IGIir HIGnf cW I.- TIRM tYES Gni itrONt E OCCURAIICN R N l ?CHECK(,j -IC(FAS:NDnvir'rrEaANOrraeu ?CHECK (? My--CLA IJYt[dAN01 n TDN:.<4 CODES D. D a?' • '"' I/ s t ° "i.°N`,"cu-- CODES 1. * 3 oA. 5 6 5"O,.Nn iy ? n y IN,R, RI 0W,R 3 fM.:ro ?q,.KI ? ?m. ?re: ne' ?? N ? zsm w T VI v') 1 V'1 Vq) YLAL vtN YtM M MM IDLRJGt.CN[v.l MOD[ IDMt.NMq) Slr41E DV .CONV.1 L 8 K E ' O 51•T( iRArlfR0.Arf N0. S1AIf H V!n IX R N A F lvµ r ?? 9 t3e30 R vfNKLelarvrlnwKDN NO. ? vew lF Rwlsnomow++IR FASr nasr MrDme rMNF ND. O r WIRER. Gi Kiau W s ADDeessd Owrf[v N A- 6FXUrF7r_ •Mt [ A—. d wsw•Na co aR _N' R u --- p•MAGI MtA 5d6 l t ? ? AWAY ORIMAN[D s 00TOVr D ?irwrer oDIAPTION OF COLLISION; '• f ° .._1/13/L1tYL?-tld 1_S-?rP>i9?C5 /ri/ LrJ - r. _ fCpI N ?L?? /_Jl/lL?-??'Y.?.?ZJ? ''?A??f •4 vL - o ?j $I gVb 6 ._:.SSA??D-/29llK?S: ,'^'Wr?.?l?y S NA/AE, ADDRE55R INJU RTES OF PERSONSI NVOLVED 'CODES I - 2 3 <__5 6 I IVN SWRIMIMgl5M11 --' "Nl` - - m6 OCCUPANTS / WITNESSES rd ADDmoN•1 N•wsI s[r AC{ - t s",'^," msrR tacr ruRio' AMR c n q, mnv e. F 1 morn '° , rD,ROM O•M[ ?:°I,M L ?yh .n ?6 ?": 'Oo O+ :, KDDII Sf v F ' • p ryry t W N/.41 apt - 1W10( r?T ?•MA ?r?.' ?iMrN ?Nti ?,i'i'rrq +74 ? 1 I-ri! - 1 •l•De151 5 ? _I ' t :prK1L 5N•vllR• SAD OR •W ,:r 'lO aR•r("ID RO,K °vVID 0•Ilp vl roKl •1 y I 4 ?/,?`?-? ! gnYs ?Od -bey l0 /.SB ,' 1 ,II,r r. X n CSO ? ? - r " 'x ? ri? r ?, ?y?g 1 vt a ; r J ,`,1 s ? v .r .?.r : ? Itf 111 f c ' y 1 (" 1 J '1 1 , lI ' pool I+} ,12 r. a ?` \ ? ..+r..tit+:L--.:,u....` .1?.. "W. _i.J..w?:L "Sa. ._ 144, f? 1ti`51rY5o?'4fV°, fpm STATE OF WASHINGTON OE / OF / N ¢ a R POLICE TRAFFIC CO .ON REPORT o ,3 2 2 9 q q ®TRAEHCWAY o ? f` 2 Rd uwr NUMec9. S' { ?_. PRIVATE WAY , _ 1 •?. wr ro rw lno.l wn'1T 1.1, NOURI COUNIY OqN -NO I- ?N pe pIN CI,I OR- N NAMF . NO.a31RFDOR XieNw•r i? M1t ,. RoDrt s m(fs ?s ®w ®af L3.T aosZ, ON AS n ' -? ?QO NNesfa Ne w,1X srRlE oR Ro.° NoN.ERUCnorv C 77"" Y3.1;/tF'e9, O nIx fO. Mif Rosr E - atiWE[N ?[I? SEREfIf / DIS ANC l efM RF RF .CR 0535,RLE 09 NFARF3, MilFW fj f, 2' fF ' S 13 [ l[S t/t`J couis?wvdve° N veR h Dr AC m' ?''e [? ACCIDEN( Am OIA RAM W,A MCODEE S?p+ 1-1 N0 NO SLLI[O??NO.iNIURlD,? ?s:IEEADE (YVlXICI[S plvpPLRrv OAM•OF ON Y f ?Nil a RUN SrdfN 'N"?R1ti 'RD IMlR Cls C 1 NO Er 990Af)Oq 1CifRlNd R0333R[[TORpOAp il' •,. T' .k - I OBffCl SrRUCA INANEOf OBJ(C, 31eUC9 ANDOWN(RS NAMtI pRESUl1[D ?-1cr 'l . - est DAMA.1 SPECUit CODNO USf ll 7 rcr ? 1 -- - Zf 1 UNIT NO.1 l Dvwtv's NUAE ?q51 UNIT NO,2 ? VEHICLE p PEDESTRIAN ? PEDALCYCUST DeN195NAMl. IA51?-??ES7?? 1 kR „°f,: rs4 L/Q , 314((1 ADDeE53 C +II j? ( p A.l ?? R? 1 Ffi vE33 l1e I `M ( n (f" I Jb C [ !1 /? r, ' / 770 ! ?4v _ LG? ? g : ' Lw liPcDIX PROM NO b?Y O t »SE? 983 D9 VER'3lICtNSf _ 'Y D sAF ? R A 8' 732 f ~ / e r SAf ' , x X M A o• I I I U trv rv0 V A ! E •r R r• yy? '• ? . i? "" CUPA110N . OE NAME.-I N F s "1 X, E euvAl oN NRM N[ a .XONe o , ?? i " g ? CHECK (?) ' nwc f A N rt 'r E OF •NOrNf9'Al ??• ins c.rt r[IOM . PL 9 / EYE5 R ep CMECK . CODES?* D iin 3 r a.o u'"°SS • Ic1w.? Ioa.cl M ' ,r1. ? (f ) vfX CU •s AN rmnor""rfaw.io CODES ?' ?"'.. . "' 'R9? // _. w Es u A, N , i .35 inC 3 u fro a ?Xn 'c"-- R - ' L N 1A. MA•I IooDt,E.cMEV? rof E?f1?V?in• ? ??5?? ? u«s I ID NOV•I Sirl! li De. ONV I w"DNfy?r• pu,eu."cl p cl p w5'm. ? ii. 4U Y r ? A m r, I {' _ `? ? ? ,. Z ? a D ud u iN nA1f A F P I " vAl v.l A'GX ID E A AGE ASS 1 / L '^ , v n 9 =re NO rA E . H vf N e R I Ij ? IT! V[XKl[IIXMiNCA,IO ? N NO. _ T- p? / B[ ? KT.P O A A , l? 9 3 7 7 9 r ;,5' ' E?X/. ItIIXNDN A `NL 43 1i O ? ' 1 - v(d3RR(DOKNfR lµr riR31 MI-1 -Nf rNO O ? D Vm[R. r M, !1451 .1 - a :? AIIII r-1R . ?? W ??TM ^? wN / + ? ?? N ' 's` ? AMta ADw(ss OF INWRANCE CO O9 ACEN1 ? ??p E Q v'mFtlZb? i'F ? ? , ' Y ? /?? 5 E R /° T.o 'rte.. 9 m w ? °? .10. • w.•'O.c°A CXAROt a"ARee wa°D".°, gAMAOlDARlA ?+ ? ? ?.-. 'Ft, - i 5 luio,io 13,. DAMAG 1 ? ... ?RIAWNlO AWlniy (?U I nr NrUf.WAY ?RVM N[D I, 1ow[o 1Sp SJM .n.n..?.. ?, E d.. ?i'4i1 i? r x, L UI?- -? .?. n__? aOR ?.VF?RANCev(ualoN'. IusesvruruMA(sfRliuNee(ssARrl .. _` ,, _ J ?CooKiJZP sTo? SP9,?/ .LJynPt/?/? A,f fxL - - iT /?CRPOSS 71?6.inTt?P.PEtT an 5- °?? ka QQ: ?ce .?F vFy.GLE_YL.z. ?iOfL 6J _.: - N?i Ti jq ?'D 1.-, OVFIa AJ_.Fn.L?aA?.C ?t nT .LOn9: naJ ? ? I ' (_ I ?" Rvc- t??s? _ ,'d? s• ?^',e _. s/,' N _ G Ria6s _ _ e,e. ,.c` e S CODES I I .L, H.I .,?. 13. ?. S b rAME ° i} e. ? •Me " . ? H: ? ? ::,v ° t` ?eRiY?:'? , lDMf13 NO •l Of •n ,^y^• 'y? .E 'I X •.a31c.?.,calKl•3N.rf u.N° woYu SEN1 e. O+Me p.Dn CI "wn. ?.. ?:4 'J .ADU O. •clNC. uNioD. •1D-s, ?c-tD ZK!•'r3 .??Mf?(J/(1D3 D•Ndnro•I °•P" IDe Y D «l• ,'. ?y?' ? ?,? r STATE Y E OF WA .NGTON W5915v19N I.DO) L GC / Dr No. ) 7 ? POLICE TRAFFIC COLLISION REPORT OTRAPflcwAr 9IX,cemMn,UNrNUMUe t Eo1 L PRIVATE WAY 1 t ¢' i. t-. ?tii. 1 ?0 9I eou3Nr-r cN w enrvo. rnwa K .,y'. Q Q1 Q //O?? F6N00519tE109nOnwaY Cls a RURAL 3 Mlts ?s ON ] e Rohr/eox srRfe J? tRSFC Gs Er OR 90AD NONINIIRSlCr10N 1?22 . ,..,5 L?C-G/? /?i?.J/ eErwE[N 99n1x E ml E9ou .1 ANCI 1, MRCS 'M S ! CROSSSrRt 9 ntavf3l M,lE Sr9[Er 6 Sr fET (! I N W ACCIDENT 9 aO AM aI ;g , FEEDI or MILEAGE RE1'f COEISONINVIXVf Sfvfv lV •cIODE - ,d R rot AL NO NO KLL[D.W N-1. ?SG1-1 Qn1 64UN ,MF CS CROSSSro [TO Rtf ROAD OR 9FEE9tNCt ?] oV r Fn CLI Q940KRly MADE ONLY 0111U1rE0 ?vI-N w"o0. ?'L I'?$Pp OB]t<r Sr4VOK INaMf of ODIECr SivUCR aI+DOWNf9'S NaMH - L 1O L/ ?" ,., ailL'?' ? ?/ Esr=aMacE s4EwlcoD NC USE ?? _ ? '°3-- n ??i"+??? UNITNO.I S - + "u'dl9 - D4nw's Nave Uul NR r M, 1 DRUNITN•Mt2 QSVEHICLE QPEDESTRIAN ce /J u ? PEDAICYCLISTZ G W '/ 1 d • 3r4tIFApOVF LG ?'-' ,1 y- 3 05' 9 r'? REtlApD9tSS = ?oiZj sort IMCOa s' s+EI "oNI NO. 0 sAIE "? "ski -- etas uctN?ENS ' srar 3 3 ?? R ?f I N t Cmoo 4J.rl" ?iv ? ,.off All D oc AMf E 9wNF No / ?? Y J " ? ,' n 7 r 2- ns lcnl onr E acuRanoN MN--_- Y+ %.. r tns IDnI t<cnr R _ ?'? ? CHECK (V) v[n¢ [a W. n a,NorntRA [] CHECK Al U - COD[S?* D a . s F uwN (?1 vFnKU as.N EA.novnaa Y1t wEU os •s' M n e i owx.Ncn- rN1R CODES 10- 7 o".u A s inM" n Mn .cu 1y n...... w.Qe loo°eE <nN 0 ql"'wMDDEO.ar:NOrAO snE IROR vt ? r`urp Qw ' ? roYc' ? cS.rt pQ ??KD ?C;;.3. 1 - n . kh CON `f- //7 ?C217 1.t LLDA41. va) 1 .) ? L. tN SrAIE %t'? „spa/Z E r r 0.,rE NO SrAr I'I V l09 n. A ? ! ?? r r? ry s ?A _ I n EN . ?, lnKIEIIXNII(.AIK]NW C ??? 4? " ,Si-' 0 3 ? s7 3 y 9, L R I Lt DFNr A I r Fes EDOWNe4 IASr sr .. , , <.aooD??taif /fit???? --772?f S. ? wNE4: I Las n9sr t? r? ADORtssaowNle ?, J? W MID 'C " NtR L ?. N J, w as.e u°DnuorwwRANC[eo aaewl E n .s A ?I a? E R i ,.?f ?. wMact uu o ? o."cc G o o ]] ??gr'... Y - ' R loiorre':K cN.orW c..)1 cnA•I?o«Di guaAU AAt, TTt E S Esl DANA- ? A AY" ? RUrMNEO G wAw., ?.°.WAY ?RIMUNID 11 AMAOE R]iDK i• y t T r s/ E7 Dr. C !?'/T rors° e? s DIAGRAM OE COlll ON. rvsF w.nLMEn f .J , ND?urE NOVI Awar er. s O-a7.; f/G s"ul e. A.aow OESCRIP ION OF COIIISION: (last s++Rn[MerRru stR[r Ir NECISSA4rI ,. ?. I. g l-ri-?r T w /cG Ui ,t O V G• E NAME ADDRESS BINJURIES OFPERSONSINVOLVED OCCUPANTS /WITNESSES 1-:M.,"N'.$.I CO_DES,._ I - 2 -fir ns? ? cr °'+Im N??i1lS "_s/A 319 •m Eru - Mbr ?, GAO S Sic 7, w:rw D S.S-? _ ''fj I' L N.Mt i7?Ea s? t / .L r .M. Q ar. Q ., i f YDD+ts O_i0 ?..A73E'2 ? rN'.°n,. L•??/yG7p tolRw. L - '?W e 9 .•. '.?',' f J.' .owt/!lnCG / Gr°+ r'3/?tJ..l ao dl3-moo 5,?' - • NF Qaus Q.oar Q..s:. Q.7; a", .,.r NI ?'J P,AYl1 ?ES/lP nc a(.l?<I•S..w.I Er.N. ?Aw`Lf+sa.? fGL t it Q.w./)Q - 'TAq s ?' Ss' 7E WyR ?01'{r 7 OE"i otl CJK?S C7YC KPKF ••. N° •t'IV rKa,Kl Qc• r 0'."._ / J aI.pVIDE DAII T y S ?1 d? - L dt (, n tR e ? E J r ?h fall s ,J 7 , L 77, f .M POLICE TRAFFIC COLLISION REPORT ?IRAFFICWAY 9ouee eoMnAwrryumae9 2 PRIVATE WAY > D•re ume counrr ?'l W.. wr, Ir: 1 w1G/G 9I SGif?sa J counrr/'° anrvo. i rJnw o Arv ,2 Z q r-Al ,rEa r cu ADM Q Dorf q r t2 9 ?d/S ueAl f dGit ?` rvr[95tCUNG VnrN. SlgtEtOe gpAO rypry,rvrtg3lCr,ON -' / LLE/L eerwetrv 519[!1 a Si9EEr MrIF POSL Z O//' 06 Ary t .C90555r9[f nEA9 3r M,l ACCIDENT vtmn[S r v a F W MILEAGE rEFT Of CODE D MMDA1A - " ' ' COI11510N NVOSV[D 3tvE9rrr. -Al ((??j NO [rIILD_N ,NJV9[0? ? 5911A01 L]Nrr69Un wnOMOrr. qD IMF9 C11 9 990A000 gfrF9fKL Cg0a551e1 ROq eO•D X55 _ pVfn ClL1 IZ'J? 0 --D- DNlY ? r9l 11E0 ?v( Iq[ / 2 OaltCl SrgUCnINAMt Of OBItCr SIgUCn ANOOwryF9lryAmtl E51.'AM-1 1tCrAl COO,NG USf f UNITNO. I UNIT NO.2 ? VEHICLE O PEDESTRIAN ? PEDALCYCLIST ..SA 1 09wte'1 N•MF: u.31 S m I ?Lr? e•nAS /,3/ tN 9rvt9aNAMf. .11 ? i t lMI l G77CJ S G .l?.NrC ? - F?z A009E 3j /?/// w b? ?a - e z,geox NtNO?3 D ,` o Jc 1,,,j />o?79G /G/y R • SLVSr C.ii? 9 G 1 3:?8 0 N!9 I,CWStrv 5 A , " 1 - Ir N A /3 3/3 0? c Al .7 o Dyl `/ G-2t??/lE? .?9 rQ / E oceurAr on NAME afCW4N0.??. ?? ns 'J, / ,eN1 E eur•noN r,qM ryAMe a alone no. s ,enr r°nr 2 7 oi= -arV?, t7 C?iC R %cw.Ss?•E% C.CC L ?f1L? Zi o ?3 CHECK (" r ^' •N - ? CHECK (4 ^"^ VLN Clf AS AN fM0.0rtt A a ?* ' n CGDE$ ",r 71 n,° ? s ln<wn / D sD .aV CODES No ' D ?,ii . is -?7i Z ' N 9 J aJ - '°7 VlH YIA4 MA,E IDDOOt CNfv.1 tIIDMTNOVAI Srrlt 1509 CONV 1 . A+. M.. 0 vcrl 71. v .DM 1 n Vr DA l NvSOtI . 02 Gn,;`o bit E E , . I z z, d1 DMZ ,- 5a z. v n le yr rnA U9 nAle NO. SIAr n yAB!/ ca G1 - -- 291- D H vlN. p 9 o s W? ' vFn at,Derynrlul,orv ryo. 6 / 83aG L A r 06, 1 to Sr/12 qfO SR lOOwNfe tAal R93t wOplt rrgNf NO 1 Fe: u5r nn, I O W •DOflS3p DWrvte iYC Ai? oiZ7? N E Wnt SFI.•!L ryAMe a •DOnss p INwr.rycL eo w Aeenr C /??S..?cam R nJo..JL 7 DAM•°IOAfu ,....c 8?238J `?' wl.n ND AM M o'v".+<? cN A.L JD /6L r 4,L c.A9ot w:euc o q G ? a rD. a 1$i'orioY Lat. D.+.? o ? 9v ? em,uryeD i ? Dq,nry nD•uNm wA r l e1.DAM ! 3 ro inTioV f oao -111 licr.?,e.J wwlD er AWA, f)LTAG OIAGR.OFCOLLI$ION: { /,zgJZ " ?} un a I 1 rMIN. noe r?NrN ¢f1wr1 DESCRIPTIONOF COLLISION: EustslwruwryrAl slKtrrrwcessA,r) ?? ,.. - W \ .. ra+W °i .a..rs a'?b...l .?KL.+L3 ..r?c[dre -7? .. ? 2> ?; S?G.a + T??..D ca.AT...Io ?. vG? 'd? ___ i , 1 NAME, ADDRESS 8INJURIES OF PERSONS INVOLVED C 'ODES 1 2 3 1 6 3 u 30rRfw R" OCCUPANTS /WITNESSES is puonNI rvu•E Il Sl su ADF uru3 ".,"'" D'; :' nsn Encr NAMI _ _ _ M • WE153 V11 Or ar AM a 1 ? ?Ir . ON x igQi.Y N 1 ? N ?., Ap01113 urlp r E 1 repM 0A r r ." IO-rnr O N? ? ri:iy $ O I ) P 1, v tit,°' E •.r o.e! ? ?;110??,. a: ? :°,!. . x wru u.,°o,ran,N.w se•nc a•DU Ce . . iKlJl•'4RVl? •°I.4. n `^ a< m5..• •ID ^+„erLtwe K D .?n9n±xF D•n nlrOn r.eovlDa D•n !...^?r.,.ln-r..T1v.-m:aula r 5 $Q 1n 1 b I 1 t I 4' "Elio i G f Iti? T ? b r..r STATE OF WA-WINGTON w5PI3R,°`V.,.R°' OF B 3 POLICE TRAFFIC LOLL" ON REPORT ®TRAFFICWAY f .17 E) FOUCECOMRAIN fUMB[ - PRIVATE WAY ?sr t ¢°I D FO LOLL( I_ N_ _ _ °y r It,i USE RRDp..U41 COUNTY <OU ?• CIrv NO. FMNA x5 rl3!$7,R":?i a Rs J /Sv Q°a"" 's I ?N OE ?N CIYO4 TOWN Na 6N0 Or3fgffrO4HGnwAY f CfS ' /'/ gWTEORS E SEC ON MfES ?3 Rw oOFC'A ON (o0I 0 f91ECDNG Yq FN.5T4FFr04 ROap NON rvE[vSFCr ON I PREFIX T^ ?- MlE P05( ,? 01rµCfaO f?? Q BFTWF(N SrgFftA Srq[fT _ 7i I - •V I lFSF iFUtN EC40555rgffT09 NEAgfStM tf POS ACCIOENE RAMP DIAGRAM pAtA 6.i. rFfv 5 F w Or S MILEAGE k' c ll 3roN NvIXVED CODE E-111; X-RD IN cl, `~- TOTAL NO NO RUED NO N)U9Fp ?$VIAGf ?Hr6 RUN w W` IMER CU C4055 S1R!RORRROAIIR?? ?F'RMF. - ' C[vEHC![5 ® FRoK Y-AGEONEY ?FSUtTID ?vfNlClf X J, _ OBIECrStvUC[INANF-fOBI Cr 5r4UCaµpOwNFRSNaMfI ESr DNA•GF SPECW CODING IAf --"( s^ oR VFRSN.mE UNETNO. If 45r mIDOL UNIT N0.7 QVEHICIE QPEDESTRIAN QPEDAL CYCIIST ITS 5 k ? E4sLrvgME: rsT--?s?•- F- n 3TVfEr AD09ESS 2 R` ORV L? ' S[ 1. SreFEr gpp9E55 ear IA Lee= G„Y L PoGDpf IPnDNENO D s P Q 1UE 11 Q Q SrAi IP O i t? n ?/ ?/ r22A] a., 3.GfN5fN 51 q VUC g1 'C IF'' + °+2F?. ." 1V R ? ely Of•EOC B9H ? EN3[NO. , E ?q Po FHB H I i5A1 ..l :?A? mo i ?D.. ?1 g ley} /1? Io A12 ?Q f 'i a occuggn prof a RroNE No. ?_ Fnl GNT rf I'll GNT E OCCUPgr,ON E 6 PfgNf NO I P Y R Ens wFIGNr rFlcnr E ? CHECK (,l) `^ !??@ FnciFAS:N YFFagr?arHEgL ?CHECK (?) vFHaf•s nNfMROrFEagNOrHF4gF ,? ;„ CODES ?' ] n, 4 nrM 5 E ?l iw Ns v ? CODES 1? 1 3 ci:i°sF a s:srt "'y 5 Nt crro" 6 oS qo n +?? mw0l°opc. 0 WE 0 M, V ? Nt. - Pad, ( aEV r ?uDq?.convl U,M r ?sn" ? C. . I ? ;. r+ovAf 5ne •• $R 4 n E qs""'^ I vl MopEL 0- I ? 1} t . ?uN VAI r I v. v.l REP 7 v/ 0 a M ? 04 EUrvSfPUr N S''rA1••E'',^? 9atfR RATf NO. STArf H v <Q09 ;t P . VE UEiDfNrNGT ON NO. i v13lf pFNrF q l? ? ? qA ( r -141 i I-1ui i I air i IOwNiER A3 r NN i Ti 8t 31 -1191 1 eFG151FREDOWNf R RRST pOlf Rgn[NO. O etG Srt4ED 4 $ S ? 51 MDIXf Nf M. l? R ' k? ?nl`` Ia ADD4ESSaaw,+Ew r?? ?? W a owN? RIV R °S'A ?'L ? Lem E A'W,aN AS 42 NAmEa ADORESSOFINSURANCECO. CRAGENT -tW fA I R A I _ :.d 4 "'(P.. oAMACEp.nu ,?,?. ,wo ZiJ rr. R1p° a esr ww•ee cn Dca vEN b eH•qu - oµ:o.",eNr DAmACm ARU u `J d, 9Ft ' tJ:OllOii• ?AWA ?N-NeD ?nwwN ?R(MAIN[p f51. DAMAGL "' i s2 "w"o°Y' 1D+J ?wwFO f y' d DIAGRAM OF COl11510 I E ND Cgrt NOnT eY' TfJ(s IC IS:airoii s 11 Tu er Aggow y H OESCRIPFION OF_COLt15ION. I nl w4nem[NrAL snttr f Nee[s5A111 I lad R$?-OAI 43 r.T_ T- - - -- ----- NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - r OCCUPANTS/ WITNESSES I 51 G! TAr r. .ivl n[!- Il Sr9 ou:iD1-ATIIASwpNATURE or 41 __ (e ? Me ? AKr Hl p Ap04111 NO ? • ? v' t NA ona....gYtp room •me '? ? y'y}?. a NAVe ' R.I er '?j? q ?tt ? ? ? ?'.n. ? ?pU "I?i ?? S I R 1 .' 4. fFtk _ _____ _ -_._._.. ...... _... No ?Nr H" ?::w•A ?4?'rt?k(' ,IU,??ti, • ADp4r14 .. If Or .. -.. P j _._-. - u1Ne nY ?AMe ? !' R Wes' .rvnrq.r NCar.cL.s N.r.ts4,n° a ?04 AcEr,cY :'?Ja,,. O:P.r ? :4'ns. ? ? p?.j9Y ?• X ? ? g, ;,, I SOsI c ¢ I $IS"ED DAn or nro4r T APP ovm n. ou ?? , : , .?:+ ? ???'{I E' ..5 3•z?47 } ]KO nvf S y ? ++ ?? r ??? Ts ? b4 ni'! 17"1 .l w ' I D ,b. ?I rps 15- 7 Y1 ? I Vr [ ) J ? ryn V:, yN.v., fi?4 • I ; .4 ?E 3 h 1i 4?1 n L.?.v,?lw $c, r? ?l TRAFFICWAY POLICE TRAFFIC COLLISION REPORT -- 1 PDUCfcDMPwnrnuMwv. I PRIVATE WAY _ D I! F Olll IMf COUNT^? r (U]ER?HOUn 31/? $r7 Iq; I EI-r.. 7Gi6 ?iCC.LI.SO.J NO .:. - ' CITY NO rPIWA pu4e•N 4µ ?' pN pflN ?Ir O/R IOwN NAMt OOf S1gFf104 NIGnWAY .WI,$ ?5 pW p0F 1?4E7GrJG? ON-o/Yf?S C45 gOUiF OR i C1 •:635 O .. ' -M lM[RRCI NnO WIM. sIREEI Ov RO.O NON lH1ER5FCIlON ?,>S0? eF1NKlN S11111. 5 UT Dl5 AN E. R M .CROSS3rgf N1AR 5 MITE ACCIDENr l43 5 [ W MIEEAGE rtR OF CODE R[Flx [ lE POJ? .. ' i '00 R D - I cOlISpNNYOEVIO EVf RIIY: I.OF ?nI. RDN wMD HO NO xllltD?NO N1URf0? ?SP IOTAl D IN I RHI RO_ cSEE4tNC lIllit Cl5 CRO%3 . Tcj IT ]] aVEH CKES PROR9IY DAMAGE ONIY p!R[IiED ?3(aGlf Oe,tCt 31 (NAME OF OD! ISI RUC R .NDOWHfRSNAME) 1511) - 8? N - — / ? 5KCIAI000ING USf UNIT NO. 1 UNIiN.2 DRIVER'S NAME: ll3i r.= ' ? VEHICLE p PEDESTRIAN p PEDALCYCLIST -JE GS ? ?1 OR ER Si E: U l l - - 3 n1IADOn iI AGGRESS R l r ED /4 I-'/?1 1S1i I • I u N R-1 ...I R CUPA[ION CK (.? v[HInE• : M w wN ?CHECK(?) v[H tt1 AS AN FMw e r .[i CODES ?' 7 o . '„ S I rclxv. a s,° - D.t[oFA me CODES ?' D c"l.y . e°.svM"' s Ex N e' :. u D I ?r 2 IN, „;;NM ° NN ro3, .. p . M .» I ? R [n .fM 1lOOPGf Cnlv f ? n,m. ? I .84 O.gINWA Et 31 7 ' p p ?,cl ? B R ? ? S: Ku l 9Slo ??s I I rU?D CONV.I 1i4. ?cG 3 biz. E I nv.l EID vA, l .aM _ ,. S SIAI A [R 0.AIF NO Sr.i H q ?? "A I' 'D vlHKlt DENIIN[AtpN NO S3 ?x3 GS' i v n Cl OFN l A l I I I I I I I ? I I ? I 2 nasrt4eoowYE[. uur sr Mloole vHONe HO O ? I wN n sr M ADOnssaowrHU W N E AM1..DD.i55 awsu.AKI E.O pACw1 U R Ell D.M.c[ .•u ,. o ' g.MAa .ArA 2 &.2a zgaE ? ' c: - l aOA ?.1-Nm ??RW1n ?RlMUNlO f C W IO.DOO? F t3 -"010 1W v iS:i 3 b S = I r S Q I=.. . A'..-Al. -5 7-b DIARAM OF COLLISION: DESCRIPTION OF COLLISION: IuuswnlwNtA, 1.1111 HeaSLU1.1 1,06 "123 C 2 w JE Zt) T??MAS: 1 I. ?") I i l .. W/,lci/ Tu/L.15_ i.JTq_ /lI?SLW _ 3T I I C I D2 F Z TaviL //iS EJ/ES ciF F' m/' _ _ . -. i NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES CODES * I Z - J S 6 N OCCUPANTS/ WITNESSES .MI _ . AGI - IAtV .1 Rai :I MIrR .It INC[ ...._- -. -_-- . N Dam .,.E ? .. •M. ? E?Ix' O" ? aJ ? X8,1. " . no .. D No _. e l?? a !o . p.M. ?.aa ?"In. ? .7: ?.?°;,. ND .. r -. ... I MF ?rp pD.IN a n ..c c??< u.. a. ..Duo .cEHC. aaDOr.Iam PQ , . 61. e w ?.M. ? ?EDnI. F. ? D•¢ rT o- n q lD.r wn + "I• y? 1 l NI , E t r Y r !F I "G l r t aRs ' r y?.y • z 4 3 A w ti ) t R h ?A ti E l t NB+? r I + ? L POLICE TRAFFIC COMKION REPORT TRAFFICWAY WIICE "-NT NUM . 3 PRIVATE WAY BAs r gyyl w L• j t . ul? LIME (USE 111 U41 ah? courrr ?C.<Gc2so mIII'E vFRO / (F/ cm HO. rlnvn URBAN FIAL 2 1 ON of CI Oe IOWN / N feNO. IPEEI OR HIGHWAY INIt3 ?S ?W f lo, `? / ON 1 gW/1f OR 1 f 1037 0. - k 11 L INIFRStCINGSNTNS1REf1ORWAO NON INtEeafCIION NH stRFEI6 l"'D PRffl% f MILE POST D?S? I S1ANCtSD etM ON reO MVrFRtn CROSSSIeEE OR NFAef3l Mllf POS lF3 N S F W Efl OF ACCIDENT MILEAGE ILEAGE CODE RAMP D RAM DAIA 4 HHRFN t coll.-. NvO1V10 Ev 1 "'1'" TOtwlNO NO < IlFO INIUR[D? ? SP l1AGF ? H a vw efts AGE ONIr ?aE°sullfD 0viaaE 0-- -p1 (s1 VnwGF 0 PECIAL ?RD IM[R [la CODING IAE CII O C CAOSa?C? - - 4 . • AND OWN[93NM+[I 3f4UCRINAMEOrOBI[CiS S `- (J NO.1 UNIT UNIT NO.2 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST - -' 9 D t sNwME. IwsTI TIT as MI -E -w l I sT . ust NtR'5NAME ?w -? ' . y _ S EEI..DR[SS 1 tl wDDe[53 ? ? - -? G / ONFNO D - /y1GbJGG ST B1AIf IPC t r . CIr?O?? S,wf ZIRCODf oc,.W SE.R? LJr4 Gd SS R i.3 DLoUL ..s o _ rvtR'31CtNat NO. ?LS aAlt /O IH .2R ? I v t kNSfNO_ /oc?ECm L wlE All 111 11" /'v T ?, GNI HIGHI ESMONf NO OCCUR ION F E N GM NE GHI CUPAIION' AMFSPHONF NO. r . / iL!/1?i?7 ?o1?T cw feT7 R iJ o JC- r wo.o C- - CHECK(.? ei r A EMRMY FOF No1NER'Rl vrw ?CHECKI.7 vrH Cir AS AN UnviovEEOF ANOIHFVAI °c•cY I CODES ? D ?uv. • 5 e 6 "'O?O°`•c'C-- 3 -- CODES 11 t 2 A i inm" 5 to 6 NI EN I? lwlt3 n2o. ?? i s o - U w I'll p AMe,.AHEI p m" p M;it. ? „ ? --.NCI ? u°1° ? E8mP O Kii C N ' / VfH. rfAR MA EIDODG CHEV.I 7G G/GPI fIIDwR1?NDVA1 atrlE I4 DR?C ) o/%9 2 E I NEV.) MOr%IIDwR1?NgVAI H YEAR ?D5 C?TG+ss v ( 1 RD2 per 1 U fN tPIA OR SIAIt IRUI[R RAIf NO. S1A1 I'I [H C l - A _ Il N 4F Z, EJ3/?f L??? - - _- _- VE.-I.NrrCATroN NO. IX69GdL /;L$$/ 7 L vtH <u lannNA NN ?? 9 y?o7 nasnRtDOWma IASI .IRSI MIOIXI rrtoNE NO. W Is D WNER lul HRSI MIODIf w C - - E - 1 ? L ADDRtasa pWNEa 5.9? " E A fe - IN AN NAMEaADDVESSOINwawNUCO.ORAGENr .Job - R " w gAMAGE3 AREA- DAMAW IAEw "u r4 ' ' C.- Olr,l °1O° ?v W014 A4 wC CHAR , REMAINED 1310 S EST DArnw WAY" OpfMNNfD A,MA -N O IC?OTIO?' IU iO,lOii s IOWTD S ?? iw:+°er? ` ? AWAY er. DIAGRAM Of COLLISION: lu lu ND V?°QIH DESCRIPTION OF COLLISION: (use suvnEMENI Wnu HICtSSARr) ` _ ?I I ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED ' CODES 1 - 2 D 4 5 6 , OCCUPANTS/ WITNESSES ufa urtr NAMt cscsP Ti9ME5 ;;dS ?S NO i ta.,3s _. .._. . rpdfol O G EN nr ?AMe 0 K'3" W 15l - .. ..... ... .. N rU Id _ epIROM ?AMe 0RaKI ern. 13 h: ?n°INw .° .. _. Dc w%s ' OAV.e ?::" OP'ml. .I. On:,,. FE 1 X /l z1/ r<? n c ?(JnGI ° ' ?T6i D DAIF I D.I A .POHDe Ma. a K K , 1 y w ?? 4 a k a?J/•rtL ? T ) t ^ i` 1 4 5 f? a n ? 77 t?; ?'?x ? t .4 [ ?T I Y;, I I? . . u k ? F - r j.? 1 )73 r I a r ?1? rl l 1 _ F l ?' 1 , T 11 i? 1 1 1, t ¦rAElle?i r • ? ? T l' ?S tlT r ,f^ 5 Y l "1• ?, . A Mi `y ? r? 1 ?3`F 1 i s tS 7 1 { S N I - O •? a rt 4J d 1` N yyh1?WC) co O :.? 6imo t 1 ! t ? i 1 r i r pl $, rv i F I fi M ? " d •-- PRIVATE WAY - rtofca,sN A r uoN Iml co IY muNlrYn,. 4rrYq. - +. !e w, w IUSF 4ENHOURI // iHWA ?URBAN 4Al ?N ?[ • C O O N N 00 SIPff10 G Ar 45 RWIF GA 51 i .11 E3 ? ? ?D ?•..Il,L.. ON 1, --_ F ?/.. 3 X3300 Nlf4N<I NG Vn1R 1911, Ox POAp NON NIk95fCl ON VPRFiI% E M q Bf POST ' / • •% CrY BtIWFkN SIRtFI d s141f1 - On T& \- IANadUU(?10N 4 m4(rlPtN f. C405511P[Ef 09 NFwxFSi MIf[IVSI ACCIpENT O "'A .,A IF T W Oi MILEAGE ' - S tR it ACODM +, GOUrS% rYVgvIU Bl. rq NUFO_NO INIUNIU ?vtiAGl ?nIe NUN .uNDROIn [' INIFq CL5 O[?SSWIROR ROADRRMpOR R[fERLNCE r vin " i Q Y e cl s ? v4ovtplr pAmACf oNfr ? of mun ? IN " f Ub,r<I SIVUCXINAmt Or OOnCI SIpUC%wNp OWNFp'S NAM[I F31. pAMAGf SRC(w{Clpv{G •' % $ UNIT NO. 1 UNITNO.R ? VEHICLE' : mi ? PEDESTRIAN ? PEDALCYCLIST n[X1 NAm[. fA51 q 1 DIF DRIVE45NA f M lASt Nt 1 ? - I RtE i A pDpf51 ? ?/ ry , / I . \ ` Y\ /• 1 SfAIf ZIP<ODf PrWNt NO D DC sAIF zlvc v 1 .IV tril CENSf NO. SIAIE b XI« DAZE f ( ENSkN V 1 IAII SIB D If Of .? Mt, 4` J 1 .XI V Y ?h A BpM mp. 9Y 'rv UPwIiON MNNA[BP«ONF NO. [r[S WtIGHI flIGNI E OCCUPAI ON IpM NMEf6R ENO. EYES wEIGN1 HIGN I j ? CHECK (.I f«<i'r +s:ri'rMa Ar;"or«IC'AI ? CHECK(/) x IAt K [ ws i o , I wN FmA ova f ANDI«f e CODES ?' 7 5 .11 e ;' CODES ? * 7 + rA " e i 1 BI IN I If 9, ? ; [3 and A K ? . <t ? 8'V ? ? r ? wYN l ? Yr ? ? GC 2, ? s.. onlp T IDODGI1"111 MODtlIDA9f-1 1 I RUP. COVV.I « F I L«EV.) MODfl lpwxf Al Y 1 VI ^ , r aw[ IKl- Plwf SUIF I-11, RAZE NO. 11A1[ H a«. F v[«Ktt IpENUfKAfION NO f«ICl[ID[NNEKAI L P, N I LA b: 7), 1,1 1 ' ' , '? YfGI +R4tDOwMR Iwll 119SI MKKK! plgN[NO .......... WNFR, fA51 fIRSi MID0.F W A u wopeessa owwR '_'-' N LjDI E NAMIdAW9tS1G INSUVANCl CO WAGt Ni ItIF[SSbTiFY*-E,tNZ[[6- IdiZA EE1- •? R qR ~ wGID wM(w rxr UNA f o-inclr ti 17• C«AR4 wtinxiN iNAAG[D SEA 3 I311MMAGt . V'N C,tA4Gf 1 nx .r I/{_??/ ' ryD? ? ?RIM+INIU 1:A DRivIN ?RIMAINID ISL.Dw/I i 1 .Iaa?1 f ?. ? ?WAVpbY ? AWyrtp by 1CJ AWAY 5 ^ 1U ?0 \ LR _ DIA G AM OF COLLISION: sisfl liNi41wir1 r'p?::i'NOX'n DESCRIPTION OF COLLISION: Ifni-MVINIAL vx[ID Nf4s_1 ... 1, / i. _ r r f:l' .d f _ NAME, AD ESS BESS 8 IN RSONS INVOLVED E CODES 1 - 2 9 4 5 6 OCCUPANTS/WITNESSES SIB wGl IAI,n '" 4f31R Ina M•! Mro ?AM A ? ti'O P . ?h ?.: ' +n NAVI f ra ? XMOV,pfe - ??? AWIS O:". '??,.n.?Hx ?1:.;.? ? w- ,AI.«:arB 193«. A , gAlrAtw A D rQ I KF UiWgUtIU EY.AKI NO DAII (%YI`VIII wmpy3D 01 Uwl! , t` r : ' N n N ii / r. n REaI % •' rY ry ' ? 'TAwici" 4 1 .... 5 ? 1 I r 'If 1' y i E ? ? , i ? I t, ti r t 1 't , 3'' 1 I {? Y I 1 , I eft x:4 Y? .m y 1 1 7 w u a- ?a ? C srF,? Mt ? ??§?? Y . 4 {y IF ` r ? . , t PRAFFICCOU.IaION REPORT ®TRAFFICWAY J • -0,,C-ET- J rol¢EC wN4v°azR S+I ,? PRIVATE WAY L MvA CItY NO, --N., r N Du;d IX IMt Ct-1- CIOfE s IUSt )uUI UURI u IwRS 1R Y1" x Y x N x1 Q LJ Q UaOAN L/v aA4 sF IION I O 8 J LNr Oa IOwN NuAt°NO.Or sIR[E, DN NGnwAY D. pw AO - r ON I ROUif deslRf! L rd L43 !a0/S? 1 8 c F !a s F W[fI% F Mal VOSI Vn,n s,vltlOV xpAO r NINIfRYCI UN INIFRS[CI rvG 51x[!1 Q?/ , [Iw[ RFf(° ACCIDENT DIS1ANCl°DPF MI Orv rxOM UGtPENCf. a055 -1-k N IL M "l sl MIEAGE C ODE s N DAGRAM MIA I . J [] ? ? OF y FFFi %.RD N YCIIN -111URWAD0RH11RFNC! ItOAD s CR(XSSIR[f10N IFR C 'tf cdlslorv NVIXVID l10lx Nlp uNFOL7QsV 4EAO( ?r1 -Al NO © {? Vu OR FF AGE ONu LI'LLND ?sI-IN d v[1" Ctfs r.Inu.IUn? tsI DAMAGE VECW IN l CODING USf _ ? ZS.3? - ?. ob%n slR4xx INAwt d oxncl slNUC%wxoowNFV s NAMFI s UNIT 1"0.2 ?VEHICLE PEDESTRIAN PEDALCYCLIST UNIT NO.I NSI last MI -E NAME ' NAt. Nsl FINS MI M ICE : S DRIVER sIRtN ADORFSSJ sINLI ADDatss 41 2 2-14 CRP -% NON!NO e T s,AIE -CODE v1IONE10 D . rv Cllr s1Atf _ 3- Cliv O 2 ? R 1VfR's uCfrvsE NO. IAII SE% OAIEdeRIN DAx rR e F -IF DRMER's UCENSF NO. rvo l Fs wFIGH, IfN:NI t% ° E EYES WEIGH, rEIGNI FIRM NAME!PNONE NO 4O ? = 0N A11 OCCW R r tS gT 2 ANOINFR A4 CHECK ( 1) n F `? OCHECK (?) - FASAN,Maor"I-ANO,r'Ia"f w " = `] n ? s . D ?. " e u1 - - CODES 1. ]is uA" 51x N CODES? 7" M IwI[as -?`? nI C) ? c C' 011'51"1. ? ? w ?""'" ;fF""1:. x ?Avx"I.r<I -r Y[1" Rt IDODGf-CHtVI ^ M-0DlFIDMI NOVAI lf I'll . ONV.I n ? rMRM 1"a ? Z", ? roan. 01- aoa. .1 rtAR MAR 1 F. ntMl AwoFI wAR, NOVAI V - tb . E to ?i Q uN c.`iCnA1F NO s,A,t H . vln d N B All NO IF 11 Z [ udNSE a V s1AlI . I Wt?T ZO 10R. IJ X FNCI-N1.-AIFON- 2 MIDM[ a10NF 1"0 ? F r C L ViH-RXNI1fI A I N C u 2 5 2 5 3 7 0 NF- MIDOIF RRtD WNFR Asl Rsl R SO Iail [D tR. IASI gtG151 1 O W E.C.ZL.- • ' N ' NIB AooRessd OwnfR N E Z H t AMt aAOORessd mwRArva co d+ACINI .R HOMER u s?VR " . . w:AN Nc .? .wu DNAAL OMU f ww bbL• cNAU°r o wii n+"vi 'Z u E u cNARd ?. DA?ct?? ??> .-n ... D.., =AT ?REMAImu [s, ° -! s [s1?wvAACt ?DxI^I`, 1" ?RI MNNtD wA %%%%%%111111 S ' m R .l. ? A Y l ? lo WA xr: AWAY Y sE SUVatMFNw srntl lr N[L[SNarI ^ lu Ixn NAI uI n DESCRIPTION OF COLLISION: lu DIAGRAM OF COLLISION: SrI[IIU NF (S5ARr1 °`MI \ W? E, BNti, ON T11E ?TR?-O Ci I n Ef: µS.I.LIc.R i1JJ• ! FLA,L,LNG OLCr FROM THE \ S'(UP SLC?N ( 11.1E yNTE.('?SEL:TSON t/JS.TH ^! OLZ DSSC.oV&.R`Z RD O,p nccCOVERt UEH. H.2 WpS So. BIND, ON OL.b DILSW- _ E r3`? Pr .?. R, L RID- o WRS UNABC.E 'M AVOLD lZoll, © 4' STOP (VEH, # I WND 8EEIJ IvgvE.Q pRS.OR TO ?' fTRtAH MY F1RRLvRL- ON THE SCENE) " ADDRESS 8 INJURIES OF PERSONS INVOLVED 1 CODES 1 - 2 9 < 5 6 NAME f .1„avN Inn ." '"??" ' M , , _ 11 .?wa vA Aa ums :?1 OCCUPANTS/WITNESSES Iliwuwullu iii -! 348 NAME BEu"plilm, L_. 0 323 0"Mn Qr 0.L ?Rr Dw„' x11 "M 6ND[! .TP " t .r0?'332=1673 . .IMwIDr dA Q M ?". _?;"< . Q" ?" RFU 71 s NE Nb .mRfd MIN" QANx ?" 02-,0i 1 x rA f?3- A IID ? I.?r. GLLC t:RT . SkR.cs1' YL`A?/ ).nH aS',:a7n3 ?t ?IA m y 'DE ibv-, ICE TRAFFIC COLLN REPORT IGy TRAFFICWAY ' rollcf coMnMNr NERnbER l POL . PRIVATE WAY wA l E a DAIS Of IXE] UA p<gUSION Imf COUNTY . IVbf 3MA nOVRI COUNTY NO. qTY NO. ? URB ? , .? rxr, .rR w., Z ,.r a 9 T?f??ila? 3 j : 8. s Ax / !!YY ICI ClS RWIF ON,I4E RM SECTION C.YONIOWN NO p]IN{fTON INCnW ON ORN / wlES ?s ?E ?oI HAr, DAIS ON ASS"Corn e: /'r ?J ?Lj?OG9 u 145EC1 NO wtln SlRy.?Ox 4uM NNIIR]FCTIOH Y4tfl% f MITE POS9 , V ?NRl57'N RD• ntlwlw s1unT [IOENI AA,V DIAG9AMwu E OINf p g{rs tNCl.C4U 55 sIRIFI ON..A9tsl mr,trOS1 IS M AC MILEAGE CODE Ilfr ? of "i'r,?„ IfNS<C LNG ]I9IH RNMON 9fifRENCf R n CAOSSSEPf[IOR ROM rN 23 ? CIXLISgNINVgvLD. lNUY: NOINIU4 -IA 1 ? ••?NGIn , O .LLI[0?. IUn ?III16RUN " r ' INI{ ?p / ?3?9V/ q IpCI f pOVNxC?S ?YGORRIYDAMAGI ONLY ?NSUIrIU ?V [ST DMAA(:I / EOE O01ICT 519«R AND OWNF9SENMFI A VVV SRCW CODING IbE 9 / ? ORRCI SIR«%IN M C S I UNIT NO.2 NIT NO l15T ? VEHICLE ? PEDESTRIAN C1 PEDAL. C . U poll ......'S NAME. wI, NR MI Dlf 9 AM WRIR'S NE: V31 ?A CC./• cVC?L •041 2 J?J?RFi q /24 N? vC<•NC slxtEl MDxlss ST9ffT ADDRESS il /Suv ?..z{ e0 ST 73AZ t-r-, "D G..z_rN Qo ?3 2 un n a4 cool ,DILL No D s E rvcoD Gllofn 3 J i NN 9833 y 3?s !1 H R 3 3 J/qp< Dc.rS vk 8 oAll rf bl4m ow<o c siATE % I blR A I Iv9 ufN]F NO. ArE IwlvfxsuctNU NO. F ?N F y2 6 ir v y. )?P w? 9 i 56 ! ?8 fns wrlcnr wcnl E cnr r<IC.I a5p4ANDN AME s YIIONF No. Ens T «DUYAIION NRM NAMEfREONE NG 9? ,3 CAFL •?! • S ? I +flQt y'A R o S.// //b sue'= >< M Ro TNC PaR?S .Slu +'? A ::w . . l... + /p3 All o rNADMFU o ? CHECK V) i cif ASAN ImROrrl A vf " C A ? CHECK (?) D I AILS In q+ > "` ""•' v + N r NI nIC * NY 5 I%c a" A ri CODES ? ' 3 r".:i + ,z r? Z ] ? ? CODES ODES x Jr?oNt T Y n . N Iw bnl. ni s9 ? s ? ? rIr u, ; M ? mN AN l a,: - ? M • . I ? ? ?.;az I ; UANT NUVAI }IYlf 19 U9 CONV.I x MOOfE I MMII nEV. v1 MODEL IDANI NOVAI LL1309. Ip 9 MARE Ipopcf Cnf V.1 Wn75 DoDGk I Au 202 E ?,EV 36a ?v A llF, lA No. Al 3tl W / n L --IN STATE [RAILER RATE No SIAIE H --ow U N L . ?? L ` ti II nn GN 931 wy s N /JC I C+QE Nrp{r NIIf CATIONNO. L w B+ESSao?. 60 L FnlgErl%NIICArI C I Z 3694 v ISTF4IDOWNFR. A51 (1951 MIDDtf E 9 I IGISR9E0 tv. IASI 1451 MI DlE cc.% E N<e: ?" RgNI NO _•LLjS W ABO Wt; N i W A t.?' ssq ON+ER ADS i ST NAP«</ E N- Ct?Ha Ra Fv?RE?t 49M 51 t !N E, NAMLaADORESSp INSwArxl <D aR MINT '" R ?. _ " tAMAOt? ARfA t " .,.., I A %x . ,WLN?xD ' " RD DAMKAD A4lA Ix,.N"r. VGI ol??ao w?i _"` LIAR In"? p+,WW NoN' pIA NcL.,? f fs1.DAmAa ?tV .. r •EO• • S lST DfIMGI RJ pvI ^Fn ?41MMNIU " Id eww ?RLNNNI. osonp? IC4011piI .. i01 wID ?TOWY•IY bU S?OO y IMINIAI SrN[I IE NtCt55A9Y1 _ $ `OO ? USF SURR C vAr Nin DIAGRAM OF COLLISION' iri"EI Ii Nic{ss%RrI DEXRIPTION OF OIHSION; 1 Sy_a W///6 IVAN O Yclfl NO I 14S TD b CN/{ly77VF ? X I x AFT Kc z_ Dz? Nod sic A Tv RN F.iGNT 1 AND STAR3'c? ARoE NO • yro I pe i'Nf J- ? ,z # co Ko S)Ot. Nol T?nN?D lKT? THE S)D? y eJ . o>• vef rlI N ADDRESS & INJURIES OF PERSONS INVOLVED ' CODES I - 2 3 4 5 6 NAME " , OCCUPANTS /WITNESSES rnIEaf _-oMlr+MNlM VINAw m u u% Acl .IMm '" 4{sTa. Era .va WIF w1 M> tirMlo, *IrAV ' ?AMb ??.?.I ??[?.?Nx ?iK IRE" , Mx'AES> AIXIW ALIrKY IUI'.YAIYr9p IAV?, Tp Al1oEVIRHI A44. .8y WTI « 11.M.+oollav•.LCwf9Ar.. . •n 707 /7fb /f . 3 /6-8 -NEE, I Y GhJ..Ce -1 3 ? c a I,P r ..W +F " 4 a ?I •?? 'D1Y`.dr'?A • }.. ?;'SEIriE' ??fsrr?tr•?? ® M " " IYU. TRAFFICWAY REPORT POLICE TRAFFIC COL. . . PaK[cawAlNTNUmDfx 'I 1 PRIVATE WAY 3 AIE O/C s?. w xu Wx1 RN TIME VISE V,a NauRS 2366 COUNTY r7EF;=e azo CdIN1Y NO. /!. CITY NO. ?iNwn URAL Ib 2 .A ?N ?f p N Civ UR IOwN Mlles ?s w ?ol N D a O SIRtF OP NGNWAV ON L US RWIF ON SIxt[IC ..3 G" .5 ECI ON z! INItYSEUING.WIl.:SI 1 ROAD NON INifRStclW DE-11 DALE }Z?,EV a I P- 1) -11, I% E MILEPOST DISIANC[{DI CII F. CROSS SIRES I OR rvf-1 M11f IV51 Mn[5 15 3 NIT El 0 C) OF = ACCIDENT MILEAGE CODE dAGRAM MIA COIIISIDNINVOIVfD: vENllr l NN{RUN rIO %llf0 NO.INJUREO? ?3P llAGF ? nonoi •un « IN kD INtfA CIS INIfxSECTING S14fFt OR ROAD OR O![RFrKt CR05551YfEl OR ROAD rli (YOVM NO. fNIClES a ? PRORRTr DAMAGE ONLY ? itFSUIrED ? S pCIE R.3.3SO 3 D[%CI51RUC[I-OI... 014-ANDOWNER SNAME) [IDPmAGt )Fl 5 13A l CE- I $ ! d0 00 SHCw OOORRG I?SE _ UNIT NO. 1 ' LINITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 3 WI NR51 M1Ddf DPIVFR'S T L 11t MI' if DRIVER'S NNAE: AT - RUI 5-TADORE StREFI ADDRESS Z SrAlf COD PNOnf NO v 5rA1E IIP COM NONE W. CH 11Y1 W R I Z!5 -967 R l S UGf IRA3,,?3 E E IF [% 6v. I V Ev. UcINS , MATE SFA DAIFOI BRIM vu. w. .v. _ [ NO . 5 GNT rf GNt CUPAIION NRM NAME{ RgM E OCCUINN- 11RM NAN[ { PHONE NO. Ett5 -1- 110111 2< M E 2 - 601 N R 1 1 ? CMECK (.? vINKle+s xW,N1 ANOmIa L [I CHECK (,I vgC^ AS AN EmPiorrE Si ArvorilfzAI r=1 CODES ? D a a ss IIE CODES G n:3i { 31°. SIR on 0 :ii :`cY°l , I 2 5 °«;o;a U %1 ? S.IIR ? s" ? "3 • ;.' ? ? N MV U RI ? zs:N. ? .; ' ? .1 + VFN.Y[AR MA[f IDODGFLNEV.I 72 m00ff IDMr.NOVAr slYlE lrOR-V.) Phu E 1- I .) -1IDARI NOVAI 1 OR V) ? ? PIA t N SIAIt AINR NAIL NO 1^11 H vEN cdoR u'FRSFYxTCF7? A All AtNO 3 AIE - Eu otJ )(M I q47 W A I ff VINKIEIOfNIFCAl-ND, l o ! 5 i vfN Clf drvlN Rd3RREDONntR: WT NRSI IDd[ EoGAQ I'2L E PFNJNt NO uouG O f IStEVfDOWrvfN: Wt iIR31 MIDdf NO. 2 AOORtSSOOfP.tR k W 98339 (bB 112, E N A ( OwrvkR 00OR AGFrvI NAM{{Al1ON35 Cf Yx51AAN0 NON R I UI A 121 11,.33,•!A MU 'd ? OAMAGIO AREA • 'v'O AI CNARd , / .IM • 3 {[/. DAMAGI ? DN VIWAYN 1411-11D - fNARGI nr?IVnecr ? AWAY ?YEMNNID E51 uDAMwGf I Dii 3 • To.. TAL ilo E] -l11 OMD ? AW.1 5 ' DIAGRAM CO ON:n i?u[In r¢eesi3?Yl I pc N DESCRIPTION OF COLLISION: 1141-f-AI SMtf It NlC-ARY) dl _ N uEH.Q Easr W ou TROODALIF RD, -TCLOJED SOUK ----------- - -- - 6NT0 MASWIC. MALL r2DAD GOI ti1G - o FkLSr(s0 mPH f -r- -.y 3KIG--K Top lM,,ED up rcuA2 BRAKES -p;zwr BaAeus Tuommn , ( ;` Zy ? ? Y r SKIDDED ME,wApuE.>Gour Sol of 6.5m-u E4PS WIRE RaXG I 4 CED429cI.E5 AUD 7RW STRIWAIG _ .. , D ?p{y j >` 4Y1111ir F 3 R 2 Te6E5. PAISS. Was TPAPMD W VEH• RP, APPX. IEJW 30 M AJCQE3 WHILE, DM%L WA3 PRLE.D d'EN[ F& 6® ..De 'f O o r W r 9F SNIFTER ou6o- rWPX 2 mer Fm. a4B of PAA. PAtis5E STRut-W, W1011TWIELD u r-AW. fZoAQIWA`I LOP% Im. I ;, NAME, ADDRE5581NJURIES OF PERSONS I NVOLVED }CODES 1 - Z J 4' S 6 ,, OCCUPANTS / WITNESSES iEwf :nouarwlr?iA°.M"Ii ii ST. AGE um• '";;" R nlx ula NAMI SRI -rRourn,AN MAR7lAJ M moo E - Iv1 w t :0„33 „d NOM?AM„ ?r. I?^ , oM ?z LI a X wvE IKIn34AMF ER+r.. • si' eAdau M ??' ar.cY o•.I ,. N 2 c. Yrt,•PUU[D 240 X-T 23SO 6-21-89 LATE x: NS6 . " q: t !, fC u?ly?l? ?• ?µ wr '. :GY Elxh 'vtJri'1M.Jr'F'?J. .v:y:" .??'J'?r r i. ?1 {fh...} fJA??Af?'f tl \rU ?IE1+i?Ql+,?rrt[r• 1 1 r ?1 !s1 1 1. ? I l?r. , 1 !T fl E :! ma N 4 ? r a N c 0 41 U U N Sa ? C J? O ? O H h L- M O m O O 01 ri ?D 711 wwlsv lxfv I em STATE OF WA. HINGTON PAGE Or No. } } O POLICE TRAFFIC COL NREPORT MAPHCWAY ,•' -` _--,, ANT N Mtlfv •• PRIVATE WAY O 19 •tOt GOlI N 0 ? R,. x ,x.5 ,,, ,w:t"R ., , sEfwof.ouv c ourvrr COUNTY NO. CITY O wa iu 3 ? 9 As E Crv OR tOw „ t f p9 S9 ? N T'a`FIKd.'.;oN un18 NO Dr SIREiIOR. G.WAi // (O f 7 G ? Ran" u ? ? [] N / •utfs ®s w ?o RT76-'siNb OND.k D,voo.&R Ro t 1 vOt,IEOVSivffE 1[CrpN 3 % lrC?SL% INEFVyG NG wIIM SIRF Ov vO•D NOV ---ON C41pi c.SV• RQ F-EEN SIRIIIB $Ieffl U, ?Cfl EI Di3 ANCtfp f tv[NCE CROSS S'?-I OR Nfavf5l Milf p0l ACCIDEW 1 R[1 f w Mp DMGVAM..I. I Ittr OF AC CID IJ.r-LCR RD MCODEF C li1iO„ NvOlvlO SO RRltfp 101AI N0 L O [ f ? Sv ?RCt ?" ''" dv[.GfS © ?ppOttRlvD FO' ? t IN I'D iNr R 1CI 11R1E10R WAp OR R[VtvtNCF NrFR Gs CvO11rP1F10v ROnD D 9 ? 11 ?VfpCE UB:r I11v CA N•Mf Ot OV,E<f SIRpCr OOwNF SN•MI 5r pAAACF 5KCALCODNGME s UNIT NO. 1 Dervtx sNUnt wsr .xsr Mmpll UNIS NO." q' VEHICLE ? PEDESTRIAN ? PEDALCYCLIST vlv I s M DIF /,•s' ? C!•//L.s_ Ls v, C ^)-' N - S N s'•' A C K F, f { / vxeu ADORtss . . ADDxus A ! 9 TN AN.D HC?C c• /?j';i Bah 1+ O -? 1141E pCOIX PORT Trw /Sti/a wN 723C G?-?? 6 D R St•rl tNO PvRs7dt:.,rstND wN. 9S'?pE p 537Q, I• 'S VCINY rvO IIATI E v^ [ itl p x I t<ENY NO S[. AIfOIB RI p 7J?PG wn M /o t z3 Gh/?G wN F y x6 'sb 1 ' OCCUp•nON Mrv•Mf 6 v.ON[ NO tv[S Nt c.r K G.r E OCCUp•I ON ., NAMF fl p.ONI No [ t1 WF G.I NE,cN r ) /S L RcT 16D R l ? "1 5 ?CHECK (,I ?o I •N r. :1 4j /1c 5 ?CHECK(?) .<ir ASnN Unpiovtl o <A - !L ) ?< / 5 CODES ?' 7 i"' e i " w CODES ? 1 151-11 n 1+.u ul 3 j Jj> ?N ns oNc' ' NC No W p. •.,.,:I p faE "Al MA%I IDODGf'Cwfvl fl ?Fb>,I. ? : .6,, AF MODt.IDae1-Npv i.r•r )OV <ON u?nlvpD, uo °" pw p .:l ? vi?r'i Iv.ia O o fe. VI E 8Sx 73..,c1:Epl AV v-0Dtt lp DY C skyl4RlT SDP, V x,v ?fl w uuN pu EN AIER xuE NO swn H v. cowx .. ..ENO An ;•1 73,:•1 T76'l6 kN wH;R` ?? 767 w// _ Vl.iCIF IXNI rrC%, ON NO 7 FrDrlSf ] ?r%A/ % 3 c•, RlcznelDOmnR s t?RS+ R.carN L vf.,<II 01Nr r CANON N / I-" D3 7 z 3 D fir x s E ?Cj O t.cvrc T S?-J 8r i• 0 W u NI •sr .es' ,--r orveNo c,•_4 t IF -??^NNY C'Az?NAfl?O J SO AppRfss a -1. / 9 Tr! a /i oL. c . •% N E ? 3 s GvANr Mr-r-RS /.V6- y ?, `?.. /NPR Po41 Te,.rovt y,,I wM1 aADORISSa ?NSUR.NG CO a•eeN1 N s. .N U,.NC • N I? R DAMAGID.PI• v.tiOr. ? r? ? ?? r .. ": i?l :; n pANAGt '%v! 1 U,e .y D,.V. wwGn IS l CwA G AA O N ?etv.':1!? wl: C. •RGf ®iw•v ?RfMUNID .: ,?, r?i f1'> •Gl {{((fi??r? y? -T o ?Aw:l.Dar $700 16 DIAGRAM Of COLLISION' i?sfr>i NiciszAer ?Nl ?ieOn"' ' DESC RI PT ION OF COL L I SION' Iust 1-11 MI NIAI 1.11111 N1:! 11-r, C-0/2c T'?" ?' 1 vc N. /v f•/ .?A? Tf. raN?/Ye YIEFNT "rTu 7 r P:: co Rr? F4c .a C- M o..A D,S^m??Rr Rq 7 57C Py O NI- X 1-4S A POO.A <Hi,/e C-0 D/mcovd Ay ON CAPL G4 I, zr r4 z1 e?•a O .. AI, qn . £ T•o r,. PAo:i S /v e• w A N o 1< r No i_ Wq. I'.,,v,?73,.i 7a MA,!/TgiNTHc I c'Fr's + -0nc c F TRav,, A- o r -,STOP AT THE %,/T[ GCE c ?Tj n// NAME, ADDRESS R INJURIES OF PERSONS INVOLVED ' CODES I - Z 4 6 OCCUPANTS! WITNESSES 1$?:;_+L-s7't?',:;7 ,10 u. Aw eAlus '';;!" RfsIR ina vt . DaES• uvI al fi N v • M4111 NAIIIII (!, 'u NI ??rvy'E l7 AME ?v. _ . ?.i ?ii p r?l • -.x.wlY x C7rT fi ` e 5 tlr ww9 G r r s y j . 4: 'TAn yy ?7a Y z .a ' MTb i. " f ! ' L 7 l : db A irTi?Ja , I w ?N? 1 tl '.11 _ Y , p Y 1 1 C;:, - R' ? 1 hr ? l,?Al I. ? h ' r .( 1 1 J t , a? A( 7 ? ? _ , ; rY ; 5 1 i*4 7 b t? ?n? I, ,r s I 1 Y ?a s ax 1 .£ 4 .1 >4 J 8 i' t ?y ?.rt JAM Txq R _ lk rf.? .aEg 'r. LS ... ' f v POLICE TRAFFIC COLLISION REPORT J(?TRAFFICWAY rol¢E Cawnuw NllMffR 6 PRIVATE WAY 12 1^11111.C au 2?I DRls Cro lv IM! coupJrr luu R.DD uRl pW X Ono JTEFFE,R"ll", couNrrNO c1rvNO. p[uNRU1 0 RURAL 2 ON OE OIN CIYOe TOWN %NOOSIREFt04 NIGNWAr CCS 90UIFOe SfR EIC -LON .wLFS JM5 OW 9.1 N r' 3 Gtr ?D NI[RSfCI1NG VAINSIR[f1 ?A` wO NON INIfRYCt,ON RfIW[fN Sluff[ 6 StvE[I 9REIIx f IlE 1p5f f 1-_71 " 6 IAN ACCIpENt MILEAGE CODE -A N f O %Ill[D NON1UN[D ? %?ND INSECIIIREEI OR - _ I!R( SIIXFN Cx PRO-YDAMAGE ONLY of -1clf Cl5 9 1[CI StRUCx ANOOWNERS NaVSI 51. DAMAG[ F SpfCMI CODING USF - _ s / UNIT NO.I UNITNO.2 p VEHICLE p PEDESTRIAN p PEDALCYCLIST DRWFR'S NAMF: VCS[ fIR51 -.1 gWFR'1 NAMF. U51 i19 qE 3)" LA-T- R 2 IRlfI ADDRtSS E 1 1 E_ -111 O-l v N orv emcoa eNO D SMIF trv<oDE PiIONF 4-7 W1 S- O R - rvf45lICFNSF NO . W Slwtf [% VD IRRN D- rp I V Rlvte VCENSf NO VAN f AIf OfRRIN DAr rv OCCUV,IIION? EC IRMNww.-,NO. EY[5 WE Gn1 NFGn1 E OCCVPAIION 7 1 I-NE NO. FYES wflGNi r[Gnl -- 2 f?l.F MO - R - p CHECK (rl veN Clr AS:N [YDASar[r iN weMro n[e AI p CHECK (?) , MM r+ ,LI CODES?? w 5 I<I a ; Il 5 A CODES?' wa "' ws 1 e;' ' ?R 2 S ? uvrts YFN,11-N MA%E EDODGECHIV.I -1111^11-VA 51Y1[IrDx CONV.) NYEA9VD 1 {n Vl N w91NOVA1 LLI I- v 1 I E l l b Ov w / F T F IAIE s IAILIRRAIF INII FI n. CUIOR l W N AIEN AI _7 ' "l ? W I v[NICLF IfRNNfIUIION NO. i vFN CIf D[NDNCAII NN 3 z 1 7 r6 S A 91GSrt RFD OWN[9 I/SI {1451 M,DDIE PNONINO REGISI- WNER. L I.- MI-i Nt NO. our W IR._ ADDaeSS A F9 2 E NAMeE ssnlnweANCl co oa ACtNI R i u AN -DI 11 as •MK DMIA D cNARU Z oi.c nAMAC[P ANrA , D:U I51 u RInN ? IU1U ?RI RrMAINED y IDWID ?AWAY ? I I uwmA 5V $ Y O S !J p i a Na'I I er. pIN DIAGRAM Of COLLISION: sIRn II DESCRIPTION OF COLLISION: lus[sLx•nEMrNlAl sre[t lr Nlc[ssARrl O Ye.H• I 5AZLE.D To NEGoTr-o, E. q (:l?RVE oE? GAPE C?EOFLGro RD. I Pkz SLmi> of E ROAD. THr- VENT WENT OVER AN ' - v '-" CAPE, GEORc E ?•1 mkmc--" T CF%REE.weo OF A TREE, SP14w }? ,'AISD ?'TRU[-K fv E011-ItiR TRCcrl;, COwsIJG A „ Q r E Rrc,St APPROk• I{O Pr- aoWE-r Y"C- EMBPNK .. CAP r' D . g?eaaEUt LArf.f',1T , ' TI{6 Rom SV.RFACr- WAs SLLLSH`r St-joW I ?p .cn>F1;sV P. O'I..S MX.K*-U Wr_'cN SAIJD. NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES I _ 2 ] 4 5 6 st sup IMFNIU rR OCCUPANTS/ WITNESSES iEw•DOUIoNAINAev ll srx Aa ,IAIUS 'r1,",n ? R 151R {E[a N •AV 'S,LLS..AM E, 1-?PJOIJ ? bIE'r O B5-?f451 A -IP6J3 4"q D yf xRY pAM A ?rv' a ?a ?;c ? ? DD.,55 ,IIMfM M 1DIRfw p MA p; ' 0 • O n ?,: Y a M! •f %r.11t Ir IxIM iwxMVS klr?Xr l p•M [.1-- ni' . ?13 ? it ••,v • 511GAI. ?In*1w ARAN. X II•j E,I G. ,v',I rI..Y IU rn , „lU <%KI lcs IGIN xr N /3 D UwN I'R hn w w l • UND11Y DAIF ` p _ 5 1.263 . v xg' ?? IIf1' r ?r >Q ti AA 6?i c?k ,Po fr v ? ? N Ra V , y r L E???,w? ® TRAFFICWA Y W No. POLICE TRAFFIC COLC N REPORT NTNIAM&A E] PRIVATE WAY 51 OA fOiCIXL1 r3 V1 " ODHOVAI ? 1D ,wn 1EI 1113E1A If3oo COUNIY EFf a COLIN, NO. Cm'AIO, iMVA G.. ? U RAI 3 Oc F A NO. OF STRFETOR HIGHWAY ON [3f o'. P O MMES Os H. OOF ON ROUIFOR TON . INIERSFCr NG YnIH: S1PfE1 NON INIEASFCHON IHlDI AUlEfO51 BETVEfN -III STREET 1-3 DIS AN lDR r RFi[HM CROss SIVEE NEARESrM EE 51 m lE3 H'I'T 's a ACCIDENT MILEAGE CODE A MIA <gl15gN NVOIV[D NO N EIED-- HAIRED- ? sNE1AGE ? FARO RUN TOTAL NO. wNDgDIH IMFR CIS [AOss51PFEfOA POADR REEERENCF CFVFHIClfS ® I, PRO 1 DAMAGEONLY ?.SIFTED ?VEM'ICIF (OV ?J E/ A -1SIRCC% IN- a OB1ECr STRUCK ANDOWNER's-1I "'OMAAGE 5 ---NG WE UNIT NO. I UNIT NO.2 ? VEHICLE 0 PEDESTRIAN ? PEDALCYCLIST rzi S DvnF45 NAME: IASr NRSI m1 DRIVER 'S NAME. IASr FIRST ? j A N R L1- 51P[t1A Rfss RFEI A 2 tir- f RC.C?.R c5'TgTE 1 L- STAFF zlPCOq ENO p , Ir STATE Ti?CWF PNONf r LioLnw WA. O R RD ??? nFR'SUCEN]FNO. SAIF F% . I rv HSE O. S E EgORiH u a V MO DAY rv. r n IXCUeAIION F NO ( fvfs GHI HFIGHI ptLCrE`ouL^+a E Es?cu NvM -I B PHONE NO. FYES WE GHI IEIGHI CRESGNOaL. 2 R COMMA H SO O CHECK( HKEt ASin fmn OrF aANGr teM ? C ECK(?) vtH qE As Arv m+PlorrE of ArvorHEV.P1 Y CODES ?' D R S E a :ODES? H s i a ?: 5 t% a i° ' 7t1 2- Xis MsoI DM o.NB .%I ? VFH vfAR N Kf E ? zsm. ? K,, a m A Ow N .HEI a E r M° oc"&- o'a 0111 2 . A IDODGE?Cntvl 2 LI Nu FN. ODEIID Rr?rgvAl SrrIf IRDR?COnvl txG 2-m. s1ATE AIeRnMFNO. - E H Y g I HV.1 H 3 0.949 vEHCgoR 1 MODfIIDAp1;NOVA1 r I ? V.I AJ -DR. A IL A No. ArE ?zB HAMA 9,5 Z57 F wR C 3 WA veHlcu IgNrIncAlwN No L ? $0 2 L-1 C600ZI 3 C CZ2(o3F 1 397 Rtgsn REOOwNER. uES1 FIRV mlDge PHONE NO. O mowrvw. lASr ilRSr mIDgE ENO. 0 D&65 E`s ` z 2 ADORESSq ovmtR N A - 4 66 L2r• ! ?k aI oR w, WA. 4836s 2 NAM t{ADETRES5OFINSURANCf CTS .-E F R CO. Nr R , DAmACEDAAU E n p'"rOiN CN C• ? -? 1 CNARGt v Inc o•DiN i???MEA = n S 151 ?DAAUGI ® =r ? 0lMAfNID IOIFIF • ® ^wN I5O101AMAGE 01lMAIN[D r p OeOr E3I0wEDnr. w ? rOW[D 5 p TT a NIAL ONORrH DIAGRAM OF COLLISION: I SH[E SSrAVROW ? DESCRIPTION OF COLLISION: II1515UPFIEMENtAL-TIrNECESSARr1 a ? ® UEN. t FLcE.cD Oy'Tq T7/E ES ouE.DF(cR ?ERST- & V C R ? Ea .1.1 ou / 6swES oRAAEA D. VEN• t was CSO EA)rBOUAAD OM A116aa65 CORAAEk ft /IASSSfS PAABR /4b. - - _ ., aA,D AS r WAS (rotN6BV V6N• µl, V6K• MADE / ;EIDr Tupw , Nsrr=A VAR. is 2 oAA 7TIE , ['? ?y?? -ej (? EAIG@R S2DE . CSkro MRRKS O THE uHOG E BY THrr &r&14r d'zDE TsRES OF N 4R ov 4 E??'? . . , 0 (o ?z F6E7- FRoM TRe Fo6ttATE, IAADZCRrzNG P. o.T• VA-14. u r 84AD SEW EAIrXRELY our of THE TRAVEL , NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 1 'CODES - Z 9 4 5 G OCCUPANTS /WITNESSES jOp $1-NI.:Mi ii SIR AGF IA1u1 '"„°,'," ° ;s ns1R, uEO Aml Alxwss w1wEq mnr O Am n ? P6'1 11, 0 o A - I 0 i ApD . OF r MOV IROM ? On%<r On1c N 0 ..D p Aror1 h vla AIw.E, GEIKIr3 7' lrAN• FT !? "0 / /B •; P' ter ti 21 79 ? 'h• -'ft S'A, ttr • ,IF S ..TifS.iR'I? AMe Nt n. ? Ho 1ur?Ris°' ? Amn ? .. "• ".P r ? Fir . O EN ? ? „' , W Or A,1NC. W ,. K666 rc"tD a x¢1 wo Mleq Rl Nlpl PpovlD er 0 ? o.n F„:? ?.?iY;i.Li •",w W,?;Le v N I?'? iD AD " 1611.. 34'N?FAN'J!6 III: r} t I, lu 41 •5 . .d+.ri,55'S Ry 1= /f 4 as ? n f ..Sy f '?" ';'?? ? POLICE TRAFFIC COLLIS7DN REPORT u • 1?+'ER^FFICwgv IVU. rroIICECO AINT14-10 4 c 7 pq ar cal s pqy PRIVATE WAY Y,- ?,xi R'r wl i s.r counrr 0-11- arr NO. A R ?5jyyatl1opRl JfFF??Ic-,,, 16 ?u }. i 4' ' pN QE ?w cnroa rowN G1?(y roGLS cNwgY icrcES zz A aoulEOxsIRE xc " IF ON nulfs ps w''[)oF _ Irutgsaurlcvgm vfnoR o ON S?o.,ac'? ?J l` `'. ' NON NIfRSf<IION ro 33 0 0 a: PNEE % FO Mrtf PoSI i;?j pETYEEN EIKE, A S-11 d• 9J' yi UISIANCtCpxl[l uryry ????OM RFifR[N.f.CRUSS S1atf10R NfANE51M11 -111 ' I MlES?ry?+ ACCID[NT R P pIAGRAM MIA MILEAGE CY tY ' lEfl CO ID ? p E p O! CODE ILRONOIV SfvfR 1T ND SEC11N SIG EI RROAp OR REifR[NCf ?I'f DIAL NO NO KIEFD??NO NJURLD? ?SP IIAGE ? Ir6 a}IN NNEN INrfq -l CtG CRpSSSIRFFTOR ROPD YRj I : , al p PROPERIYDAMAGEONIY ?( SIdY/1, "'rvourop? / /3450 N,•CIND 5 S(/ ( IflE 51NIICRM-OIODJECISINUCRNIDOWNLRS-1 C [S1.DMAAGEI SP[VC AI CODING t5f LO I 4 / s [' .? fk y I., UNIT NO 1 UNITNO.2 EHICLE ? PEDESTRIAN ? PEDALCYCUST tl d4 Uu yr k'S rJgMt. 'IRS, MIDER. D9 vfNSNAMf: '51 Nu srxn.l Appxts5132/iY/k T/4/_= f /- ?twsF..t? i2E• 4 tEI aDONFSS Z o d.L rTl2 Y t'T / f 11P 7?r7. CITY SIAIf CODf •0. ?/ Lu ONE NO D II Slglf LIPC 1 - pRIVFNSIEENSENGe"'?' r 9Y3GS` 353s=11GG R %993 P"4;;=3•Z/Y,? s 2 SfA1F f%_ RIN I VFNSIQNif NO ers .. ......... ..... p .. J? ?-Yi•;? L s.,? , , 3 lMrG/t ?- GOGN/ T- R " ? U04 tIC[NSt PIA f N SIAtE IRAIIEq RATf I?Ctf OFNINUTION NO. 3? yv:.rQ9s-: 7 C'/L y r?Anr/yu nE+? ?? T OCCUPANTS/ X V L S"7 3?1 E OCCUPAIIGN iIRM NAME a PNONE NO R m Li- u -u-, p -,ct ? z6:rF. ? o11. E C 0 ?/ IWYK I D [ EV.) MOp(l1DARi.NOVA) Y 1 DR. IF EN ?GR „? LsNE2 H %stu? %ia?l oy? Gv.4 q NG. A L 1 !N Q[D(NIi F 3 2 y z? v? ga IGij; i i l l RG151[YFD OWNER: US1 FIRST MIDDLE n Nf NO. 02/c--R p ADR N E R ?.... A tsl pw+AU • f ?A AWAY ?RIMAwfo ortDN AWAY DY: S ro be_! '?In DESCRIPTION OFCOLION: IuSF SUaw1MLN1M SrN[1RN[cfssARrl NNaKJ(!F L C I I S A - 7U/Z1J 0,u7o MO Mr. - I Din lJor s x:- ,cwt /-f/T- jN .. REj.,r1 ? / WA.4 4 41,1,C 4jr 1, hire C W S?aV-cOGR -1124uaI0164 .fAme- lLYfi?? I/or Zak h,7- s a/YiA dcrvtcr S ; r frJ (I fvd _ H/r /iL'W 7, &q _jk. 2 NS INVOLVED ' CODES t - 2 ?3 4 5 Al 11.1 E 1 6 NN A ESI Sf% I AGE IAIU$ RI {IY, Nfc 111A?E ? ?r 1 r ruluNl Or vl ? u? AMD G ,?„?.? •• v,NF x, f /7"", l ^A rl._.... r1 cx n r... r , `g - „?, r L N•e Pf 'E ?? ( ??qqgg ?, _ ?. .R _ a - 3w... (y?, • STATE OF VVA HINGTON AGE Dr No A POLICE TRAFFIC COL : ON REPORT ?TRAFFICWAY . N, NI•AafR A A E F ? PRIVATE WAY r ,. '? ,• $3 COUNTY [usE ).oo NOUaf ,ur A p%, N s.l / 7 S ??iGFk/28 0 /lo . frlw ` V UN °f QIN CITY OR TOWN NNAEtNO LREFIO, WGn /N m E Qs w QOF 1 RDNmQ L? ON -Pae.E??? INI FR S FRING r :a [i 4 WAp Np.I ls? S-7d ` i 4i2 NTFR5FR10N 6 i ? C "K f'T E/Y V T ef T „„ l 1 TyfE„ 5(REE, t .eROsssreeE NuRES mllE m 'I SIRfET '?.4 "E v7 . • i.S p - %fs S F W rEFi OF ACCIDENT MIEEAGE ' y{ + CIXLISIDN INVIXVED VERITY: -Al O. NO.%Ill[D - -ND?yL QSRIIIAGE ? HIT A RUN UNJURf OF VAl NO. UX ANJ CODE W " wv ptv RVfF9 C ' - ,. ?n ' j A q f R O YDO ILI WIN QN Oe...... INNAEOf OUR-RUCK.WDOVmfa'S_Ij RFSUlttO ?VfHCIf f St D,MAGE PFCW li OII•EG /OO OEOSSSRHTOe IIMD ' ? / ? shoo ' "?[ ` 1 - C UNIT NO. I 'UNIT N0.2 DanEq s NAMe: usr D sNAMr Q VEHICLE usr Q PEDESTRIAN Q PEDALCYCLIST V4 `?C .... 5TxEErADMD,/N o Ic T c? S?q CACoL F X - P +A qN7 t, 4 E? .S? a'nl ?r ) °? // K+Nx r /Ranrc? J,: ST S AN Er ADp, ss :s T/ / ATF ZIgCODE )Do eT i?wN rN NfPSUCFrvYN RrIDNfNo. D I 9E-20, R AIf 9 3 z"cm aK ALA- 8 Ss' S1AIf l? F% I lI EN Arf m o .' " , 1+ ! / wN OCCWAIION RMNA II-NENO r, A E rem 6 V ?? ?? W!? 6 % s ?/ - . . fYtS GNr H E CUBA ION NRM NM1f t qr 1 NO. FVFS GNl H 1 J2 . ° CHECK (,I v[,oR[A 11 A ANOtnEe •u ' Q CHECK (n l . 3 c t o 5 i CODES ? .? w yFHICIF ASAN fAVIOVE-ANOTIR 5 ,iMOA CODES ?+ J o"ss t° 5 1RfD K y; '+ NN rt; G snm INU yorq , O R M ° ° - R, ' + b O ' C ° " ° a f ` VTH. k IOO GE. r iFV. E .rAVA l ? l ?'W' "R - Q N+KU ?i1nvY Slr [ 1)Da v ° U ° / LS ERC_ Co v6A ' l . M O DEl ?? E' 1 NOVAI I V.) / " ll RtA Frv S1A f RALLFR RAZE rvO sure H vfn coin, Flo FI. 7 acv VfnKIf IDFN11fICAigN NO I AE C &A-4 EfXU T wN N F /CS o S R[GIStt MO DWN(q; USS+ RSl DDEF L vFHICIE IDFNIIfI I G?7C L/ OS RgNt NO IS O wmN ?? o oft i-t S la ADp . Vmf,: _H 1451 MIDIXE f 28s'- 3 086 W Z fess as o a N SI C „yam NAME f. AoD9tssar --t- ar Ac[NI E R ..3) nAm,eeD Aau c- s in?:o"w.r cNARC[ iv ov rAMACfo Axu y j- s fsT DAMAC[ ®:w?v Q Rfmu Tbiono? 3 ? w[D S aO <n,ac[ p rn :o,",r„r s rveD ISel " esT.Da%Aee •lo• "`33 ?a[MUN[o ?s ?wiv 10- bicrtoN ' a A er. e DIAGRAM OT COLLISION: iW wElRn[assnirl f ]° O 1 Q Aw 1 1e vi,aiD°RV'" DESCRIPTIONOF COLLISION: IDS[swnfM[Nru s.e[)N Nt?lfES5ARr1 ?" Ufvr No / wAlS. 5, am 7'=? ST. GRTV?NG TH ST TNf Zy,gp CENTElZ ?/•??/?. NO 9'.? w.qS ?/?T,c l2lNG v PvN V . Aro Fq,a.?',o T# ? OF T'NE RoAap W?I s1 .Fo6ENt nro. 2 ?4iLFb Yv & PANE) Na.? *-9AVT 6Ic w-cpv NAM , ADDRESS & INJURIES OF PERSONS I NVOLVED * OCCUPANTS/ WITNESSES CODES I N.mE. u% Acr u+ avR ?fR M. a:. ADOffss a N wm• Of NO NIIMISt U H M NO a MOVID I•pm ° AMe Q 1pj Kr QNII•. Q N; Q li?xtr b Apo•t?+ :,iU[s? v15rG+wc arpf•swM[f rAa. e t d NC. qKr D15r ¢nlo fp X IM er 0- °ro.,a Qmm. °R. ? ::'In. Kl Af MD D E a r .. ? r- uful y? / . nu•Irgl A-V[De1 o•1. Sc o. .. 71 r ?r sit! 1 r< ?- 4 co ts 'Y s f t ` .QQ p? ITT, 1 q 1 qqq??yy 1 l l ZOO a. "A. r -1? ??1 1 r 71 ar f r ' P ma h r t - I 1 r I y f I: - Any. ! , 1 N ws' ` l U yt i ' : S ?' O N , M O ? a H q ? o lot! ' y ; r g ?^ N O j ! 1 I 1I b 1 ?C '?- k? t, ( I lie fi g a. A m 9 'l POLICE TRAFFIC COLLISION REPORT ?TRAPFICWAY Foucf COMRAINI NUMBER AY 0 f51 ? PRIVATE WAY TII FOi cau151GN U C N D D1 V COUNTY q r ?e? fux wur? iun nl S. f,r (USE ],DDHOURI COUNIYN/ CHINO, ? WI AN J v ` .-I RQ ? I g ` ?N r?fE?IN? <IY RIOWN NNpE6NO.0i 5rRffi ORNGHWAY KT Cl5 A /a R % ROUTE S ECIIO N y .,IS ? S IOt+ ? pr = nE cA/? ON t-? A S S 3 ? I \ -3 -14 CING wIIN -UT O R•ROAD` NON INTERSECTION EN% f0. M°EPOSr Z J1 ?? LLYC lL ?1\ (\ BfiWEfN SIPHIT A SiRlft Z- Iii'- UISIANCF eV 9LMUON IROM [if NEN EC4055514Eft OR NEARt5TMILE PoSf K. ACCIDENT UTAGRMSMtq tE5 F-^'W MILEAGE FFf1 Of CODE COlll`IONINVOIV[D: Sf VFNIIY; IRD fXS GIIN SiR FIOR NOADOR RIEFRfNCE plpl ryp, NO. KIUlD?NO.IN1wFD? ?SPNUGf ?IRTBFUN IuHUno'H INIFR CIS CROSSSTR[EiORNO C Ap CF VEHIGIfS ?- P40RRTY DAMAGE ONLT ?P1IRSi1l'TO ?11-NE (pZS3O 0_0STRUCa(NAMEOI OUJECISTITUCKAND-II, SNAMFI ST. DAAIAGF CNI CODING AE E UNIT NO.I urvtu's NAME: IA51 rlusr mIDaE UNITNO.Y ?VEHICLE PEDESTRIAN ? ? PEDALCYCLIST DuwER'sryune l usr IIR ? Du SI4fI1 ADDRESS ?? SI Efl URt55 , - SIAIE ZIP CUDE PHONE NO. D SI r ' 7 DNIVt N" CEN NO AIE bI 1 R ( A t IPC E PHONE R'S IICENSI No. STAIf? I M 6 W? ~ q SfA 1 L DAIEOFDI4IN ?. D,r ?. / OCCUPAT ON N"I PHONE NO. frfS 11 IN Elrt c E , «uPAON I- NAM, 6 PHONE NO. [YES WEIG '?' R HT E41GNT ? CHECK(,) -11, Ci-,AN ll°vlof1 a ArWHfaµ AL ? CHECK(?) i 1X OV a H O NODES S * ° A „N,,i• a MN' S Nlcr«»I D woiDx.c f c E 1 fMPI EE AN r ,a 5 C1 CODES + ;is vFH A is 5 ucra., y --,-N- IwNr Y -Sn ,o N- IS VlH'Yl w na ppWEOSFV ? C^YMW[t?jDMbl'NOVAa wStYlf 11 DN?CONV A 0VIO, ? K?i Po O ? C ? y v 1 ? .I /.eJ? N? OR ucwx BARN E MA[ YEAR .) Mppfl (DART-10-All, \ HEV 7 l=7 r , I . S Alf IAIE -1-: S H H of STATE aoR I IIAIIII A N 7 A F Y / E7 / I [aw4 !4C of LAJ VINICI, ID[NtIrICANON NO. C EHICEf IDINIIII II NN HA S fs7?u? x(Gllrt RlDOwN[R U5l 11451 L .?'hh? 12 7 IDOI[ PHON(NO IC ? O ISIEPtOOwNtu: 1A51 fIRSI MID PH N NO. ?- ADPVl53q Iv W A OWN1 - . °i tAUDVtSSp INI NSUNANCI CO de AGINT NAME N E 4 31 . Sr?ry n irr lt/ E R INU N N(7FJ DMnAGID AaIA o aW A v n I IoN+1 CHARD[ CHACGE, µ??pyN g-AGf1D NTEA r IS 1 NIMNNlD ' XWA'y" olxlR Dwtl rDP i10110w S UAmw?? W?V ? ? WAY ?R[MAINED FSI. DAMAOt S ?j I Ioeo'T_°?"\ S I ?•-? S 'D A' ? A.A1llY -. ? AWAY 16 BY DIAGRAMOFCOLL1510N: inlIt X NEC,5UYr1 ariluap NH DESCRIPTION OF COLLISION: (u5[suv%[M[Nipl vrcet lF Nlc[55A4YI . O u V- :td \ wLA S ? C'O ?S?- 47K, ? :tr Y? 2 ?E r v 1` I 0? ? aA? Cr1SY NC, Qttl t?h? \tc CUB' 1/vlCl ,y. k.11YJ2 woLsI-L. 'tT A ' • ti ? ?gK2G?\c R L • ^ .y . d•t , _ _ v 2 , ,. 1 h 2TC l c D _ NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED 'CODES 1 - Z 4 OCCUPANTS /WITNESSES 1iouR :DwD"!owr "u ? MW Si 'i 1 ' 5 6 N l, r 4A AmE. vwGN tx Acr ullus A! I . " S RStP. [lH6 A TNx,!• NO NAn 4 r a , 1o o ?AM HX B, e ?NVII? " . ? ?;7A N - A M ,IS\ rurUU (IF a- ?ru 1??y, E 11:1 v?M,pvID l4--om al'p '? w w ? 1 T? ? _ wEOE L ?L75CJL_L_ "Y M.f4 Ixl) N N 1 AouO x ? M Y _ ' U A k 11, '} it ?J .M t..?If1?? ? (?.Y.[??1M? Y(ty V. :R'Y rIV>?^EL?r . M1J??. .i "i, v 4 t AIM L 5 °0Ru1 7 77 F vy v4 ( ? - t !E llr.? ? hT? 5 ? ?. asrlTFm i `,?Y? ?'.? d l F '' ) tit Tt? r'17 j _ ?.Tr .tyII t l } ? I? r SJ, B"i LI 1 ? ?l l ia5"'1,? d, r?r ?? Affil... R S . ?p ,py } y,a, POLICE TRAFFIC COLLISION REPORT gTRAFFICWAY rolaEC. tEi W,4[4 PRIVATE WAY -_DA EOECDEU. f1- ; {I LIME COUNTY CADNIY NO. CITY IA w !HWA . tt ? USE r I Z RA? RR IN.i w(R a. 4F. ( ZKO HOEIR) 1 oi ( i a ?eFr [ oi? pN pf N CI[Y OR TOWN NAME6N0. Of SIRfft OR HIGHWAY Cl5 Au(fs s pw GF ON ,? Cd IniFRSER NG MIH STRfCi UR N.N HIE-ION DM qOU OR SIRE C SECT 01! ? 34 PPff l% E MIIF SL .-IN STPEEI 6 SIREfT ?•,?'? DISlANCE6D9fM10NfROM Rf [NfNCE CROSSSINFETOR NFARESTMI{E 1 ACCIDENT RM1P' DIA RAM DATA ® tT5 N 5 E W MILEAGE FFLt ? OF ODE B COI TOTAL IINV NO OIXVED ,KlRIIF1Y1D- NO. INJV9CD_ SP %Y CRNOSRIN OR SSTREETIgEf O ADORNNENEHCL, ?IIAGE ? TBRUN IurveR IMFR Cl5 ROAn ' O VFHICtES p pRORgIY OAmAGE ONLY ,IRS ? RESUNFD VFHCR G? OBJECT SIRUCK(NPME OF OBJECT SI9UCKAIJD OWNER'S NAME) FSI.OAMAGE SPECIAICODING I $ UNIT NO.I' Dprvws NAM[, IASr UNITNO.] •' ? VEHICLE ? PEDESTRIAN ?., ? PEDALCYCLIST 44 A srqFltnoo9fss L 745 R FR'S NAME: IASI I ry TF 2y IRffi nD0RF55 /w STAY ZIPCOOE PHONE NO, nO i y TT '??68 J?z?[•Y aNfR'S UCfF15L? D R TIT SfAiE IP PHON / _ N0. STAY I H MD PAr r4 ( IV R' LICENSEN ATE f% DAIf Of BIPtH `' ? V p IAY 111. ( q OCCUPATION NRM NAME6PHONENO. EYES IGHT HE GHT E OCCUPATION FIRMNAMEe PHO 10 d Q e R . , EYES IGHI MGHi , ? GHECK (? VPN,clF ns INN Fm IY ANOTH a. FE? ? CMECK(,I AL O I I P- / 1 D ?; s' a s °^w' 5 ((cnDH a'nO CODES J M S R YF"aE AS AN Unnonf oFAN THFR. CODES + G a,u 4 (M"T 5 [xCTgH A IDSYa Y HTr _ Z, T INJU r O Kl " ? K YE R ? AxR U"KI ? u ? N". ? su ? 4 ;:' ? " " ? Cl ? a RR ? c ? MY S SR (DODGE{HEV.1 MODfL(DA9I.NOVAl SIrLE(RDRCONV.) EAR 1 HEV) MO OfIIDAp1-VA) I R. _ F S 16A .G E w aB I H. OR "CENSTILA, N Y STATE TRAILER P[AIE NO. SIATf H NEH. COLOR ? TRAILER PLAT ccJdlr i N wNlcIL IDEMIfICAiION NO. (ol I?.I I i l .I I i l l l L VfHKIE IOfN11fICAI 1 1 1 1 1 1 1 I I I I R[GISRgEOOWNER: LAST NRSI MIDDY PHONE NO. GNmCS O ISI D WN(R WI FIRST MIDOI N NO. Il, Y ADDR(SS OTOMN[R N 4LIDRESS Of NfN I y 8L3 h+aT ,Ptl T-w N 0 t e A< AM1. ADD4ISS O INSURANCE CO 09 -11, E . U 5 pAMAGID MU L e G,(,wIX DAMAC(D,wu cu cHARC[ o' `o ' • F 's I, F S 6 wb?ibw EST. 4TOr (AMAGf ?ORIVtN ?p[MNN[D ?AWAYN ?R[MMN[D [SI. DAMAGE AWAY S L TDwm rovxo 1 loi"TiriS" 5 Aw,r er (L G/TY ? ' 1 erg $ . DIAGRAM OF COLLISION: lu 7 AWAY u NTu--plIR, NO rI DESCRIPTIONOFCOLUSION: lu5[sum[wNTUsHtEI fCESSAprI 4 r 1 . -I I... ?....I SHUT vINfC'SSMYI 19YP0 - - 'W A/0,A( 17 N , j : ATA/c gpyc _ P)Da,EmrD Ew_ A PIPE I5, _-- I ? f ? i , . 7?.,dsnva ? Pit CNAft.?ar6 -W/rN ? QR ?_ . , ? I FC/A+6 A mor*+.l. _//[cN/cue ...cJ/TNovt .._.. f ,, NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES 1 2 a OCCUPANTS/ WITNESSES rvusurnEMwIMV4 W U .... - _ _. _._.. - . .r_ '" .. .. 5 6 .._.........__ . N I ADOIIIONAI NAMI AMI SI slX AG[ taus a D ?, I o oar RISI4, IJfR o,r ? A H mass AM[ ; . Meer- AM . ?iY1K1 ? ^'k. ?N7 ?i36v p 'H N .. .. .... .. ... Tm SS - AM ., ND HAIUPra . .•.'. ... p???? R MOVEC I4pM -11 N r ?AMe. ?IAI li?v D ., ? - __ , .n Ito 1 Or .. .. aps Fwa ( en 0- ? ? ' ? ,T ? n NN ,HVlSt '[JIIK e" , S NAVR IIAHK eADG10 [4EKKIDS AICnIO K%KI I IYIO DAllp [Iq AIIROVID er DATE % D Io W61 , z N¢ !fir' 6 ' ,NA l: ?'b 5 ,! lit ?C ~J s J " FY', , I :.1 .T kl,l r`, I tS 1 'I } I a ) t ?" +N O f AllY.n v+h" x, 1 4A5in??'', ?Yf Y{h G POLICE TRAFFIC COLLISION REPORT aTRAFFICWAY Iok CEcomrDUnINU'AOFR El [] PRIVATE WAY " " .. PIEI E OL N. 1 ' . }II N._. .. >u ?tid 9I LID MRf? II. (NI. TIME ID$ET HOURI COUNTY COUNTY I., IY NO $ ? i 1 J FF ?S?N /G Qu , ?N ?F CIfYOR TOWN NAMEaNO. Of ST.11-HIGHWAY f C u IF ROU' Ca leE ?ECION MILES ?s ?W ?- Q - .//ESS (o33PO, 2 INERSECTING WIIN: SIREEIOR NON INT[RSEC110N - /e0 G6 . KO. C ? pe[EI%' FO. ATE PoE( O OO ? KA BFIVREN STRFEf a STREET . , ' DISI CkaD1 II FifRFN OSS SIR- OR NEAREST MILE 1 MItE3 ACCIDENT RAMP D N E W FEET OF MILEAGE CODE COLLIS ON NVIXVfO: EVFAIirI ppII OFILIEDRUN MIItS rv U SECT N a[tt OR ROM iE (.F , TOTAL NO. PERTYDAMAGEONLY ?LINULTED ?VFMH ICIE E 2 DBJECISTRIECk(NAMEOFOBJECTSTRUC% ANDOWN(R'SNAMEI ESI.DAMAG[ SPFCIUmDING 1 S UNIT NO. UNITNO.2 ?VEHICLE ' ?PEDESTRIAN., ? PEDALCYCLIST r. DRIVER' NM1E: WI MIDDLE HRS DRIVER'S NAME: LAST FIRST I L ?- ` C/ VN 5 SIREEIAD1D1R.- ?j ?TI 2O D 3RFEt ADDRESS CITY _ SIAE F-DE PHONE NO. Ql E I pL?vtS W!? Cfg3-$ - R TTY IAIE IP NENO. 09NfR'S UCENSEN C?T?AW SIAlE WI> k MD. I DAY ?$q I, V IV LICENSE NO. ATE E% 'OA gBIR111 MD. I Y I.9. D B IXCUPAIIOV nRMNAMEIPHONE NO. EYES IGNI HIGHi E CuPAIIDn FIRM NAME 6 PHONE NO. EYES W'EGHT HIGNI .R. n! 2 RAT aco ISS 5`/r R ? CHECK (Ij EASANFMPIiovEE OP AnorHFe. v cL _, CHECK (,( VEHICLE AS AN FMROYEE Of ANOHE R. R 6 CODES ?* D a"A r a 5 T LcT DN 6 Ae.DrinxY SI rn CODES 10, D cuur + s°`. iMw' S Y a "E. n 2 N U4 (s 5YC0 • PW' T, Ace-A. Cur f,l In accldc..d! R PIDr D 9e NDL ? M a ' bnle ? w.2,€ ? ; 3:' ? --,NCI ? U1`I C] EBMk ? M ? T4 Ir AH S I VE EAR MACE IDDDGf{HFV.1 6l C?4U MODELIDART-A) q, SirIE IT OR. 1 S M AlA <{pQ E {NEV.1 MODEI IDARI.NOVA) H V l .) ? voN ? l fN PNIEN STATE TRAILER RAZE NO. SIAIE H -A.C OR PLATE N ATf ?Izm J A V[HICIt IDENtIP GTION NO. I I I! I I I I I• I L VEHICLE DfNiT I I I I I I I I I I I I 76 - 4IG131EREDOWN(R: LASE FIRST MIDDLE PHONE ENO, _NO ' O ISIFR'D -ER: LAST FIRST MDDLE. R. IuiR W 1]? AOORt53gOWNt9 N A NEA 1 E NAMEa ADO4essglNSU9ATRa co,wACwr I " 1. UInI.N , R n . OAMAGI .RU "; ' DA D a mnc[ A u rwc,a .? cHAacE DI T r '"A" ?Y -DI j. DAMAGf _- D0 ?DR. ?R[MA1 NFO ?AWI= Y ?R[MNN[D ISI, S IS S 11 - TOWED ` :Y TD 1 AWAY ? TOWED S AWAY BY• k - 10 DIAGRAMOF CILLISION: IID DESCRIPTION OF COLLISION: ILnISUPRIMENTASHIFT F NECESSARY) I i ._-5 IRNFC[SSARYI ...1 U TEROOWt .. -._._- H I- I i I ,. l O I_ Vehdl A,-c?-P U 'CI,Iw c;>? ?a I B Sk.,M u-AA sz e. cxl e 2os5 AL? / I 1 ? i 1 - - T ' p _ c.1 I ,_. i i I! I I I _ -- I , ? I I , NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED * CODES 1 - 2 3 4 S 6 OCCUPANTS /WITNESSES 14;, o^ICMVIrµ N ANI SI SIX AGI IAIU3 - uAT' "wr s I -ilS-t9Nin ICT . Mlc+- u S N ANI .. -... A!]D0111 ?IAi uR q .. Ir,T eY. ?AMa . ?C'? ? n. ?sntX ? rg;,. SCENE r AMa ? H IROM 1-" ?.,M r ? rCDAHV N jA -fSt ilq IM?AM/ Rw1y1gAIRrO grKily hAM141AH1 1A X01 AGIM:Y wPlp IIEp1. - IIC(D:SNICMD I "A4R15+0 DAIlq IE-F 1lll f 7 AI40VI"I ,At[ j.. A 4[7 Y d 6 „r?st day I ?w ^? a . I v k • dm- POLICE TRAFFIC COLLISION REPORT IQQTRAFFICWAY PoueF COmEw auunneN , r ® PRIVATE WAY " _PA. OE A l? vN_ Iva I D - { 1 furl x. Ipp. wlO. hwEfj l?I7yl_ IMF 1 ER.DD HOU9) COUNTY COUNI? Clr l.+0. •? IA ? I ? / ?N ?E ?IN HIGHWAY 10N CS .......... MILES ?W ?OF V O oN INTERSECT NG W I i Ei L?J.7.1w0 I RE N^^ OR ROAD HFNFRSECIION STREET 6 STREET F."'. E f 'O51 / _" OISIANCE6U 9K1 iR0 PF RF .C9 0 5 5 1-1111 NEAREST MIIF ROSE ACCIDENT M LE5 5 F MILEAGE ELEI OF CODE RA.vP CIA -TA COllI TOTAL NVIXVED: Vf RIIYI UN 'SPILLAGE iOTAI NO INJURED- ? MNSH .unDRIpI» E9 S n q C R[E RRO..DO ERLNU CROSSSiR[ROR aOAD / R ESULTE OE VfNIa a PROPERTY DAMAGE ONLY LY ? pE5URE0 / VfHICIF -111151RUCK(NAMfO.11C1SIRUCKANDOWNER'SNNA1) ESI pMAA 5 CAI CODR.G U,f UNIT NO, I -,. UNITNO.2 ? VEHICLE ? PEDESTRIAN' ?PEDALCYCLRT ! 3 -WR'SNAME: -I N NAM LAST I l 1 'I /?/ ,eA GP? A r ADDRESS 1Y IE P[OOE O EI oNF D P "y IAIf EIPODDE L GZ It D91V[v SUCEN.Sf NO. STATE EA BIR R I 2_ Rh9 /o/C H ?r it izl6 - V IV V NSF NO. - IAIf E% DATE l-I DAY DAY I I t Z OCCUpA110N {IRMNAMEt PHONE NO. Ate EYES GXi NFIGHI E CUPA110N fIRM NMIE6 HONE NO. EYES IG NI IGM .y K (.? = IVEwClFAS AN rMROYFf OF ANOIHFRU ? CHECK (o, VEHCIE A5AN EMROYEE OFA ' 2 D a n w ! e ° O° ss nm CODES ?+ 7 n: r e s°.svM"` e u R e 4 La ?i eu, I .. Fl?yo DM ? MEM » l ? M.", ?:11- R z ?N Mzy- EA » 0 C ?IVAH ? ? ' I VfH V[M FIUOUG[{HfVI -MADE IDARINOVAI S1YLE1]DR.CONV) /??? ? 'EAR I F HEV.1 "DAR'. NOVA Y 1 E Y (,/ ? J J ? y D / PUI N If S IR ARAIFN STATE H VfH.CIXON O. . A I I C ? VfHIU[IIXNIIFIGIIpN NO. 14'1 _Z 12- 15572'171 i I I L VfHICIf ID[N11EI 1 1 1 1 1 1 1 1 I I I I I REGISR9[DOWN[R: _, LAST FIRST MIDDY PHONE NO. / J O t WNfR: U51 FIRST MI IXF J W I] Z ADD9f SS Cf OWNl9 N A TOWNER ]I E NAMU AOOaI•sar NsUR,MCECO. ORAGIENr INSURANCE CO. OR-NT- NAME A ADDRESS OF R ]R oAMAC[D NIU o-s.a N° IC, cHARCE I DAMAC(o AnU. °'•^'O" cN_7 .- Eton fsI oAMAC?" AVA aeMAINm ARIVLN E.c uAAUae ° µR ? ? WAY ?PfMNN[D 1! Ib toriou L $ s? F.Al Er: L Ae ? IOwlD f Aw eY. INpc 1 Rq Wl DIAGRAM OF COLLISION lu a 14A DESCRIPTION OF COLLISION (usE SUPPLEMENTAL sfE111 NECESSARY) SM tu e - t -I i I (. I I t NECt53MY) .. driver-stated lie was {ieading_ _The. S ? S P d i n o son and. s stta ate o on att into_,the cur, I t ]P stated that f the wires.hang_down. and th_ i I car. -I .-I -I should have been n.t_unk.yard._. n -in should hav be .,,, ' e The cause_ eQP ' I eA tl ' i I .aaw6? of the.ccid nt. - .. _." __. C) o A JRww PrTi e s . A : ry A //5e IR ._.. - ?6U5 I NAME, ADDRESS 8INJURIES OF PERSONS I NVOLVED + CODES I - 4 4 5 6 OCCUPANTS /WITNESSES Toe eoDPifro"NN:i uASME? ii _ sL+ AGE taus '"w," 1 2 .- a u1R. -TO "iv NAM[ ...... ...._., ..... . ... _. A oluru NAmR or .R. ul nr ?AMe ?£31c1 ? w:. .ml ?.wilT ?IA.»s+ AMT: - - ? , - A ppY115 NAIUR W - -- E 9 AYNIU IaaM n.»N NeV' ?AMe. ?IaKI ?w'TE ?NS. ?•'Ol A - N AME' .• .. A DDPa1 AIUE 01 Awl?f -GM AHI w4.. 1rlr ? Mt. ? ?comE? IT ?»01 N X v IK WCWI E n tALwT Oa ID .c[NC E US?HID 4 ?IcyAR?Y•,p (?7J ??( D 1141 KI)II PEIIOV1D.1 DAn t I l AAF Y$ l!' r 1 thE? r A, }. 6 Y ?I f N L: l?i * x S a W, . ti . P I r 3a s Nr d. 1 I, I' - - I y ' r ?. t. r iJ, . ?? ? ; STATE OF vvA;;lNGTON ! ? .. i GE °r No.- U50 POLICE TRAFFIC COLLISION REPORT [ TRAFFICWAY POIICE COMPUINI NUMB gY Fq DgIE Or. ous N PRIVATE WAY - I„ +" OO N fIMF COUNTY 8 '? Wx'Npn lull wl INt NI tAr. I?Sf? nOURI ?? COUNfY NO. CITY NO. - All TT. Y RAJ O? ? UU µ ?. w ^I ?N (]E ?N C1YOR tOW/? N FE?NOa.?OF(519FFIOq NINIGlNMJAW rCr ClS AOAA 1% ROUTE ONSIRfF ,µ Ly AVlfS OS ?W ?Or MOODAl,.E ON EDAfZ r. tJ1 / sfcporv yµy INIENS[Cf NG WtIH'. siRFft OR AD NONIMERSFCIION QG? 6.3 I?r as pNEi1X EO. MITE POSr - ! - ^4d ]? UISIAN[[6DINf?pOSf M?RFILI HE C405s Sr IFtEOR NEAREST MRF 1 SIREEid StgFEr ?iJ/? z ?i ACCIOENi 9MSp pIAGRgM WIA IEFI w OF MILEAGE COIIISION rvVOIV[0. fVf RIfY. ?E. ?CODN n-?•9 tOIAI NO. ^ O. KIIfD RO ?NO NIUREO OFVFN ?Sp IIAG I?NHIr.h RUN nnlpulUrx R it .. ff'.I M& RRpfE OAp q DOR RifERENCE ]] CI[5 I.Ef [] pgOMN1Y pAAUGF ONLY ? gES UIIEO C] VFaI(F 1 / INiEq Cl5 CROSS $IR[fTO OBIECI519UCK INAMI O{OBIFCt S1gUCK AND OWNER'S NAME) {? ?O yz/?Q t EST. D-E SPECUL CODING TAE ??? F UNITNO.I S ^? ' UNITNO. 2 S 11 E NAME: Wr a T MIDDIE NAM1: UST ? VEHICLE ? PEDESTRIAN PEDALGYCLIST R 1[u R DRIVER S h/ SI4?EFt ApORF FF G r P-T 6 Rf[ DDRfS + Ily 7-4 ^ {? , tF 11-DE pNONE NO. D d 3 p ? I _ ' R surf /f , c a o '. yy;; DRVeasleNSENO. STAlE f1; • i BI n i 3 v llCfw =ENO. StgiE fX D IE BIRi?nE VT 9 W? 1?1 02 26 e t v ?.E B OCCuPAIION N4M NAMEe PEgNE NO. EYfS WfIGHr RIGHT E OCCUPATION v4 R FIRM NAME 6 pNONE NO. e 'ipp !?' pEVALL? /J/ EYfS WFIGF}yI EEIGN} I I ? ? CHECK (s? 4U "R ° + x nNOUaovfFar ANOrnfR:'u ?CHECK (?) Al, A, ) CODES? ] aiiY VFt c?A;N II ' 5 r clw ns ? unn%?E OrANOmFV. . MOm c, E ^ M I' CODES ? a c„gvr vFn aEA AN ° 5 EA N b Iox.nl , '/,+ e, Ass M ' eI q? '"?qp„ ?IDOOGE Cn[v?p6 AS°DEIOjDaar?wOVAO TSi/ne5pDaor?iv) ?renx ?AM N<I O-Egys_I, ?p$pu. u ?wa? ,` D ?? fcl 1nEV) MODfI(OMI.NOVAI i?lEl RV.) ` k 'tq ' OR NCl NSE pIA EN 51 f IRAIlF9PWrf NO _T_gtf E VEn. q Ads• -E NO. a IiL WFE I N. A R ?"Eyix ncu IDENIRICADONIEO C T " ' ' V S 2-C L of L E T D NT AI N ?' '_? I q[G151{4f00vMlq WI /Ig51 MDDIf T I ?. , PHONE NO O IF FD iIN51 WNFR: lASt p (?/ /?E?E? ^' MIDDIE Pn Nf " I.1 ' . x;7 ?. AoD [Sap pwNlR © "1?Iry KlJ V N A NEx - Eago_SS OS msu4ANC[CO oq AClNr ^ " E W ?.` f {C F+ ]DAMAC[D A4u _ IN u AN ?.I CHARGE N-N xD DANAC[ AREA a], r j T, V LEJ(/'?,/\F/' a ISID1pW.AGE q/UR A,N ?y/MA NfD oiwieowr /?- --? y V I_ -y0io f l?ry .NNED DIAGRAM OFF COLLISION ?AWAY ?4[MAIfI[0 fSl OgMAGF E?I 1? ,? li ,tiy d *I' ?? wAY BY ' ? W"; vBV. ? rooo . Eu cArlN s I?Y_ no?,a s" sr9r teiuRY) 9YARpgy N I DESCRIPTIONOFCOLLISION. IUSt SUPpIfMINtAI SneEI lr NeeFSSARrI e ?-? 'f0 VEW Q SLR 3D. iS-20 I?PN-t?q{ z , `, TRW STOP 51C71J A(ZMZLAw AND IM ? X---- -- OF UEH m 11J C?l Oh" iZE 5'sKID IIIj,rElz*s27 0Ij0QA 2Ue' B1 CYCLE, 21 g F siRUCk Kt5 F'-REH6qD OQ GRIkJ1, OR , EIU61? SLl6Bt1'i I._ICG2A7(7N. EH TM ?lI 81.H'HICE.5plJl? ?l ED 127; EJ U !L x y -x- ?Plw Tarr HUYI &UYU1A 'I 15.,eoapanaY uEqul?Y G aAoft A flrrrnrs `? ' `? NAME, ADDRESS 8 INJURIES OF PERSONS INV-c -W OLVED `. c v OCCUPANTS/ WITNESSES I;oS„E;?,^r!N H s? it CODES 1 2 8 a 5 6 j ' uM! ETR +Ix u UK AGE srANS" n S Rf Slq UICr ; '? ,,? •1t5 ' I.L INTO iuq _? it.l y y 1 , FN 0 A.. I •L x2r„ /L Al%WI55 u?? w,.v - - I °.?{'? .. r.i .I ?I? r S Y Y N ' X ???YBJ POLICE TRAFFIC COLLON REPORT yy TRAFFICWAY R>lIC O n olh'!N PRIVATE WAY . -RITE EGGI N .- A L? K_ TIME COUNTY ?kr ?L 'ry11L IUSER,DUHOUR) RRT 1Z? COUNTYNO. Ci Ob I I04s fF ?N ?E ?IH (fit. CI YOR TOWN ?yM1Ea OF STRETTO/RHIGHW rNlfS 5 ?W 01 1-1 r ON i & P {Cr CLT ' . r c 1 AMk I NI [ R S EC I NG EIOR ROA NON NtERSECTICN Fr"SSJJ W IIn: SSt RE . 1 G - ? / ' 1 gq J ? ?lV1 SU•J FO BFIVfFFN STREET, STREET IXSINJCfa DIRfM10N iROM Rfr E .CROSSSiREEtOR NFMf51 MILE I N PREfIN ED ACCIDENT Rt5 5 MILEAGE {[ET N ? OF ODE RAfW R,vn WtA 1 B TOT. COU SOON NVOIVfD: E NO NOKLED RFD- J W IDin F EH ICI O a fHlnIS N / ? N E C S C 05551 El ORkf?El INN•D F(ifF Ct • ; 'e•ER UU ?. v PRORRtYDM1AGf ON? pS J6J D ? W ODJfCTSIRUCKINN.tI OF OBJECT Si4 F AND OWNER'S NNAE p ?/.9 ) FSI.DAMAGE $ ePECRU CCC NG Ibf ??! l - "- "'UNIT NO 1UNIT No.2:. : DRI ER'S NAME: ASi FIRST Q"VEHICLE ?PEDE5TRIANTal?PEDALCYCUST: - JRI 3 ORNER' NN E: LAm r MEaes (k w , ?o S, ULIADORESS N51 ?? L W`lI A G, - 2 ??s GTY s1ATE EOPCODf D IPEFL ADDRESS Izoyo ?iT`^ Ao? s, PHONE NO. N 1? A 376 ---- fT3 R TIT S1AlE P F ZIPCOD 5 rrle wA G 1-7 ' - 2 RNERSDG SIAIE E% DA D H I- % w[R' UfNSE NO. SIAtE All B H LAM4Eh{( ?845RP lJN M 12?14Ar fib O v 1-NEADwGssoCD citj M c? ?wr UK u CCUPATION {RM NAMEa PHONE NO E Y FS GHI IEIGHI E OCCUPATION FIR M NNAf ePNON E NO. EYES WEIGHT HGN} , •• /? ' ?? --_ `?^ I SI e R 1 1 T Titk.Del,, Rf.. .}VIIEQJ)D Te 'S. W Ste ; _ J CHECK (.1 EHnEASANEAwovEEOrANO ?CHECK l F THER. (r ) FNCIFASAN EMPEOYFE O{ANDinFR v ? P a n x° 5! a .svD Rc.cl{_ Ass rin nc11DN lin CODES ll? ] a \ < i s 5 Ix 1 e ' " ° Au E n W n e °C ° s ? - n F MRr r O tE '? 51 $ °D M u s A t r W r -- r . 1 5. U I ? •ue a ? r,l e 1 ? Cbm, ? vi K I OV fr E ? F er: °Wr1 ?AMNRAKI ?UDIICf ?Cg_ ?vNEMICOi ?{uilY VfH. T AR AMREIDODGLCHFV.) fl(DMT?NOVA) STYIf (ROR .COnVI % 6?f P Y I EV,1 MDDfI IDNi.N VAI 4. ?t? F1 u a r E 79 PeFst b 1 ns" 1 / - CFN PAI N . STAR 111 NO. STALE H FH.C OR CEf $F LSTF 7i. CFO Ayq 582 Li C G2L? Xz?(cR tJA V[NOCI[ODfMI{IUi1pN NO. I j l , l L VfnICIE IDMII I 11 RlGISR4[D OWNER: USI rIR51 MIDIXt PHONE NO. 552r"'EF W .......... WNER: lASI {IRS} MIDIXE '{-RA rt?-.tiics•n L°p 710 .ri'fIAvK? .. Is AooRau R E SEATTl L C)!?1 NMLL a ADDRESS DE INSURANCE CO. OR -TNT UAk4, R TQ,aL .Svfd, E . POIU{lA CRt R iAM,eu "I• wa`ro°,N Dw IF i'?AGfo KREA CHARGE 1M°R° CMA°? eiDl I6-- 1 IT DNAAGE AVI`ZN ? FIT" 10 ' DPIVEN A[MAINfo l T.ID °p ! , f 10I S I TONED C iOWTD WAY ? IDe S 1 ^' , ] ?" ? Awxr er f DIAGRAM OF COLLISION: Iwxr er ROOVYTH DICA DESCRIPTIO(J OF COLLISION: (LRE SUPPIEMMTAI SH-11141 5 1) 17- sH[E14?IE 11 er Aa ...1 ' 1 ? 1 ire E? V .\J41..i1 ,O'C?S*-?1tu-. (,%( y-, - l .E 1. , e .l .?lstaXA Y'f' `1 7 ? l -- i 1P,- I _ ' II I iI I , -_ _ Se I i I - - _--- - w - ---- --------- 1 _ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' 1 CODES - 2 4 S 6 N luu 3Ur%IM[NIAI SfrE° OCCUPANTS/ WITNESSES 109 ADOIIIpJAI NAMES A41 N T I -- ---- SIX AGE IATUS ?!u:r I N N •Wi' • °- PESIA. ---- M¢r' !l(CT e• r An ... ... .. ... ... ... ... .. .. ... _......._.-. I -11f I A N Ri MINI RY• ? AM R. ? Wl ? HI • ? 1°!i 7' ? {FRgiEv Al - r W .. .. . ... ... ...... _. .._ NOS mRESs R I 101-y ?AMe. ?rrOMl?Nw ?mv ? m. MN I..Nfr IJ ' . .. ul R , . J MfE15f la rw ? e ? X ? •Or{I tuN e101 0 OR AGIr CY d N /O?IA1C qD rO K] KO D IE 1 0 ° ? E ' ??:ix ?".,s. N ONDeY DAR gI?? E"r1}? c E ? "' J' Y - il.? :•? 4 -u.:. "Ire." L ,iA 3 _? ?'?.:- law,.-: l.J.,?`A="/ u^ !yI T '.4?I.at.PT'?+?h...rl_ IL' m+ Fwsv 'CR FT »]I - 4t' ., aP" p RT:1:, w r n y 1 I r 4 -.. Yl ry ! y A p.?' Y} 1 -?' M '- I ss. ? I Y , l - y . ? J l I l 1..? 1 i 1 1 Ij, 'r ®'iRAFFICWAY POLICE TRAFFIC COLLISION REPORT fOpCf COMRAININlN1BfR PRIVATE WAY Dqr r au N Ar N LIME COUNTY ' I'D .... Mn. v la :LAT. ID$f }"00 MOURI X400 L?,Ffe'.ISErn COVNfY NO. CITY NO. iHWA RAL ?N ?E ?IN CIY OR TOWN NNAFa NO.Oi SiPFf10R HIGHWAY lC't ClS POUEE Oq TREE . / AvLts s ?p 1&0, ON IMfRS[CIIrvG V SFC110N (0 99.5 ¢ . A H: SIPI O AD NON INiERSFCT ON G G(COVN 2. v>YYll ' 1 PREFI% EO. MIEE PpSi ?y 5 FFN SiRfFi IT SigfEt c -R-1 -II BEM pI T .CROSS STREET q NfARf IMIIE 1 (> e T / 4E5 N 5 f W ACCIDENT M? RAMP pIAGRAM DATA I EEt OF MILEAGE §j f=,h 6A G CODE " 0 OTlIStONINVOIV[0: SEVf RIIY: IOfAI NO. NO.%ILIED?NO.INJURED? ? 5PILIIAG[ ? a IUNpelpl4 ® I %'RD E IN TRIET ROAD RRFfERFNCF INTER Cl5 CRp5551RFETOR ROAD OVfHICI[S PERIY DAMAGEONIY ?FEUIIfD ?VfMCIE Cl OBl[SIRVCaINNAE OF OBIFR SIRUC%ANp OWMR'S Nano 69®6D 7 [ E SI, DAMAGE SPECIAL CODING USE E3 $ 5 UNITNO. 1 DRIVER'S NAME: fIR51 1A51 10 Lf RUNIT NO, 2 IVE."NAME: D 5kWHICLE ? PEDESTRIAN ? PEDALCYCLIST ST ---?T' ' ' /R> L L I Or 1 0. STR[flgDOV[55 11 ea v\? e 1w. I I V, °? IYD S. ' D IRE IPDORf55 y`_ ev \U ,\ C QZ'IP CODE ONE NO. L 73z.yss4 ' R STATE D P N ?- d? ' - Z ORI vIR-SUCENSENO. HIll1? S 76SR9 ST IA IE f% lL64 F DA rz!z98 iv ( V I R' ITC NSE NO. R EANb-T(c, 44 33 P All & 1 E% gS Ys3 > DATEOF BIRTH o a4i _ N Z OCCUPAl10N 111 FIRM"AMEaPNONI ND. EYES IGNr HEIGHT E , acuPAnON IIRM NMAFa PHONE NO. EYES W[IGHI IEIGHI 1 r 7-e ( /? sG R /lr !!n 3 L ? ?(i u ?CHECK (Q l CO DE S y[NKif AS:Nr OPhtaANOmrR. MaroRC.n - G a . a rEC? N ?CHECK(/) fwnf ASAN D%MOr of ANOrNr. i P + s 'y ` ? 5 E arv ° CODES 1'. t D w suM c1aN sev 5 eA 6 u Nn - l , , `i n Pa-IRDM ? AYwAHCe Kl vnrt RI _? URI O ? u KH MMEIDODGfCHf 1 a ?nI'I NOVq?MSIYIE IZDR0 N pIE01 A) El H(ggRWA Ay; ?A•--I ?m" ? a'.. mV 1 [MKU ?IPANSP _ 7y FoY? '• M ave"- E I V.1 MODEL IDARI-NOVA)) 76 GlvlG P/fA Y I 4 ? y H UR UCFrvSFPU SIAIE TRAILER MIE NO. MIT H V - I l v IRA IE. 'EA N ?? A O ' Iy Y h TIZ 6?rs wA 1 kf{' 712q ;'Y,'??` 9 u? V[HICLE IOfMIfIUigN NO. C V WII FHICIf IOEN1Ifl 1I `- 3 ?I ?'y G d11M1 REGISlE.-WNf4: NSt NP51 IOIXF PHONE NO L q N E u 4;l Yi6!1' IoI I a!81 RF . TIT RfOOw/N/f R: LATI fIR51 MIDMf SA N I? ADDRESS OF IR W N q BI qMA1 a AppflES- INWRANa CO. OR AGENT E ICeln •PsR•M AN C,,,Ike Fog 78 R Z/7Y Srxlray C2> W L3 DAMAGIDARIA E I "b00 _ 37 CHARGE wIA41DnN 4AMAGI M[A CHARD '\'lu °H O f t0P .IpYAkt • ? DI? ESI ES T A DRIV IIpP OIDTIDR I ? WAYErv ?R[AWN[D I"'1 DRIV[N O 1_..._... l_.3 AWAY RfMtiNIO OW[O OU I • Ie s A BY t{C • 1b:.A AWAYBY? s.TCrrs a IU?OR DIA RAM Of COIII ION: ii4ellr NiusTMYI 1"rsl ^roq?DRrn ESCRIPTI NO FCOL ISION: (USISUPPLIMINIAI FAITNECF.sURY) _ d 'T SSYsF SYCIDS (.,,? Vel, .?. " `/¢?. +/ LLk1J $ Wal'rA -rD 1E1. x ? ° / > ?,- vm./I 1J$ Veda cgyP(j 6 a.71Ii•sc r,ka a?? h;7 1E*3 l C?ri?i> ?(C? PAL j! D ? ? = .iMPh v T a?e..O? 573 /v / H ?- e(+e Yeh L L ? E a m /rtAv;A TA. M"ff v 7 z I A1:I? `OC?FY44*llr 6Y rME •S l J o .24 .. ?.'f rn cdr $IS a r eeC] its 4 -4 NAME, ADDRESS 8 INJURIE OF PERSONS I NVOLVED + CODES 1 Z 3 4 OCCUPANTS WITNESSES IU:I SUIREMINIA 5WI r 1 - 5 6 " p ApDNIONAI NAMls I S!% Acl IA Us l U. YAr , "ST.. IA , IcY A l: / ? -, 4 D I kJ N AtUR Of - q SCIMy Y?AM D ? ?KI ? "TII', 0 ? ax ?ruYw1/ A H No OpE115 Wld R ' MOVIO IROM ?AMa ?,uKl ?WI . ? aiY ? :° b HD Ap I ??LLIf N11 MAISM/O RMS .EGO KI 'S NqW a1AH IM BV ?AMB ?KAKI ?[ioma ?aIIY ?n%wV a aAD m AGIfKY Navin KIDSP IC ED 2-1 IARRMO DAIIO %KMf AMR 111 WE ?rv {"? ?h r. ? (I ?? l?` I'Y ! ? 4,iv1 air' j ''"'?. 'Y q'iN?"?""??+tt?`[+y5d pp ? H r J 7 -M?.• t t f l?i'? l.driippj V 11 t?;? °?pt? h C?1r ? u?l.y 1 ? T?1?i ? '?1?.` ? ± Ji ??' , i f t y -?1 ft r? r{i Mk?d r .????ir '? r ,9 .?1 Gw _. i i jT? R it ? n wt V a ?1 i?, J Ai z• ar R4 P?dj ?? 4 A u 1 S'?.:. Tt,S5 " r/e'I SY ? + ? ,. 2 rt tf c .v.w 1,p T ..x f POLICE TRAFFIC COLLISION REPORT V.?I TRAFFICWAY PoucF COMPwrvrNUmeER PRIVATE WAY ., PA 9, ?o I T' IMF COUN ?// A- Al aI R wRa?d r.. o aNU(ri" F? 00 Da' COUNTY NO Clrv? F- p uaBAN i f?25ati1 h. II 5 S 6 ?O RM pN pf pIN CITY OR TOWN NN.1F6N0.0 Sr^aff O rl ('7 LES s ?w poi N , C - nCL OU/IE 09 9 (p? 5FCI11?NG?rwi1H: 51RFf / N`ONINI[RSFCrION /??BBY INTER ?A La . r1 L BF EN STREET E ? STREET PREfI% E0. MIIE Post ?C eO•? . D T ANC IRE TI F MR FERf R055519fE109 NfAR IMLL ACCIDENT RAM DIAGRA DA I / ?IQ "LES E w MILEAGE CJ iFFI Oi Q _ ? ODE , ' B CIXlISgNINVIXVfD E915YI iOTAI NO. FF'??T NO KII[D_NO.IN1U0.f0? ?SP ILWE ?MI6 N IurvDn9rRt HD rv SIR Ef OR OR RFE RENCt. !NTI Nlf CLS O:S SIr[EIOR ROM R a-CLES IG} p PPoEERtr DAMAGE ONLY pRFS E f UIi 0? A ? ??? ? Gexn SialM:KINNAf Of OBIEn StRUCK ANDOWNF9'S NAME) fS1.0AMAGF SPECML COD nti WE $ - UNIT NO.1 - UNITNO.2'. VEHICLE " 0 PEDESTRIAN : p PEDALCYCLIST IV! ' NM1E: IA51 1-1 MI IXE R (R'S.-T: U , --F J L J I (4A' A ( F < 3 ?x 153 f ?R 8 X38 a P z Y SLATE D 0 r? ero. C I I PHONENO. vu -w CRNEkS OCEN H I Y IE P D N ?rRrvus?vD ?v • Z 7RIPP7??3. 6 SIA F X BI H ?vA ( V U fN E 0. o( A pP K f DATE • B IN Tor " l R NAMESR tw EYES WF-THFGHI E PAtIQ Y iI0.MN IFi PHONE NO EYES WFIGHI iEgHt _ I ' Z ? CHECK (,I VEw F A r,A ANOrH a. NODES ?+ 7 aA "e y S s 6 surrcn ss Ysn +IC r oN ? CHECK (r7 V," SE ASAN FMPtOYFF OFANOTHFR CODES ? 7 a a is M *q 5 ,xc ". 6 u Av in n ' , ro ff"«7. ° p M. AH , p Wl ? r8ril. ? a:2 raL rorn 7°' ? MN Ha o ?1° ? b nP a w raL VEH. YEAR MAKt IDODOFLHFV.I ELIDART-A) STYIF IID9.;IXN) 60l V W 150 zA V E R HEV.) fL IDM .NOVA ) IS ?? otirr ?? U N SIAM . IaAlllR FUTF NO. StAIE H Iu? CE 780 -wA, A 3 VfnlClF IDtMRIGtgN NO. ;'?!/o121 I I L /I ri!N I?I I ;2a?14 1`YI 1 1 1 1 1 1 1 RtG15R9fDOWN11: ilRSl MIDDLE PNONF NO. O W F D Uit {IRSi oG2AQ tES ? ? ADDassaowRilR A wNlx f I N E NAMItADCRl33 Ci1NSURANOl CO. AGENT A Z l u Tu A L c JL I LI,L L' L L) a FuS e7ub ARU D"a.rPa 0 AT),1. wi Vei CHARGE rl CHARGE LetIHD W gAM. A , m i 0 SnOY l3i DAMAGE 0 ARIAYN 9iMNN[D tOWhDeY rJ T c-- V ? DRWIN p1-NED AWAY B . FSI'UAMAU 6 e1OP 3 Io3 nms le DIAGRAMOFCOLLISION: .- I (.?HUniNF?SUerl AI? o IH a -? DESCRIP ION OF COLLISION. IUSt 5, U-MENrµswn FNFUssARYI ,,? ,? ? LAPECiLrO ( E r !. _ ; ACIDJ/C-4' d?.7/ETi /9S C +'?` T?`/ C f?ND 4? , LL, _ _? - ? -? _^ _ 7 - - lGGED- lT 577 2rs1J) lle.[1 ? la ti-ill A _ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED i CODES I - 2 3 4 5 6 OCCUPANTS /WITNESSES ?a s,D°D,^,EaFlu r?iAiu a sex i;c?- ums '„"".v,r' "wr' -°--'-'-' REsNt, lMn Mscr H AMV. .... mw NA! R 01 AM C 0 [?. " p HIL . p a ? raL,. A DOnu NA TUR a ?AMe. 13 p M." 0,11-1. 0 ax ? :°. o _ ND ns ,wa °F salve e Y ?AMe p Pcosa a? ? n ?v :Y w J; t?f i e 1 t ? i i l 1 L FF l ?+J I r n la, f I rieiEbv .,UIU H VtHI k,Lt k:ULUSIUN H )LYUKT _ u. " AF Syr M T1. MUq IN. I SAT. DU Tw • MEg N?? COUNTY NOUq UNTYNy C 9 / V IT110 ??- ytByF ? PM Y C Ott , RN GI lOYM DF 9lREET t K i < , ? Ib "?'K . , t E R N WWAY ?H?E?IN MuES ? a ? W aF nse _C ON <L ACM CLT. IIOIRDfl BIR IXIDE 9ECr. '? ? y ° p ? 102N" r 'O<E G co,26c.e o-Er A IRROT PREFM FD ' ez T p WSH.IOIPaAp CNO-RSwUP,giiEP09l ONFOFNi FYVp"i. xOWaE HMMRUMPF P.BWWE i T RruP •. ADPNAUArA A IN EPSFCTgH' -T ©® D NwWr,YE A:A I ALD aEwD,RAP gPO D - ? ?;' o o:L o RiLD BFLN.1 ?ExR<GIVEa ?GWIwE ? ! ' ? E a0. 'wi qFf t' M ?PDAD ? Y f • GiwEA FN OFVEXCM:9 Y w _E MATf er AL A RADK)ACI F iFwK9 A MAKWI 9EtTFD wwG.E COP ? ? ,L-z?v -' IF .' OBJECT STflUCK INAME OF DDIE<f aTRUCp .WN R fOBIECT AM MOAOUflE95.. jtin'rgTTI?a f 6PEC COM IAiE . ruck hi rue-$ . - ` ® '•' DRIVER'S LIST NAME ,.. ... FI NAM .. .....:.. MIDDLE MDRF TxO THAN LAPS wE L O 0111E 'SLASTNAME ..FflST NMI . ?.. _ IWOME Ara ( X r 'I L?/rI C'Ji ?F O U ? P wV LVFD IN TNa MOPE T.. T. I giAE AR B.9 ROUTE NO. MDBO%NO a ' O pFggggpE -YE-.A SEPARATE SREE_TAI DAE59flOUTE NO.MOBO%NO _... ^ MC-%' D E CITY STATE ..., . LP CODE a se cP t 'VER'S OCCUPATION spN REFORTFORN CRY .. STATE ., .•LPCODE S DRIVEfl13000UPATWN 121; LA cL DRIVER'SUCEN EN 'a Cl)C`LLCSi?/?iC(v /L%/ DATE OF BIRTH AOE C .5% 3C - OflIVEfl BUCENSE NO ,; ?elL-c ?? S C' 2 STATE. u?sP 9IX. .DA OPSINTH AGE. ?(r VEHICLE YR / S MAHE ICHEV: DODGE) .MODEL INOVA•OMTI_ y t BOOYSTYLE(2vN,) VEHICLE YR MAXE ICMEV: DODOEI. MO LIN A•0 .BOOT fiTri 12 DR) y y ?G ?( /:D a cn ""C4,4J., c/./? C2ECYier pl?? _ ? 7 S LICENSEPLATENO. STATE TRAILERPUTENO...-. STATE VEMICLEIDENTIAGATION :.,;: .:...._.,?.._.; _ «.... ...... .. _'... S67-11 ?2/-76 ' • AEDIgTEREOOYMEA ILAST FlflSTMDOLE NAME) .. DPJVEA 9LK:ENBE NO . /. .. ?. C I)C'-Lh I ?•yN pA. rt ?A//r UY C'- /cr( // t ` RE STEAED OYMER ?}A3f'F`R3T•MIODLE NAME) .A 0[4VEfl'9 UGENSE FI L rt. Ai/ ,7ypA L / 43'K¢ J.._._.. •.. LPF A t / A F _ 4 vti/ L / ., OWH1EA 8?^ADO E//99 IgTREETryGTY ANO STATE) .,,; ..., -/ OAT OF &RTH ,. 'b OWNER'S ADORERS (3lREE[ C17V M0 FB . '? /. . ?c E' .c'I(: / t J /7• '. / ?C'. /i // 1-7 ; C , R f PMTS OFVEHICLE DAMMED „ wQ INTO, AMTS OF VEHICLE DAMAGED I s /61-5 " LIABILITY INSURANCEINFORMATION•VEHICLE N0.1• COVERAGE IN FFECT FOR THISL ACCIDENT ON YOUR CAR ?YES NO • 7F•G ' ,. NAME MOADDRESSOF LIABILITY WSURANCE POLICY HOLDER .:... .'._. ..: ., . .....: .:....NAMEOF LIABILITY WSUgANCE COMPANY•..:. .., _. .:. .: . N AM!• ADCaE99 GTY STATE >70 ? I y NAME MD MIE59 OF LIABILITY INSURANCE AGENT Gtt. ... STATL ...... .... .nP. ' LMBILTTYPDLGYNUMBER,:,__ _.. Ist INJURY: AGE - 2NDINJURY. •_IUSESEPAMTE REPoRTFGi ACGroxALwJUw ) A(IE NALLE p vOUnE NAME AGGRESS ADDRESS -SEX 11M F u N ATURE IXTFNTOFINJ IUPoE9 ?? r , n?OFINIURIES ?? ' EIMMWATIONRBYOA 'g 000TORT © ® DOCTOR'S DDINJURIES REQUIRE L ,a DOCTOR'S - DI EXAMINATION BY A DOCTORi ® ? NAME /n? C' ...F 5 Z 1 C J G SiATU30F WJUREO .. MMKFIRST ONE THAT APPLIES STATUSOFWJURED OARK FIR MAT APPU S ' ? WINE W VEHCE D wD HOgBND PDaugE ? DRERN VEHIC GsADwa HDN-DapBUNO r05EE C3 J-INGFR TOLLED ISEVEREI IMHORI E COMP4w ? I.EVlFEI IMwW11 E MPIM} KILLED I C_0MUR NO .. -___ ?PEWSt OPPAAEtCI .R pAW O CI ?: ,,. .. .. .. ? S? 60 70 CI :,,.I. .ID;vI ? S? 80 70 MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMETNOTUSED • SHOW NORTH BY MROW IN CIRCLE wb<ArI GXAPVfIF Ar O\ \. ; C taf OVrtwE trwTl W0, ' i0.w < A ..lCf,E r'iTUie[ro n9Hw," w.I H[s :I 3 FACN V[ IE .RD Sr,aW ' _ DESCRIBE BELOW WHAT HAPPENED IREFER TO VEHICLES BV NUMBER) ` ?` a I-???(y C[d:c-1 Irll T.::Ct 11 v/k.A._LC CKLf( /P) l( / DP C//_7 / '• h J_kl ?._. _. /Oc'.Kr4<: /e_T /" Cllri//I 'NK n . ?L2Ll rr_ ? _ •rl . . - ` PK ' OR wONw . ... _. ._ . -__ _ c. . _..- //j/ /. Ll /IF ?_ l Tl _IJ? /IIL.._ V A ?.r/IJ • __.. ... i le ??__ / I 1J?/j 1'Cgf._ - III•j/e..A"• J11L J r[n'1 [InA _ V-2- ./__ _ h Lu!'c•? i?(a[ d?.._Ic.Qratcn_. + ell- l ?/ / 1r y 5';?/L ? ? ----- .,-. .. € '90 • urn. Y/•I rI Nlr 1?1 ----- Y VEHICLES POSITIONS BEFORE COLLISION waLAMS Yfr?c.! rH?ci[ .FARM w,a INYESTIOAr2D BY ' VENICE N S E W aI STREET OR NOMWAY NAME OR NO DwEGIlIW ![O[?Y]I ?vDFM1 YP D v!rt' OCCKD ?PAIT ?NtKL O R L AD, '" '" O n ' • on i // .. . ?: `: ;,: ? ?.- ? ? ?", ?o ,a EN. : ? '. .D DIM O ? ? ? ? ? I N G ? r naslwN ? ? Q ? ,u cb1ilosswD m OM' DIRECTION -TO' DIRECTION I PEDESTRIAN/PEDAL CYCLIST WAS USING: 1??oEw uK SO-06 2?W0. r D?W00.0[a ,? ? Ofaw.4 E?omw r? u I'D ? .-Y It aossw LPl ? ! Po A E PEDESTRIAN/PEDAL CYCLIST CLOTHING COLOR. I ? o.AR 2 ? DGa 1[-] -ID ! ? Miro r1[crn[ f ? PArpfA rt<IAnf R A I f DSUR O ACE WEAMCt[ LIGHT CONGIXWS TRAFFIC C-111.1 TYPEOFROAO. DNVk11/VENA'. RACTIONI aMCAAraI 1 ®DAYLIWIT ?'MUCa! ICN1GtlR[I ro'[wt[I T Gtr, AIf ?Y'wCUOE ICia LAOH[Ca ADPFI emu, ?1ppT1 na ? 1 ? SIGNALS ? 1 ? ONE WAY n11 lOlrpgy 1 LN a?in ui 2 ? DAW11 ? 1 ? OOINO STRAXC MEAD J k 1 t • ' IF? 7 1[Q]IT 2 Q R4NN0 ] ? DUSK ( ? T WAY '^ 2 Q STOP SIWI 2 0 r ? ? 2 ? OVERTAKING AND PASSINO T , 1 ! ??' , K.S RFET RIVER BLE 30SNOWY4 E Q LOtli9ON ? ] ?YIELD 6qH ? ] ?ROW 0 ] ? MAKING RoHT TURN W 3 df1 ? ] ?SHOW A FOS DM K.STREET ; ? E ?LONi601P ? 1 ?rLABHwD RED ? A ? ? A ?MAKWO LEFT TURN 'C ` L t ? IL00 P .IF p t 4 ? A ?,CE OMER ' ? C [FYI S ? DARK STREETNO Q S ? rLADHwG AMBER ? S ? ALLEY ? E ? MAKING U-TURN ? S ? TWO WAY 6P[GrY r ? T.ER LJ Y E-1 E ? Fit W L ? E ? UrT TURN ? E ? &01NN0 1 f + 1 t - t LMES . ADWAY ` EN ' ROAOwAY W IwACe 1 YIE ? / ? OFFCEII,IUGMM ? T ? STOm[D FOR TRAFFIC P4AP" FYi 1. (-) T ? GuvFw.lr C slorP[D r 'M N L ' . .. I I ' 1 I N `. ? T T t Yn W.,..?' "+'..r7I T lY A`y^ ~ y p? i E A? • T •iI . . . r Am Y?A? 4 j ,i . I n ?y • ? ? 1 :?I"9Ey . ?til U9141011161 IN - - I f t -•" mu I vH Vt:"ICLE COLLISION REPOR „GATE OF COLLISION , MYOF SION TIMEOFCOLUSION - I. 7 .. i EFA Un Aq N S 0 1 UR FIR SATN11 Z- S AN RCE 81 • x PM 1 MILER •-?0.. -E aU. K _.GTY.TOWN......,_.., otcuw[D Jefferson Ort 1?Y 9 wiin 5 ©® OF 1220rt W 4P .A. :... .-: GIVENAMEOFSTREET,ROADOfl HIGHWAY .-_ ,.. WTEg?SECTWG WITH: STREET Oq ROAp... axcc PI`D Arcadma-- a eor Rd dtus Rd NO NINTERSECTION'LOCATFJNOFCOL 'ION uWYNO GTY NO .. ?plq AN All DM CLS PIILFI% Rp:IE OrI yI - ? ION (?Z2? pnEfR EG EPOST- /7 RAJ •, DAGNAMDATA-, BETWEEN STREET ANO "i - :. A A' xOi ®© '-...NO3eiri02"LU IRIU41ALWD1 iNpA E-Fn sd0oE '., NON %H EPSECrIax 'EIT ©® O INTER IMEfl CLS i Imo„ LA] EHICIE V EnGLF ? wC C L F 11 'ED ?0 I ? L?j ?K CL.WLFC1 ?VF E P 01' G yO O SPEC COpE U$? ` y 1 LES ? F x:IE PEDFSI ?nOrr COL ? O ' \ .( • x CTS GIECT STRUCK ANE DFODIEISIPUCKI OWNER OFOOIECTS NAME ANOADDRES9 : LOCATION (. - o , IN ROADWAY -• Q® i 1. nEPAR pUFCT .A. J i FEET F 1YJ ? --• L 4 M -0 P "1 T" DRIVERS LAST NAME -.,-. FIRSTNAM .'. MIDDLE.. IV.OCMS - _._ wePEwvOLKD DRIVERS LAST NAME.. ,. ' Lorecki N iNo to s W DALM SiREEi ADDRESS OR Odell ,,, .. ROVTENO-AND BO%NO, FpRE SIDfx -IM STREETAOORESS curie PER-,.IRE Route i Box 909D rutcher d WMEDMEA V CITY _, .. '.... STATE,•_.., L,.:21P cQOE. ORIw,1000UPARON, -:'.. E.-A, CITY -.,. ., .... STAT p E :.. n •... pWgeE Tyyyegq OCCUPAT10N T* Port Town SAR I (lash RI 9 6 Disabled "EPO °flM "iF port To send pV A.-E A To .. .,. _ Wash B 68 Housewife k NSENUMOEH _ .,,-. ,_. STATE SE%. DATE O FBIRTH AGE, , DAIVERSUCE E . O N NUMBER AR LORECS4654C2 2 STATE- SEX.. :. DATEOFEIRTH,-,. -Ape. M F MD A ' - D Y YEAR 2 2 6 NODELL 6 ° - Wa x 2 _6 1 0 yENICLETR.- MAKE (CHEV; DODGE(. ,. MOOELINOVNDARTIBODY STYLE130R1 ' ° '' :. .. VEHICLE Yfl., MAKE ICHEV.: OOD 1974 Ford GEI MOpELINOVA-OARn.,: . BODY STYLE 120q.1 ,, { 3 . ? Ccurior ick-u 1968 LICENSEpNTENO.. STATE.,,'- TRAILER pATENO._ -, 9TATE ; Ford ton ick- 7 - UCENSEPLATE NO :-,:.9TATE TRNLERPUTEND STATE , Fy A06 Wash A87429 'N _ .. . - ash 35`? VEH CLE IpENTIFICATKJNNO EISEB MODE SJ NEWEPI:.-, OpOMETERIMILEAGE) WHICLEIOENTIR ATIONNO. -. Svl`APLI 62 6 ?± S101RCD3205 . IIDSEMQOELS&NEWEfA--. DOMEfER (MILEAGE) u k n nown REG19TFAEOLIMER ,,. ILAST?FIRST,MIOG.F?NAMEJ ,:,-. _ St_-pglyeP MO G7 LorecY•i Stanislaw 2% Esther Esther- ISY.iliJ RichardNodel --" ATODELRPS OWNERSAODRES9,. (STREET CITY ANpSTATE) A ,. DATEOFBIRTH , , _. , . -,; OW ER ADDRESS (STREET. CRY ANDSTATEI' - DATEBIgTH. ' - j v AY 'AD Route Box 209D Port E"P FAA . o PARTSOFVEHX E0AMA0E0 Oatf 2 ox 6 ort T wnsend Wa 8 P - he m er EI];d a c r 9 ?e2 RN(yiCtE., ' ARTS OF VEHIED GE DAMAG :__:,.: :...:.:..._. .?•_.; DDO•? Ngv[ lc E N0.1 DwA EBEAUTO LIA$ILITY INSURANCE INFORMATION-VEHICLE CAVEP AGEINEFF Headlight = • MOBILE LIABILITY INSURMICE ECT FOR THI N y . • y NAME AVDAOOPES9OF.LIABIUTYWSVIWICE POLICYHOLpFq S ACCIDENT ON YOU CAR (N YES C3 NO nAxxE AmnFSS .-'.1y 'RAIE. .... -.....I NMAEOFUABILITYWSURANCECOMPANY_ Stanislaw and Esther Lorecki ]P R. ox 20 ort ownsehd 1 ?.. NAME A40 AODRE590FLIABIUiY WSUflANCEAGENT...__.. _ BT - - - ._ ?? We Call the Company. P 0. Bo - S x 20 AiE ,;._, [P U ABILITY POUCY NUMBER, 7 7 020 hoenix Ari 6 7777777 I $vx 'ST. UTY ?' „11{:f ? .... NAME Stanisl aw_Lorecki-_ AGE . ' OTAL na z 7 61?01Q 1? FF NNAOEURY:'_.. _, IUSF$VAMTf PfFDRT1 OPApdT10xAL uNESI - GE . 4 . 1 ; _ Z p '. AOOAESS ROutB _„A AIAAE R MO e -ROx_209D E_ Port_Tnwnsend, _ W DrwAAFF] Nec ®niuries ._ EIXx EX wIUP DDRESS f ` EX, n F ? I? ir..` - er AlnOrOm SIATU3OFD Ea r aCOb3 P.P 1 Gns -.--'f -- ExA DDC ®? - ? -.. 9 y "? . 1 MURE0 k BdWE WVEH CLE ?M= ae NO ILLED( MARK FIRST e1w0 Ixv I We[I ONE THAT APPLIES STATUSOF INJURED xOV dexDlwb fR NwOn I E ?dP IN VEHICLE ?PSSfxOwl ? xANE MAHKFRST GVETHAI ARRLIE9 iw0 D I• KILLED ?unLE VN P1 A- A C2 REGI9jERFIDOWNER :P, ILA9T FIRST MIOOLE NAME( ., pgIVEgS LICE SE NO,._._;;; M u,ll C'Inlr::t.„ I LJ 1 0LJ 1 s© SH \ OW NOgTHBY ARRGWWCWCLE tx InE ., D U- A' I Iruce K<IE - \ <GUSxW frc. \ c?nf On Kla A'. mvAY IT OR i- f ?wl[R IACN KnCE 4ry d1pW xrlprxlrm KLP Awa ? I an Ia..wx: VEHICLES POSITIONS BEFO VfNICIF J HO IYOMq N S[ W ? [FQ ? ? N ? IOIMPI ?)? ? ? rtgtI14.N k ' ? ? ? 0 `; PeoElrwANwAlla+Ha Rp.O BUfLFAC[ TTTTy.[A1NLR ::? ' , . Y x t ?1 x0 f II ET Q owylw ??ff LL 4J 1 m pqv [ ? AAA HO ?]?w'ET ] 0SN°WG ? ] ?SHOW ? F00 ? t ?ce y OOtKA OF-/PQ f1C1 ?rt ESTRLVI Np_ SEVlAN IM NpII ? LO 111. .......... ? .5? B? DESCRIBE BELOW WHAT HAPPENED.(REFER TOw ICLESE NU Car_.1 Was--proceedi ng_South_on_ArcadiE Georg O Rd..._When, Car._two_came--from_thc road _lro.n_the west .and. ran-.into_my_rj F HDxw DR rear fender_and_oorner_panel.._._I._had , _ ehfted_gears and proceeded to slow . __ _ _ Tor aright--turn on Crutcher.Raad,__ the hit me_I..did_not_finish-.shiftin th bl e ow-throj,gh..me_in_reversa.._Sh explanation-the--Driver_of_ Car_2_ had ' didn t see you.-- ON STREET OR HIGHW AY NAM[ OR N0. CTx dPE Arcadia !LhT Utoheri•R 1 L4t;l? ad nn S}!F , o Cana ( o & ? 1?&DEWMK .• 7 O. ?WMIIWAY- 30 SHpuLO E L OHTCONOTICNtl T-ME CONTROL MxrcAd I JL"F O.niamy 01 1 ?BA,MS ] 0 DAWN ? ) ©, STOP SIG! ] 0 DUSK 0 J 0 YIELD SOH ' ?LO is STREET ? [ ?FL Ub "ED 6 ?U GHT[OEFET DARK ? 6 ?FLA]H.xp AMBER 1 ? DARK NO 0 1 0 RR R !I IA KE NO [0 . 171 0 %:11.11. ? jp 1 ?' ? ?. ?. " ?. ?, ? p?Ot Sc7o,° D 'R 0 ? ? ? ? ? ?txf FV1 • .. - ., FROM... DIRECTION TO DIRECTION ? CaMOxiiw K S ? wiL•K 1 ? OTHER II TYPE OP ROAD DRV[R VEHICLE ACTIONS r.ct axxat LK;[ iixtcMOr;tawnti xo t onxanR I?II ?ONE WAY Y F'x L]I I ?OOINOSTRNGHTAHEAO .J TL-;-I ] 0TWO WAY 0 D ?OVERTAKINGANDPASJNG 'J ] 01ROAD"Bt[ 0 J 0 MAKING FIGHT TURN ? ' ? ILIOO"" 0 . ? MAKING LEFT MAN ? 6 ? AILEY ? 6 O MAKING M-TURN iW0 WAY: J. _,i I A? '. I n[ASON FOq IUTS![tA BAWER KRYMIID WY6x dllnKTxM IHCI STREET LIOIHTI BANAL ? 6 ?L[FT iLSIN T ?SPEGN ? T 0 OFFIC[RIFLAGUM LAN16 u.A, 6 ?SLOWING ? 1 0 STOPPED FOR TRAFFIC F{, dI ?y0 T ? ? 1 ? OfNER, SPECIFY ? 1 0 WPARATED ? 6 ? OR 8iP0? SON ONAL A 4' F 1 C• 4V ?u, - l \ ) J'1 ?` , ':k, Y t ,.? t ,....41 ( -{y'•'r t .f 1.1 +..? .{4vx ,1 , , Y ? ?p? . ? I ? I f f r , I H I Yl. ' Y f 1 1 p T -. 7 F' .,,tea _Z 2t,22-4-12- STATE OF WAgHINGTON wso °"'? F?AG(E Gh No 41 I? O POLICE TRAFFIC COLMN REPORT EDUCE MINI NUM&R 5 WrE O. E] PRIVATE WAY U N , _ _ TIM; COUNTY CWNIYNO CIfYNO. Y i? 3 OJT' •• tun wlD rw"uI ID$E Eaap gURI / / fJ ?i SQ7? /[O ?UVFI.W • ?N ?E ?IN CIY_ORp wN JI 6 ?O S4FEIORIYGNWAY iCICIS p I URAI Y D Y P V G x RWIEOq t sE { -, -11 s ?w ON of OR i ocJRJ G'a/ ON ?? ..? Z$'.'i0 FBr qz eziw INTER CLING WI N SIREEIO 40A NON NIERSFCIbN ?I //q'?/ ERf"x EO. MITE POSr / j / ?I / OEiWffN StREE16 SlpFfl O Op ?Y F1$?1,' ?",'? I / ?SI.WCE Dqf fE¢NC .CPOSSSip[FTOR NEARfSf MILE EOS w??" MOS IF ACCIDENT RAMP DMG 4AM pAlA: ITT W DE / MILEAGE CODE 5, Cgl15M)N INWEV[D: E IIYI M" N TOfAl raO. NO KIllFO??Np,IN111RED? ? SIIIEG T6 RUN "UNDPEDIR " O INI Cs VEH Clf3 ® ?IROPE4RDYMAGEONIY EUII SICI[N IMIR xClS CAOSSSrv[RO4EOADR O4 ptpERENCE S 5' •,Y OOIfCT SrRU[KINAMEOh OBJFCTSrpUCK /uVDOWNFR'S NMNFJ ? ?'FD ?VENICIE r ?J? Ar a'`/ EST. DAMAGE SpfCW CODINGtaE G '_ JA 5 ?yO?SD lv UNIT NO.1 UNITN0.2 i'{ s Rlwvs "AME: wsl Ngsl ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ?• °y"•?+ MI aE oP VERSNAME: sl NI • ?, - STREET AD E CD ?_ J C!/)J GU -- L? ?. ki: e ? a IRffi ADDRESS ???-YY - R , 4 LATE ZIV CODE PONE NO D SrrE D I H mF" OR? ENK(/ - AI 6 FlS-50/z R OAT dIVNSGbeO 1 ?Nyp v Iv U FNY NO. J ?,(?rAIE ?i1fDAY&R / ?' SS WiT MD.I p"yl A 42S ?' fl OCCWAIbN AMERr ENO FYfS GHt -T E OCCURAf ON ?? L/- hy,, FIRM NAME 8 -N. NO. FYFS IGNI HIGNt ! CitN ,61 0 R ? CHECK ,7 wNlc i AsAv ,µ ?' ChP c?/ ?? s c C/ ?Ci7r?Et- W RmY rohANrNfR. ? CHECK (r7 l - CODES ?+ s .f isl. E vfNIaE ASAN UnxovFf ohANrI°r s gw '?"tlr "4i 2 I n c1oN e Om - CODES RI 51 N e ?nrh rnl o Ass snM ' a ?? .ow ?IDODG({HEV ? 1 ? "btnP ? DI w q d • Np MAKf ) FI (UAgJ ? tom) + ?'w?'A"RE ? •ND'EKE ? S vA A) N YEAR lEf]ov.C ( Ev.f MODfI IDA No A)Ov[/cnl ??;`v.) lI NSf IE IIAII G P E IgAllfR ftAlf Np, Alf I'I • ll I Gt ?tJf} \ I v A 71 +W CIE IDfM^ IIG. KM N0. (/ i fN RF OFN Ih G ?? D UA , 'r R(GSR4fDOWNt R: UST f IhIRSr I Mlpplfl prgNf NO. O /I O 0. Z! ? F, 7J IR5 ? 1?/ ' I I I ' I I ?/!JQR/ S r MI - 13 53p OWN1R G W OWNFR Q/71 I ,,•.f,}'F,' • h :.p? ^i Iwu?li•F 5 ? NAMlsAOO.ESSOINwRANCECO. oR AGlNT L?J ?? E ,? Gt«o.P t1s AT ? eaJ R GC SZ9Tr A y 54 A: }`;+ ARE i erol rn"E.D,.c1 aA4GE ? Nlq.c Nu DAMI,Gea AAN 5 151 DAMAGE wwAV MA4G! O?np - .r. ?', IO ROROri ?RFMNNlD DRWfN ?4 ES1. E eTOp A ?' , J f AWAY IFY- AWAY AWAY fMAINfD = IO ?OITDii S J DIAGRAMOFCOLLISION N[ I AE Ie NDRr BY: Ie I-• -7 -_.?.. - ,, ,sf14Nfussw ND pr)_ aK ROW DESCRIPTIONOFCOLLISION (ISf sUINEMlN AE SNERIE Neefsss4rl,y s'.? tII i+F C3?PA? --- - - c? .' ---- r O.cO Q/sCauCx RD_ /?IGNT..,I?EAe C exid ?? ,? " 4 r r y Tc-'P ?v ?o A sl Y fRu/?c/- I . tarn ev- ) NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I _ p 9 q Y ?? ?` f-_ OCCUPANTS / WITNESSES lust swnrMtMAI sl.er 5 11 "°?; .. NAMt? ao wdlbNN N.vaEN sea Ar.! ruus ",,.vim'" ;•; - ? , ' w ruru4lp ' "Rs d n •RU I ., IM Kr ?AMe Q'Y.l.' ?,.a?.E ?v'"i? ?i.?;,v t;r...l? sCMi, k, }YE •Db113 r Ilnld PIM(ri-YoM?AMe R[],xKI?"N U hl I ?'?, Nwr • Y N r Ynlb oEEKI sNA.w sclneoY "?AMR ??:''?'rri:;Ir ?p.T ? ,? 'j"(? t'' X ? Rot OK AGIrKY ,',KI D'vA D RAKt APPEND DAlIg4lgqT AIIROyID er DAII A; T I ? i A. I 3 ! ?. b 3 ssw' S ATE OF WASHINGTON PAGE f OP / No •: .. J II,, tCX f 4 N?f?ff ppx TY?Y- V" F f 4 y? ? w ^,v J _ B t d, n ? l 5 1150 . y l POLICE TRAFFIC COLLISION REPORT I,ELTRAFFICWAY q?1ICf 11 N1 UMBER PRIVATE WAY '- 1 _, DAI CIXI N F A 151 TIME CO TY . .R _ IUSF grODHODRI r UN OOUNTY NO. CITY NO. '-A Z . E _ / ? URBAN CIY OR TOWN OR HIGXWAY ? RWIF 04 Rf N OODE Miffs po{ IJA L'IG ON??iU?'SSP '. INTER/SfClING H 51REfi ORROAOJ NON NI[RSEC110N I A G 17DIIL BETWEEN NREEi IT RO' 51REEi D15 AN aDR ,CROSS Si4EEt OR NEwRESt MI 5 ACCIDENT PPT,- [ MIE POST RAMP DIAGRAM D T Rn mRFS 3 E MILEAGE ffET W OF CODE A A CIXlI3gNINVIXVFD; Vf IOIAL NO. NO. KIUED lRO_NO.IN1URf0_,_ ? $PIIUGf ? UN H,°Vpatom5 X.RD CII 5Rf R 1. ERENCE , INfFR CLS CROSSSTREETORROAp RS -?-" CP V[HIClES PppPERTYOMIAGFONIY ?RFSUIRD ?VfH CLE / • D OBACT SIRUCX(NAMF O{OBI CTSiRUCK NrDOWNER'S NaMEl ESi.D qGE SPfCIPl CODING USE Is UNITNO.1 ": ., .• ,.. :. -1-0.2 IV N USi I p VEHICLE ? .,, , .. PEDESTRIAN .r?. PEDALCYCLIST.- I IVfR' NAMf. IASi I E fl SIRf PE Y D Rf AODRF35 1 [ ? j ` , Y, IE 21P CODE PHONE NO Gur.? 5133 ?•ay D R IY igiF 111CODE PHONE NO, Wf4' UCENSF IJO StgiE I 9 v kp ,t S M. IT .R V V AIf % AEF BIRTH NL N NG? MD..I D Y B OCCUPATI {IRM HAafF6PlgNf NO. ERS GHI1 -T E OCCUPATION {IRM µNAE6 PHONE IMJ EYfS IGNI NE GHT /CHECK (.? vtH Clfw A Yr[[a ANO1XFR. L +w v Q CHECK (4 VFH EAS aNFMPIOYEFOfAPgIHEP. Y _ CODES ? 7 aA A i sn 5 utawrv a AiO1r •eu is CODES 1? + 3 A Isi+ 5 1%e N e - v ? .E?+ F% I ilmloz ry Mm" ROM p MNM f ? 11 ? 8L ? =2 31 / PRR " 3 01 KM TUR MAKf DO G I ? AM A- ? M ? iE[R. ? H ?,0 ?U R . D I F CHEV.I EEID 1.N 1 StYtEI R.CONV.I D/`? - J E .Y AR ( fV,I .NOVw) ( ROM r H. 4 [N PU SiAIE t H n P C A WlFR 0.Aif S CAR I c V H.CIXO4 tQTFA [?L7LR HATE NO. 15 VEN Ot10EMl{ICAtION NO. 11'I !: " I j! RIGISR L V MI if lOfNf I N 1 l l i l l l l I I I I I I {I [DOWNER: UST g51 MIODIF PHON[N0. ?G'C G.iil' G' .S':9 Wril D I RED I WNFR. USi {IRSi MIDOfE , u '- E Aaooess tJ 1 C-c>7 wrtc'ST S T /tt lrlf} W E WN R P L rrAMl F ADOe[SS d IMU4AN C[CO. D4 wGENi R N n OAMAGI NIU MASPq I ? ?fgMlrv6 DAMwGf A4U ViC'N CNAR E-CJ. CH•NGI Oi OMC rn ld OA ' ?AWAV ? EAW oi0tto? a tSI + NfO ?AWAVN ?"AWNED [SI,D • // f ui? ? IowtD er f DM Y // e NDIUg DIAGRAM OF COLLISION I U [R I RNO4 ssAR 1 I eyA TH I DESCRIPTIONOFCOLLISION (USE3UVKUVP1tAl5HfRFIVECt35Mr1 { HI I y ss .r O Z7ic 7, Uc'[?c r wgs T?ALczc?nicj - I - rtt ` rl A/ !rf` CCJAPCn.? tSlpL Qf -•. 0 .. /iv40• U .. T TJ y ... -• - -. .S'IYO [,r t7.1' /% GCr /N?BD? R `('I!a!J /? - .. ._ •? Ie NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED - + CODES 1 - 2 3 4 S B ' IUSt SUIkfM[NIAC5 OCCUPANTS/WITNESSES PQO ADDnpNU Nu WE1 vsl X "" """ ?" It INN 'Y°h H: _ "• -"' Mfcr H AW: Acl iAiu In E nv A N DnFU AW: "O NA1 R a y. ArA e. Q c$1'a ? L4. R p pp' C ? A Iq A N Ogllf AW NATFA or P ID IR QAMe. QrpKF?m P ?N,R'' ?Iia Ro . ? .. 1 1 A ppe[11 U1 Ree NAIeMa {[Iy 1 IY ?AA4 5 ??om ?NN- ?nailV X Rnlf WiryGprKln t1ANa .> eO IM wINC KtD PA ? 1CbL0 KAKI AeRMO U Ilp"K fl AMROVI eY D AIL Ui/z7 i v .. e '::'•n A 4H.. r. , H1l r.: :, F L "•'? Fk ? p 1 1 3` yf . ?1rP ' ? nf? k: P i 7 K,?r ?n Urv UE (JIN NNAF6N00lSIVEfrO4nOEiWgY EC 65 Rglt OR .iMllf$ ®3 ?W F .'tJ? Hl ON INrt45FCrIrvc Vern: uaEEr rvorvwrt45E<noN wenx MIU:VOSr rS] . //i.2 0.2T GG/7-GFU 'Vea O¢? STRUT A T A C bUI 11 Rf! Rt O StvfEi ] CROSS SrREI Sf4fE ? . OR NEA4E5r MILE 5 ! W ACCIDENT a DI MILEAGE A IIXT lEEr O! OI% CIXUSIONIN VIXVm: leltt: w IOTAI NO 110 Rl1ED?NO.INk14E0 ? SvILUOf ? IbirllN r„Npgp kW 11S OIOSSSivgrOq vOM a' ]] Cf V[NICI[S ?PROV19tt DAAEAOFONIY ?!"1"'. vTDN(f ? ? Oli?15JRUCR INgMFOIOpJER ST4VCR ANDOwNl43 NAMEI FST DAMAOE? $rtCLa CODVVO USf - ... ....... UNIT NO_ 1:. - UNIT N0. 2 ? VEFIIQF. ? PEDESTRIAN 24 s D4NER E: w Ia ? PEDAI.CYCIIST d ? RNE4 NAME: lASf f' ri/J /c-/o?iit N4 S fE AUDRfSS 5 E aODH We SiArf 21P000E vIgNF . D Itt VAR -= % t Sn..•pa? R ' WLRSL CIN Srwrf U A I N 1 RIV U fN.-, A DA MD V MD. p.r ' i R D4At p ION RM NwASEpvfgNE rvO. [rF3 W11 NEIONr E OCCUVwIgN FIRM NAME6vIKINF lq !? . lYES 1(Mr IEKNr / P/ J»" ?/ R ? CHECK (.? WN As qn MUi rfngrvornra'v ? CHECK(.,) VEHKI gSA (M ' .F w ROYFf Of ANOfNF4. CODES ? J ?; ° . ^sL s r.KIRrI e O Mryrot + CODES ? 7 a"'"• . sSrtN D EA<tgN 0 SA ,t Ab RM1 ra[ R 5°FINe eg N,,, ? • E ? ? Vim ? K r..' ? 'OM ° , Kn, pppOE Enfr.) . ,«ppA.,a ?u su Er. ,..e ? ? C%. h"' ? t?:.E.. llKli ? ? Ell r -A) snlE IRDR CIxlv ? ? to ? . .l . r A E I v.l IoA4r.rgvwl l q onv. ? „qA r , ? r dry,• U? E V lK w SIAr AIl[4 MfE NO. StA { H VEN CIXOR ? vFNKI DEMIFKArKN NO. L vfN I - l [GSRPEDOWNlF V3r II45i IDC t I, tE v1gNF NO. O SR wrvfR Wr llg5t I l 4G rN _-• I ADDeevaowNe r W N4 w I N E NAMe E Aooasy Lr INwrffl¢ eo. cw Aum Iw K R ? ARu cNA4cE o .AfACEp inu . J a.aee IlwN0.1.. 4 n f / esr. wn N•e ?Aw?r ?RUwNro ?^Rmn RMwnm es.or .ro. foporto. wqr ? or s wr fo r ?nwvDnr: S - 111 Novr DIAGRAM OF ... D • DESCR IPTION OF COLLISION Matt SU nlMe ru SMer rNeelSLWrI rv vP? trJdS - ? "? ! Tl _ ? ,,,, _.?. _. _ ?. _ r !? . items/i _ ?G rt>»d ?_ oa_. T. kJ Si ub?. p? w-?i!ldiJ.! ririt? er .t/rf IC S J mo " ? _ . ,?_...,? ? .? ? .? . w r Ip ... NAME, ADDRESS 81NJURIE5 OF PERSONS INVOLVED N CODES 1 - Z J 4 S 0 "' IUSESUrnruESnA15aU OCCUPANTS/ WITNESSES r[%MdrpNAI NAMUI _ NWN V U. AOf 1 p ? ' l Arofeu ? b n i?a/?f ,a.?t ?i ','?"' / ,. A uwf pr: AMe I9' ??1"'?" .?.? ??' ?J•Grb/f ?,$• •?i?FP , :+ .W541:5 T % t A? r?/??q ?ru41 s FS 4 DrRaA ?My ?,?.RI ?:.I r ? Ci ?n w ' rvo ? D li / N 'I"?1? .y,t, KI r ?AMp ? ^"' rS OIi"wV x yri.G 71'if's.?LE'fl i J /? .O flr G"ti7(r'o OI-cSapJ,?.. qo D ea^rarr w Dp pwn ?pl /? Sal r n r 5 ` r 1 'CXA mod`// ? ? Cy ?fI TVPME-?•. {r.r T-I?/'?^?T" .' YB?:? .^''+'.:.._ ... rlnE?¢a q "JE v t{ ? Y Ca' tC F, ,AS n UEC, a UTp4?q?. pF z 1"? LL ddttad'r t( k a ;der; . I- ` TRAFFICWAY POLICE TRAFFIC COLLISION REPORT '•...••' I r v ? POIICE COMPWNI NUMBER ' ® PRIVATE WAY .... f OPif, E OlU N 1 rH I. ,, IUSE}p]HOUR) COUNTY " 9,R R wUN1Y NO. [ YNG. FNWA Q) , 13D iSoi 10 YCi ?NRBA" RURAI ?N ?E ?IN CITY OR TOWN NMAEr .Oi 51gLEt OR HIGHWAY Cl5 ROUI[OR SIRE ECII ON // f AVLES 4w- V! jO /?,F s lYCL ON sr, INNR. NGWIIH STREET 940Ap NON INIERSE[IIWI 3 G9.r?o ? ,,, 1 FL (Y ?? E-EN STaffi L WRIT, pIS1ANCE6pR 11 Pf .[gO555IRfF109 NEARfSIMIIF ST ACCIDENI lf5 iFFf N 5 f W MILEAGE OF CODE p PREFI% f0. MLLE POST RAMP DIAGRAM MIA '- COlLI510N NVOLVED. i_ I . AvU1 rv NO. KILLED_NO.INIURED_? SPILSAGf ? R N F E 1 IUNDRIDIHS VNICU OFVFHIClf3 ? ? PROPERTY DAMAGE ONLY ? RfSUti[D IN 04 ROAD R[ifR NCf INfFR, CLT CROSSSTREFi09 Yl?AD . ?- (p RS ?w HI OB)FC1519UCKINPMEOf OB1fCi5 UCK PNp OWNER'S NAMFI p /•l SCDAMAGF ?ciel• viicE , y A AOY c 'rlFktJ 5.??,?cd SPECWICOpING 115E -ACA ??7?. ?. UNIT NO. 1 UNIT 0.4 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST RA s DvNERs NAME: IASr H41 l N panEq E (AST TEif'- l ?? eon ?. S RF IA p4ESS T/ •?oX 5' SIRFEl ADDRESS CI ST iF ZIP COpE .PHONE NO. r ?? f 8 t> D R CITY SIAM IPC D PHONE !a .••? ER'S VC SENO. STATE F% MDA BRtH I V ICEN NO. }Alf f% DATE BRIH ?A v 9 I 0 2 OCCUPATION RM NAMEIPHONE NO S IGHI HGHi E 0CCUPAI10i RM NAME6PHONE NO., frf5 IGHI HIGHT y R ? CHECK IV) -1C-IAN- Y[FOF ANOIHfR. CODES ?* D . n 5 G[n orv a °r rcu ? CHECK IFA) I VEH ClFA5 AN M1PlOr11 OF ANOIHfRAI CODES ? n"Ass x i:in Wl 5 Fxn n e Rc U .cpy 47 2 INA'ITS r ° / FIHI..: ? MR x ME ED] u ? m" ? '.K5, ? N? VfN YfA9 DOpGE C R To ROM R Am e9' ? AM ? Wl ? 81p.. ? x v n ? AT . ( - HEV) EI IDART I 51yLE(2DR.CONV I " 1 ASwFL IDAgf.IV0VA) l 1 •1 V 2 J J / r2° E TO R IICENSEPLA " 5 if IgA1l[9MtE NO. SIATI P. H C veH Caoq L N A A VEH)CI[IpFMiICAi ON NO. NO. O f ( L vfHCIEpNU UIN WNER: IASi NPET M1Dp1 f PHONE NO. m ?. ,t O W 151 N wN[9: 1A51 "Fil MI Dl NO. G Aoo9lss of ovmlR N A owNfq ?I E NAME 4 ADDRESS 9 INSVRANCE CO. CIE AGLNI, p ce , 11 7 DAAULf AII[A D w I w " f /MAGE M[A 1 CHARGE cnACCE nlo u 1 ? ? s lSI WSNG[ A ?RI?H AA 0-N(D ' ?"TV'" ?R[FWNfD Awi,r [SI. 0 t 1 910E ioi: o eo S !l? Gi ®lowfoer ad?l iI AWAY ?IOW[o Aw.r eW S t r r IR - DIAGRAM OF COLLISION' - J y _ S'dl IV I NAl IrxHCATF NOUrH t NIC[-Y) 111 CAN ow . DESCRIPTION OF COLLISION: (USISIwH[ aru sH[[Tn N[[[ssngr ) __ . aftp/ ! Sri?rC ?/. cdaA...Y?n/:c9..?is ?dr• i - ' > r??A? ? .. ??s . ?qqru! dnd ,Yd:?a/1 !1?!blfnd !h _/, s / 7 I / s o , . e r,F.i ydrd re/ ,G/ri^.ea..,ad eoaore e r yep .T/ira./lyd ddGlCkdrdS . So /// 'S Pd i f SS ' T A yd / !'? G rra/ ,?GI a ddC, .._. Y AO 1 /a (F%! ?/IC vdST r ° ?a ? ' f / !v ? ? p ??.? ? • ? ? , . ? T171,/ , A c . i v l /Y/oo l Srv%lii? p' edcmJr,+ {a/ir' e dndd / cF oA Un rNl:B/i r J' /? / d s , I . ? . P ? . . . e d , o r ou a ,. _ ? r ? I? 1 , a t sA Y B a//rJt/ / A NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED +CODES 4 9 4 5 6 N OCCUPANTS/ WITNESSES IUSfOPfMlMAlsHl TOR ApO 1-1 NAM AAV lr SI _ Sf% AO[ 1AIU-S N _ u. w 1 -' R[SIR. [ACT .. ' .. A N EIWIS4 E . fIR DIP HMeY AM e. ?cR'S?II ? •° 1 ?D1 T' ?qu;,V '? A lxwlSt N AIV91 lY ..... a lD lapM ?.e L ? Q 0-4 0'.." ?' ? I'iiHV q N N C, Af I IMIS I NAAAl1" 4 ISTIW1Pp OFFF19't MW l91 IM Y ?-1 ?HAKI w M ?•i?wfi n% LADGL O•AGINCy 1. 1. IS CHIC, AIIOTN R7.' A F IMF& iL. 0 C 'D K I f' ? Y ??' 1 !J y 7 a?? `? ,I `I y 4R•'? ; k F? r. R YI I '4TP r ? 5 h il, L ,+ 1 I /l: A I fit, rt'?y l rf' ? i _ 1 , f 15 J I I ?f J t I? R 1. , I . T t I]If< J yP t?RAx ; D Tll r41 x nH rv C, H CI. y n" MIlf3 •CROSSSIREEIOR NEAREStMI1E POS 5 F W ACCIpENI RAMP OIA DA1A - . ffET Of MILEAGE CODE ': . COLlISbNINVOlvfO: vERIfT . iOtAl NO. NO. %IIIED_ N..IN-fD_ O'R.Gf ?HIIBRUN wMNOatBNiH I %?RD N 1 REE RROADOR RfiFRFNCE as OV[HICI[5 IMfR CIS CROSSS1RfETOR ROAD E Q PROPERTYDAMAGEONLY Q jFS UlTEO ? VEHICLE • OB1fCIl19UC%INMIEOF OBJFCf STRUC% OWNER'S WVAfIj ESf OtM-I SPFCW CODING USf "' J '. .. - d ZZ ? /1 li. C/fF L?/i?• L f ! DRIVER NIT NO. I UNITN,O.2 ?SIVEHICLE ? PEDESTRIAN, Q PEDALCYCLIST ' NAME: 1ASI IP MI DRVER F. N a4 - SIREEIADORE IREET ADDRESS IY SLATE ZIP CODE. PHONE NO. D IIY SIAIE IP _ P EN . DRWEWSLICENSEN ST IF R A E% A IR H I ll FN NO. MO 0•Y ? YR IV TALE E% pAlE0i B19tH MD I OAY. ?YV. V e p OCCUPATION FIRM NAMEBPHONE NO. ESTS WEIGHT HEIGHT E CUPAIION iIRM NAMEB PHONENO. EYES WE GHI HEIGH T R Q CHECK (? NEHICIEA AN PiorEf A ANOI.,A I ? CHECK (v) vlwl IE ASAN UnxoY C T Ron' EFOPANOTIE . CODES? 7 a 4 s TD 5 e a y° CODES T a n , 4 5 u-N O w N URIES " a> -.1FROM ? M9DANpl ? (! ? 8"m o w ? ra». INI R Qµ' u+Cl QPUO6'C! QCbiilR ?v VFH.YEAR MA%EIDDDfF C Qi R CY I . I v E H[V.J Fl10ARi.NOVA) STYIfI2DR:CON11 10 'Y (NEV.1 L(E)ART. VA) y,) R E oR I NEPU N SIAIE9AIlFR MlE NO. SIAIE II vEH.CIX RA N I A VFHIREIIXMIfIGfION NO. C RV HI IE IOfN IFI.AI ?. 1 I L Y PFGISRREDOWNE4: IASI 11951 MIODIE PNONF NO. I lE pOWNER: 1A51 I IIRISi I ' I I I T O MI .A NO , IS ADORESSp OWNER W WN N 11 -11 ADDRESS d INSU9ANCE CO. W AGLNI E 9 R !a WMAGID ARG ,N. I •'• 'IM CHARGE el IN. 4AMAAt ARM .W C A TOP CHARGE s 15'.. GI (T••--11 OF.I . IO?OTTOii L.J 0REMAN[D ?DRIVfN D<rU to, ?4FMAIN[D "ID AWAY fo f s 51 f w D AWAY BY- [O ?DTTOii A ?AWAY BY: $ 11 le DIAGRAM OF COLLISION: iFM r) 1IN- 11NORTH DESCRIPTION OF COLLISION: jm5 ISHEECE BrARROw VVIfevN[ALSHFENP NECessARY) ! _ I I -... t NAME, ADDRESSBINJURIESOFPERSONSINVOLVED + Ius nwnE AaNr F i • OCCUPANTS/WITNESSES CODES i Z . 7 4 S 6 s ME OR T A NAMI ADd IbNR{H1 P Ai TAI INYI: ur N ? s • R(Siv. IXR MrGr' nr rr ADwtss _. _.. " .. ,... _.. HAMr NAfUY or_ RBY QAM e, ?fI11 Q "'I.I QR Q il» p ... ..., ... ... ApyE15 .... - .... NO. N . ..... ....._.. NAME AT WEq Y MOVID IRpM Sf V ?AMB Q"RI Q"{:R. ? »x Q - AOpRFSf - W,tD3WJ of wv11 IrgpH(Ir3 NAW EpANR !W Y. Q Am& Q M-11 Q „u GIT- Q X pADw op AOEHCY• p?Spi }ELE}I ?!R ? /??J ?qWO DA' W I liplt Y D N"}` 4 ??:. 1Kv l?µ yam. A?? T 44 x.:1 ??. Frr#J? _ -. - •I "- ?n f? NW ... J. :.tL?LL <. i.? Nb 1 E _ MSIRi9Aa.Y' d'JJ¢PIJ4W "LTEl4fl IN. ti ? ?1 ? I 'yL d Y-. V ? E °' ?M1h v T`IM1 11N S1Bk, T.R 0.E ZN'Rt2p4i m5R! WM4 E t S ? 'i y? {F to F?1? J J w? I r 1 I N l O + 1 I ? 1 l V S 9 ? S'1 HI E Ow VVA*1wGT0N Oi GE No CR POLICE TRAFFIC COLLISION REPORT l ®TR AY . PoLICE COMPIAININLW1BfR r 1?% AIE i C l ®PRIVATE PRIVATE WAY al . I Y l ?/?/ (-" iw10 11 Wn I I IS I 1 Ii`.l IO (UaHOUF) COUNTY C-TY- CIYNO.. iHWA QURBAN I ON QE QIN CIIr OR10W N NAME{N?O.OFSTpfEt OR HIGHWAY // ICI CLS pO1f1EOR5p X SEpURN •?. MIIfS ?5 QW QO r /? .ON INIFRSECIING WItH: SIREEIOR RD AD NON IN11RUCTION , $/ ? ,. aa ? fur/ Q' tlfIWFFN 519EEf S IANCf O MREf R SiRFFI PPffl% EO MIIF POST ' ?'' ' ? ? ? ????C??D?y??"''?'ti?? r i ?t ?,;?r?y.??., ?`a f te'e`} t 1.,d'i??' ? sii7s,; ??' ?=3.v r .,?i?a?4k'??;d'????SA?iy.?'?y,, ?? ??x ? ?;mi . ?f r !'i 7-1 t 1 S r? ?? Y ,f.Ef V 4 { .>!P a 019$ STATE OF WAS INGTON PAGt 01 7 4 H POLICE TRAFFIC COLL NREPORT ®TRAFFICWAY -cE A-Nummi k ,'R'f S 'I PRIVATE WAY HwA / Sark ?" •? i AR OiCIXI 0 v C l51 rv TIME COUNIr COUNTY NO. CIfY NO. 1 / ? ,rvaT W D+r rv wR ?R I5 AIO nu. In Mt. IUSEabpHOURI /? ? ?.? ) U AN oi3 sr. r?P ? 9? + Q O• pN ?E ?IN OIYOR TOWN NAMFeN0.0 StRFftOR rPGHWAY Kt ClS ADM P RWIE0R 51f Av 1I Y tfs ?Is.OY' ?Gi .v5/eND ONC • ,/l. _ sf a '? INItRSfCNfW VAtH/:,3?IRfE 9ROAD NON INi[RSECIION PnFI% EO. MIlf P05i ??_-???-/ -•y1 }n'S ?• ?, ?'q DEM•FFN Si9fEt d• 5IREFT USIANCfe I ER NCt, CR0555tPfElOR NEARESIMIIf POST / ACCIDENT RAMP DIAGRAM DAtA IE' MRFS N 5 E W n MILEAGE 6. Q f[eI Of o {" K / CMIIISODE N St URIOrOTnl NINV OIXVfD: SFVfR IYI Dn9t" D INIEP CTING SIRE RROAD09 ffiE9FNCE / a] cA WEEIORRWO '?CO NORItUD_NO.INIURfD_ Y?' NSPR E ? 9119 k&e Hm• MI.E/R W UMS f Rf 5 IXM W v ./ aVEHIcU m ? PROPERLY DAMAGE ONLY C] RESUl'I. ? VE"IC,E [4-0 1I•/,J fCr StR% ?NDOWNER'S NAMFI fSI DAMAGE SnCW COOING TAE OnA-TRIY_KINAMEOf ER) UC a 5 UNITNO. 1 UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCUST a yM?p' " T l 5 DRNE9'S NAME: L 51 FIRS MIDDY DRNFRSNAME: V,St FIRS I? lyl R SR[t ADDRE SlufEI ADDRESS rv,. ? 9? ? u D y SIAIE IPC P N NO. { y SfAIE ZIPCODF wfONf NO. WNFR'S IICtNSE NO. Stnlf f% A eI IHyR R NIVEI'S U NY Fq. iAl IEPBIRTH 'rj D D, V 9 -PAIICN FIRM NAMEe PHONE NO. FYFS IGHr IfIGNi E GcCUPA110N FIRM NAMfd PHONE NO. EYES WfIGHI WIGNI R CHECK IV) NwnEA nN fmaY rF anNOtwRM ? CHECK (? M. ctf AS ANMIPIOYFE Of ANO1WRpl ~ ? CODES S 3 a x ° 5 D e CODES ? + 3 n" air 5 Ix D - ro a' IC1gN + xr,R DIU wO.tu, if ?M"' Cn N Rry vRle - 2 l1.91f ? ? uaKe „RRN ? porNE. .. AAtN t ? ue ? ca"... ? ? :°.., .DN ;!Y°`Ef fDRI A.wulAP9t ? c0n. ? ? DP?GONVI "YY4RroM 1 "fV.l MODEI IDAR I NOVA) .) 1 NH.YFM MA[EIHFVI MGDEIIDAN1a+DYA) StYIf IR v 6DODGf{ . CK"-1p E 54. rrMRRT.4 ", ,' .M rl_ 14 W L Ott Ei 5 V K 09 tlbtPlA t SI iF IRAIUR Mif NO. 5IA1 H VfH CIXOR N A ? N . A F ? y?4 y.6.V~ 14- A W L VEwRfD[Nlli RtG15R9[DOWNER: IASi fIRSt MIDDt[? HgNE NO. 0 t IS FRED WNfR: IA51 1 fI.1 MIDOIE ENO. ; A-D Ark NDN 6 W A 3 ID ADDnssof ormeR N NeR 3 f tit ?e S I? ow i ? 3 Z iJO E d. NAMe a n1wwaANa eo. o9 ACrNT ? '?A TF?_ Si ' R wMAU ARU a"5nr'?w ' ? F-A Gt GF lSt. ?AW'? ?R-NED SIVI AWAY erZR{LrcSOrl dCOWAY Dv. DIAGRAM OF COLLISION N IND Cnn ra9tH DESCRIPTIONOFCOLLISION Iln[SUPREMfitlu swnli wcF55ARr1 > ?' QN JEru«E: WAS. - Cotrlc 14oetN.6N_..0-4 A¢.._6zoe4e >e t TV 4 ?AD...._ CLoSS/0 -Lp -4 RI14E- .4er - 13 M/<------- ?_.r. oV P?IOOao _o?s< ar+o enn+c.re_R lest kPS to L.. ?3E _._. SC'P? i L _ Do,,oj, rdnnf . /nOgeY MA CICS..vs».JCce 3 l.., _ J•(f01'. rrop /!r. SroO. S/6r'• IJO D,c??¢.C o,?..._. 3n "f'?a.. pAMS /LeSFidT I ,,2F PERSONS INVOLVED + CODES 1 - 2 3 A 5 6 'n •? NAME, ADDRESS 8 INJURIES wl ut. OCCUPANTS /WITNESSES Misr SfrrnlMtwu swn wl Ma. nsrv efcr . FoR Ax9rlaNU rwuslslz Act rATUS a PMJh NAMIIq i RI NAIUR AMe ?'i ?'R" ?r?H ?{•i1,V + -i • . A? Ss „uln! a .. R Mct ?1D IROM ? AMe. [(Fw%I ? W, f ? W, ? I: w ? , . N E 0 N ,.I :wtr e+A°Iwfa .I A[Rr:33 NAIRRS Ictw er ?AMe ? ?o.n. ?G'Y ?n:,M wvES'ASAIK.41 ,195 MW eenh[ enUGIP NHIRy ICI DISIAtCWD P(Ay;T ARRINP DAtI4 PIKR1 APPPONDnY DAII I. 7t, VP' (. M Ih [ 1 ? T R,D paN?o ?R 1 rt"f DER Cto p31 ,I uE1n 45 °, So 0 + r E ?t 1 ? ,I r y r ??;P,py7?E? Z kl ' STATE OF WA INGTOiV t P GF OF NO. POLICE TRAFFIC COLN REPORT L•'?1 TRAFFICWAY WIICE .AINrNUmlfx- out Ecaus N PRIVATE WAY fev XDY (tun wC ll H N.' LI TI/AF COUNfY 'IG I J? I T Ip COUNTY NO. CIM HO. ?ry 5 JS QO IU3E } N;0U9) I"wA !^ ?, J O O.$ C, OFFEdiSoy I? ?'?/??? ?uge,Fa ?1iT i uN OF 01N CITY OR TOWN fANO. Oi SIRFf109 HIGHWAY iCIC ,f IRN ROUIFOq i AY[ES,?s 0- pfS? gNw ONC '2 3 I I[RSECTING SV IM SIRfEf Ux Rp NDNI FRSKI ON _ 22 f, f j PRffIR E MILE PO$ C BFfWffN On( SIRIT 6 SUN, -q All UIR Ei f .CROSS SIxfE OR NEMFS MIE PO "q!. k MII[S ,q N $ F W ACCIDENT P p1AGRAM SSG i5 j 3 > f[EI Of T? C j MILEAGE TO CODE * ?y COIDSgNINVIXVfO. SfvEXIIT.?-N _? ylllAGE ?HI bRpy %'Gp Cg SrR OR ORF6f .IH G( NO. IuO XlllEp OINAI9Fp Aut13 " IHIER CL$ OSS 51NFRpx PpAO 0 PgOR91YDAA1AGE0NlY KNCf 1l dy'K,F L` 'jtE,fy,M CFVFNICIE$ ® ?pF4ulTED ?vfO1Cl"E ""rv0.o 5tRUC[INAMEOf pB1ECT STRUCK fWDOWNE45 HOMFl ? S '' ESI pAMAGf SPKWE000ING ? NawF s -1? UNIT NO.I U<Je1TN0.2 s p9News NAme: f, si VEHICLE ? 21 ?PEDAIk CYCUST B RJt_ fw r mI a o I sNAME: sT ---.:'.N tl ? y, ^,`,`3„5 vRElrAOORt '£ Na?? ? ? u f Apoxu -- _ a .? ?t.1H?ES Y IT STAfE EIPCODE PHONf NO D Y STATE EIP ((<„•?( Pa 1i .t Ac'rnf I-ly 6 Sr R l fi # ym I XNF9'S LICENSE NO • StATF A E B TH ( Iy F1D ?r7 '? ? "t C 5 AI 5 % DAit 19 H -RP t tc-/r_ v Mp D,Y I... OCCUPATION hIWANAME aPHONE NO. ETfS GHT IE GHi E EKCUPATION FIRM NAMFdPWNF NO. I k CZ MA1..L C .7 1J.L R EYE$ AEIGHI (EIGHT _ 7[?.•y' 0 CHECK (.? ?•2ds+t?; WHRYf AS ?N FMPIOVFFA ANOrHE9. l 0 CHICK(., vEHICiEASaN fMR()YEF Ohof OTHFi ' X NODES?* 7 n a "T 5 ".1- 6 Z2;U CODES 1. * 7 awa ia:" on v rcu a is 1 5 Ix A y WIF, Cn ^ F u as Hwo -.1 A .l ? u ^.! ? a:9. ? n Ka?;RRDM 0-- -Ell 0.99 o Pp KH ? :. KH YFAR Rf IDODGm-EI(DART NOVA( STTtE (IDX.C V.1 s< ??yy qq 7A 1 {HtV.I MOpFI IDANTNOVA) Y IR V.) p^• ?'ti? ',Sf I/.?Y pR h'NSEPGIf / C"33-oHg N HATE NO 51AIf H vfn.C 04 .. VFHICI?fNTIfIU1gN NO. 06 STN C N N! A ?7p - L Yln Cl IDENNfICAn ?y '3 C c- ea E: 1 ? i i I T„I V gfGnrFPEO 1WNE9: EAST hlg5f MIDDY tmpNE NO. R fp WNEq. GSI hlg5r MIppF c 5 P ' e^ I ADU9F35 CV OAMlR O C W A ! q . N OWNER N tm'; s `?" NAM! aAppRF53 P INwRANC[ CO. OR AGENr E ?. R I AH A N ,E OAMAG? KG' w wv I A I • rT^ Ero. , f>o; CHAR wi,." cNnxcc w"br°w gAMACe,D G u ^' y r ?elAWNfn p N!N ? fMAI ISr'pAMAG EIOf q fPf AWAY Nfp S IO:OIr:i?A 3 { IV ..:CI S AWAY B ? toWID BY, U 1 DIAGRAM OF COLLISION 1 ! A! IND{aTe NOgrn A R t I 4 I ''--• ,$He[r fNECEi3Apr1, Br ARROW DESCRIPTIONOF COLLISION: IIISFSUPPI[ EHIAL SHfItif NtClSSA9Y) A $y A ,,, 1 ? N f r ! r ? ^" ?H. Et;R 40 S ? ? .^? ?. A F -J ? - ... -. .. ... Af lL?!•?C:?J NG TiY? R A' a- . T?^. G . ?/{{? N.9 Y ,`, ^' vNfp?tx,Te s,E"J; oo; NF?R..TN.G ?ti2q.,U_..? D, l., t tT. I3s G/itY ct},sinra TN.t' J.a•?J)--.- _ _ 17r A FR?oQT To AL+c+?A '? O IC afl o,N ?' ?R ?-- wi'Tt T 7Ti? TC' CvAA . 7Ni ly . C f S F!] _ 5B ? lTV />,i0 A p ?EGL }?e3 tv 7Yt..' fS i a:C _./ OP?62i+ a7Z $ !?i Kts . SJ.;;d TTY 1?TahJAN ? w. ,) ;. 9 ,.? E I ApFtnx '20??5 ? OF ?"'lav?E'/hEC ?,?-v? t' r DDRESS 8 INJU RIES OF PERSONINVOLVED DES S /WINESES ?M?AN i ? r CI ,hrr -, RISS q R d V ?y 1?;n I' AlYfaf ?{ VISIXy D , IURI01 w1t SCHNIIr• ?aMA ? :"I I ^ :) \ ?t ,N p KI.SMWIBa H[ X O ?? pylGf (le y?ffaC1 +.lo fNI Sc o s ic, SM D f Pa KE vep nA lc Iroer oi" C f0» w ? PPa Dnr AO"t DAT! ' ? ,r?, , ? ' E 13 /3 /SQO a< 1 I`- I ,nr„ Q1 . 1 ?, pryry lrsl 9s ,? r t 1 y TtA,?1. A P ? I ° ,.l Y > 3 ie ' I F ; I ) ( ? 3rra j?. (1hs '9 ?z ??55 G3bE ??4, r w ce" '' s?J POLICE TRAFFIC COLN REPORTTRAFFICWAY PIXKE Nrrvumx4 PRIVATE WAY E Oi COIII N AY III N ME .. • O Nn .w s nI ' . IUSf H OU4) I COUNTY 1 _ ? SON COUNTY Eq. /ln CITY NO. loO/S? FHW A ?uFeA N ?F IN CIYORIOW NAMEarvo, O<Sn[Et OR HIGHWAY D ? -!l ON4]W C3 OF ?, ctk q)41. w2 ON - "' INI[45ECT NG VAT SrR[R OR?CUp Ndb NYIfFIKTKXY / SCOT/ -- FCt - t(04 F .3 ?O/rf0 Sf ION ,. PREFIK f0. MIIF PST??,.?/ ` OF r' ) BE W FN ytgfFT a STREET .1 (V DISIANC IR I f RE ,C905551RfN 4NfA9f51MILF PoS / R P A AN pEIA F AC MILEAG MttFS N 5 W fFAGE ? p FV[r OF NODE COIISIONINVOI Ep SEVER TY: ?1 %.F IT NO TUIIFD_NOINFU4(D? ? SPDlWGf ? 4r RUN 10TA1N0 W I INTFR CIS CROySSiRFEIORROAD OVER R[S PROPERTY OAMAGF ONLY ?qF u"T. ?VEaCE U w}.? ???'gQ Z OB,fCl S1RUCK INAM(OF OSJFR SigUCK ANOOWNF4S NMAE) fS .DAMAGE SPfCW COgNG IRf is s UNIT NO. T - UNITN0.2 ?Sr VEHICLE ? PEDESTRIANr rv ? PEDALCYCLIST DRIVt4 Nave uur IRS ml a C4Nf4sAASf: IA -?--?? R' - 514 f ADOgfSf REET ADDRESS GIY .IAN FIPCODE hpNF NO. D I IAIE awOs6v 5 a93 R NEkS C[ Al SI [x BIRH D DA ( F rv IKfNSE NO. Alt D" MRIN oNe m 0 1 I, M0. I i y OCCUPATION {RM NAMfa PHONE NO. FTES IGHr IE I E m NPMf a PHONE NO z Dn1 E r?1 5f R . EYES IC+IfI K:H 7777 ? CHECK(. (H GF ASwN eAwo F ANOIHfR'u p CHECK (.? HICtE AS AN WROWf Of wN ODES ?- p c s NIaKH a H?rPCrcK Y prHF4. CODES ? * 7 a ss` a iinM"' 5 ExcroH R ` n .( N E? INfErvIi s a ,q , ? AUDI 1 ? ? Mm• ®? << ? rDr . FH ;°?sI DM ? M A„ I ? M. ? ? K ? lma; V .YU4 [E (DODGE{NEV.) FI IDNI•MJVAf STYIf IROR CONVI Io _ J f U E v H ( HEV.) MODEI, VA) ww T m v CgOR G PlA NO. 0' z 7 VNUCI(.1 NIFIO T sigrf If, I4AIlE90.ATE NO. S IATF H vFH.COIOR c A I A S IONNO. I ;q .t. RtG15RF DOW F4. IASi IIRSr AN-Ut PHONE NO L YtN GEIDFNIIFIUiI NN . I I I I I i l l ISI C -II C A ? . O W IA$I {IRSi I I: , ID ADDRESS pf ONrvE 4` ?. " 01D If N E A NfR -II-OUNT. Nw4ANC[co. o4AGwr , J .R N u AN ?. AM.upuEU ' _ '? n w•s.c CHMGl ,. CN/,9G[ ?lo g Sp M[A, Sl 4rOrtOii S F D - ?AWAY (AWNIO 0URIWN 114(MNNM AWAY ce fsI.OAAMG rTM _ S Oi O ' S I &N-O Y: L SCa {C AWAY LT ? lOVRO wr eY: 5 I I rO I DIAGRAM OF COLL ISION ,- 1411 t - -r NIAT cure rvoRr t n DESCRIPTIONOF COLLISION (us[SwuMe ru Sl<er PN(OfSSAEr) -------- 2 1 r _y-, I.. .l._E I ;'D: L 1 . ?L)f},r [JRi,_ rZtrcrJ::??]], /1JC_a..?GOGtou .a?_._ N ._I_ ? ' I "?• /lp/n/eo .SXId?J?iJ. i?hL?cM.....fs2s>_. 6,J (} 7? y v .' I fcT (1rsJ_OP-..C L-J?>I( __ ' r ;. I I f I I f ? ,rtYA f /?.. wA/rr O t I I I ' j _. ? Aac t t b 1 ... F .. vc /.t/lrs ??I/Gt(•lil6, elf W,r a s-,arcs 7NAY Sv?Jfn-IA d i _ fx. LIB:_.OR?v IR -r I..I I r ? .-? NAME, ADDRESS B INJURIES OF PERSONS INVOLVED i CODES 1 - 2 3 5 e OCCUPANTS /WITNESSES 'F--AODI ',I.NfAI Da IONAl NA w51 S/A ACT IAl ': nsa. ena mc;; NAVn IGNREtI A ?? G 1 rrvo 3f5i0L ADOrISS 1 L' ? 1 AIry4Fa INr rY ?A Me. ?WI ? ,m 0cir V.. ADOrrss .._ .. AM( NAluo a ." _.... _... 9 MnvFO1 NOUe1 DE»fs F?9 TMRp S?lnr rY ?AMS ?il ?Ctrlr?H ?I° wvI SIK.ATAq AWl a9oGea AGnKY wlp KI DISIAICfED WlKE Ar91V1p oAnarif0 9 1 APrTWHDe' oAn n f X - .C..rCJ • 1 r _ ' ?, nlds. ?iAB rhs /FJV Y x I F wI r r? I ?r?v w?h ..`:.!A ?i H 1 ,v4 is r?s$ a J i 5 ? • [EI Of R CODE r11 N ED 1 N f1 UAE OF O0JtR 5tRUCK MDOWNfRS NgMf) f51.DAMAGE SRF<IN CODNIG USF •L s RWf9s NAME: Dut UNIT NO. IFI Sr O M UNIT N0.2 ?VEHICLE ?PEDESTRIAN ?PEDALCYCLIST DRWFN'3 NAME: Ra ;?: 43r flq , : r •o 1 S1RI?q/R?© ?//? ?? 39ffiADDRE53 ? ..Y' } '? ? Cif? Sr if ZIR CO f D ?F}J ? D V ONF NO I y StAIf R N Yo?f 1 v E ,A 9Q 6 ? R Y•' a 368 DRrvn SU<fN5EN0. • Son E% •3 Y 9 fi DAFE OF BRH Z ?j, '•h s r o ¢ ( WA. F ( RVR UCEN NO All % DA BRM' D. D,r i i 4 I R A t ,- A R OCCU.A ON f6irgNE NO. i .1 EYES GHI GHT E OCCUFgUON F9M NM1E6 rHONE NO. Erf3 IG t F g ,?;. {? ?` . ?CHECK (,? gNOrHfR:q? FHIC FaT PN fMA CODES ?* a '+?, S r H rEIGH R ?CHECK (r7 vFH Ctf qs AN FMIKOrlf oFgnomFeA' c CODES ? 3 L 7',j;' y I ?„ r Sea D s,r n ro ,t ly ,Iy g` 0- p °Vt' ?,&q. ? MN W_ p g N I p ? Kf p S DR p ??KU ? ": G 44 M EIDODGE FV I MODtI Dgg 14v , S P y ? rNOVgI I /y9 FoacY/ ion // t E"ll Ii DRC ) 4 MM ) NEV.) MOMIIDARI-NOVq) ? r.?M { ?., ,: 5 CEN r41EN SrAIE iRNUR MJE NO /S4rF H -.1- N AI 23nDE.Laq P3'S?B? CL??4, I I ,. .H4a:t Y,KA WH CIE IMMIfICARION rq Ec srtRfuowNfR• A c »CIE,DENIa GAE NN y? : ,JS 'r_Se .Hrp Q? QbOye I?Ri7 e .. !`+ ? ADDgfssor aWNte W A ? WN N f9 NAME RADDVf53 CF INSV9ANCf LOCO. OR AGenr E R Y n wMJwF AREA Ra,: o C4- 0 " a IwcinHN cHARee crugel Y s"c",ruNO,,,, iAMAC ?ARrw esI E 5 oAw,ve IIqql fN o eIVFN uqE Rror 0 TIOw ^ p OWfG3? IAUINlD ?AWAV ?IfAWN10 tS r __.__. __ y RDrror Io S r. 0. ? r r ?:w'A` B.,.".Y. El "A ° ' ? - r l 11, er: f a .IA AM OF COIDSION, I D AY uEDlcAre NORTH DESCRIPTION OF COlLI510N: elneswvlfMEN l3NFHU NECfssw _ NtR53ARY) .. B .. OSlp? Cr OF1 / m I ....? ? . .. Th _a Ckkv?, Vehlc,le 4y•f!?_ e 4 ?+ ._.:_ C?DV Ft s /e/e on W? •Dh 5 Ih is -0 ? .o ? 9 Gacrte tiQ/rP N c2 X, aN r ht d1c NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED + CODES 1 Z 3 4 6 OCCUPANTS WITNESSES IouswruMervr,usrnu - -------------- AMT, Id ACpIgNµ NAMtfI SlI AG! rA1U IN NN Y•r , RlSle. I1tC1 MrtY' -5 '? , EI53 N Arwld ?N FrRer. OAMR pR1'O» .?N 0 Cr2LH. . Y •VhHD nOM O n'4Y Fµ1F55 y.rpRtor NF .? pAMe pro;crp»Im. ?Ny rio - ! .Tura. a•rwrd - f alvq OIIK1.3rNW aY•NK BAD(:I GY .,:IN[r ?NAMa3 NRRV OAMR pK:'"" 0 M.. Oii.T OI'i D ov.°ur ?tul>I crab .alct AUIND Den GrnroRr ure°stoer Dart nr1 li iC rN.a„ !? C>yU I'NS Lll.wS z- ??/P71 , I x 4 " $L ? N h ?P S t' a L ?R • M1 POLICE TRAFFIC COLMON REPORT 14 TRAFFICWAY PoucEV 4 nAINrNwnB1R / E] PRIVATE WAY D 8 wf CIXU N,- pAYOF COIUS ON LIME COUNTY IRI1 h f xTl IUSE LNOp OUR/ COUNTY NO CITY NO. '-A ?UReAN ?N OE ?M CITYON TOWN f6N0.aSI IEETORHGHNAY? MITES drlE7'" ? of CX ON ?dQ ')???e FR iCt US OMO RWIf OR SIR ` 65i'00 SE ION INIfRSlCtING Vn ir51RI OR ROAD NON NIfRS[CUON I PREFIX EQ. MRF POST / D ll ?ti?gEII? STREET 6 SIREEr p 51ANtk d DIN MIfS N PE SRErvEf CA055519Ff1U9 NFMf51M lF PO ACCIDENI CODE MILEAGE FEET Of r/ R Q? RAMP pAGRAM pAIA R R CIXNSN)N INVIXV[D: NO.KLLLO-NO INJURED_ ? SPIUGF ??1 YjRUN TOtAI NO O<VFHICILi PROPfR1Y DAMAGE ONLY ?VE11 E0 UvFaRF M wNOMGI" S - /I (? N NTER X?ND CLS IN RS SRC RIIOM1DOR RD RCNCE CROSSStRF?E/T? RRtOtAD ..f?/?/ N I S o- O /S OBrtCI STRUCK IN-101 OFUECr 11RU 1-*IWNER'S NAME) 1511ANAGE S -UNIT NO. I UNITNO.2 ? VEHICLE [I PEDESTRIAN ? PEDALCYCLIST S 2 DRIVER' NAMF: USSt FIRST MIDDI DFlRER'$N-E: - FIN 1 NOW (( - 11 ,, SIR[EtAWR 51 EEr P S5 / UII SIAIE LIP CODE PHONE NO. D yigiE C H 6 s, a73 R 3,3"- P Rlvke'SROINSFrv rA fX AE B, H MD DAY r. I vFR' UCk SE NO. SATE EA OA EO I MD Al Ill W F _5 1 „ a? -leleAl w?l M ; . S IF CUPAIRN HRMNAME-NEN EYES WFGHr HEIGHT E OCCUPATION ' IR NMSEA PHONE NO. EYES IGN i HFgHi ?o o? R -- --- u O CHECK(.' ) 'MfHnFA; qv FM%OY FOIgNOMfvPf ?CHECK IA VFHQL AS AN-OYff OPANOtHfRpk .? y+ CODES ?'H 3 uN N i in 5 NKtIDV 6 yp1Olr ` CODES 1. * D 4 5 III-" e wf IM1 '? j5 " ' Nw RrR t " OM - a r? a - ? yy + ? A 1 11 - alwa. ? c s11ER ? ? Z" o;?N Kn rfM II- ? ? A N. N I Pick ? n".. ? K? ,? ? ow- R . [{nEV.) ro /CGflr? - NADfLI1A11NOVAI SIrtE I:DR: COYVI Oy E YA 1 {n v.) AY)DH IDM NovA) ) ? ?? 17 l OR ICE suit IRAIURnAIf ND. SIAIf H VEIICQ SA N 1Q se 3 Gt/? ? 6 2 f} . --- !- ° VfHKICI MIPKAIWN NO. L VEH CIEDtN1If,Al101 d 3 S3z's I 6y3Sil;G;l17/IS?,?; I ! i' RWbRREDOWNER uhf IIRSf MI IXF PHONF NO. - IL1C.?-?A ?. 507 ?Uk, f ISif fDOWNfN 1A51 {INSI MI(KK PHONE, I d 112 ApDRE55aowwER _ OWNER Iz rvAMeanppow arwweARKLCO. oR ACENr R ?- 31 t3 OA' C] ?R1MNN[D 1 .0ANIAGAWAY ID iSnoL rOWlDe ?A er: S 0 N DIAGRAM Cl COLLISION I mN.u pu NoRIH DESCRIPTION OF COLLISION: WSURK- -5.1111 ECIi{A Y r .3,911 ttCLSS.SRYI RON '; .? S IJe'N +?r 2 I FQI?CC? To STbf' i ' ? R ' ;- . 5 _ .?_ r a.+nl , I+?17'` 7?c! F?ffC-A f' %6- /-v PI O ? f ? . _. .. . ?.... r . i I//!7 . _... _.. 5> / .iivT?--iutc?xKsc?cTio?rJ---- ------ - R - ---------- sro .e NAME, JURIESOF PERSONS I NT E NVOLVED CODES 1 - 9 4 5 6 (use sprnlWmgSHL OCCUPA .S TNE 1014 ALwIIKrBy NAAV Cr a __... -.... -. _._ sill, Aw rArus INVIn A 1-2,11 H R c. 1SIR, excT NfN N AMI I ?AM N,eY e O '1 ' O I IF .P.E q N Iµ AMB. ?M • NiY ? IiD ND N n- H, 0 F N OR1 IKIRISS N ATUREOI NR lS Y.1-ITV ?AMe clc 1 c4ti f'? fJ \1'T ?ii rev MI31 UIKIRS {RANK ApGI OY yAiKr W CI DSPA,CHD r?.' fS0 ?N,Y ?bSHn nM1KI PISM EKO pAllq Rlroer APIYOVTDRY C? ?d MII .? sRtlti...: _' ?_ca... ... ?y r.. .,.. ?. _ . ,r .. .. .'r-...? '•, .I, ??.,? .I " f ..1 M1cF , {1 t ?2 .C /UYMnStLiti^> /O?,Ilrso: .MLLESrN a© 6%.MiOWNr s.,twu?..... 21' .IN.M, 'AWTY.C#A IG TYY iv'tt ADM C{.9? Pi1EFli t gVBM ETpOOE 1, SECi?ON ? ' ? ? aPP?` ?FFEXISON 1"LT°1 1twNS 9 : Rita., po w, EnD , s 3DD: ?2 °k ...16i.uii.WENAMEOFSIPEET: OftMIGrM'AYS?• ..u+C r'RTS.FRSE?)[etowlTH::SfPEELOR.n0A0.}jy.,yJ, ' -. ti? mm '-n"5 :. ! . ' ? EO FJIE ) IEEFQ`(y VZf,.......... te?' Y ' Q ??p.rie efe CAI/E ' . ' " - , 7 s. DNNTERSECTgNiOCA NOFCOW N .r-gyp '•: 1 ` t MM . nj DLAGPAM MT V fiETwEEN ? S ?"? STPEET AHD " 5 ?' eTREET - M ? IWr .. ©© [ OA°VSwtA iOFI, vxq tia M M ».•WpD[ _ pq,? ;v1+. NIOr1R .j4P0-0?H1tBw/a^?`tVe{ii??Yi?( 110W ". t ? ? fF , rrPxaV»: I[n ©® a . - - '(O? ?G-uAr.. c i' IJBA l U?sAY.NM.vfpa?WrK I`'vo?Cl! -OWKtFb4nY[ OpMAI RI / (fl ` ( ? UF, ?rL { wvel i'iea ?..: ? M. ONV ?cawlw -OwT T? / .f F mv.,..nn.•nvr ?''J .. OWECTSFPIICM rYl»Iw VGa6TbR^wR -".??-?7••OWPEAOFOeJE0i9NM1EIN OADOPESY ,••1DCATION. , 'pF'^ [ MM[p 10 0 . 6> FEET 1p ._?} ' ' ' Irv`tg''`-diiar?`?i "°"[ OriIVEPSUBLYY~Wb?vrze•n:atdFW4LluME.mraii:rrw.7...61'.MOOI£Gt "wrrc wv0.Wp J'?r?7 ' ?: • • a r.. ?R ?r OtiVEPSIA:r NTPEETAO ES3VAiypy,trZvw`'UM.1''3113Y6psi?,nOUfEl"ANOBO%E " MMBMMtvq STPEESFOOf1E5S:,,;,:f8•v?'j,•,ty? T"?=i"•':?, ly.•+RCYZtJ IEN4ANOD0%NA.,• T.In.= ?.,. box 70,5 :?. ., .. oir..,•sxac4ucr'i>15r'STATE.V.' .•+•v».. SORE: Dn{1nI1S000IIR?, SFAMAR p?A GCf.?tiui:1.9,:u:Er+..sn.S7A7E'?Ll?y{:.lfi?.cODE'; LFWEpSO4LV?1!?pML'di poRr iocA-?v? WR 968 tai ??1R P[?«TIpM URIVEPSL Morn •-...r..trtr `. SE7L ATEDE ••r :/'OF,?. DMVEA9L1 MStIUMeER --° STATE. :SEX: :R OAiE0Fa1f4H AG :': 1 7 VEN[S MN MAPEId1EV. MD D B YA-0MTEry"Y 00DYORMERDFLLWX : M O t :1 , ., YFMAEYf1S MAPEIONEVA0DGa. MODEI:WOVMDNITluGP BODYSTFlS 12 DKWL Ts ,1 } y r , ? ? crrL=b. -UP=,. •. Lf.ENSERIATeNG{? ATEQSYF' MTErq.;.v. IsaiCSTRTE:i![fe -• TjWLEAPMTENO;yAU ATE.'.S< ,......, veNIaEIDEr+T?FleAmnl+v+cmar.?12•OOfLaWSlsvfasF. - ,Tpe:z .. Pa+FI[E ...gam4oDESSarrtwEmisa PEGSTEREDOMMF/YNN.r:F4N?F'FN9L?E.?I. tONYEEUSENDT[?!'iedl >E. -E(A m E ?Cl:BT'?- ••••". t _,.,, rrQi?.Wd? : Y UwNEPe?DOPE -' -- ' ceoaslrfEo-XTe [._?t-. AGOFBB4 •?°L.: (S.. . e+., [TiCN'i 1$0 ? S . QO 0 liJf , >o. it r[M ?••. WM ' I.wrA.ofvExKlERWAOEn' -eaIIMA? tmF... ORJK]11):tE-.:._ 4riRVRk•? 4 ,t y..wASrNEReAUraPaaPEUAnuly uawlPANCe' ?,YE3 -- Q NO LIABILITY INSURANCE INFORMATION•VEHICLE NQ,1 COVERAOENEFFECr FORrIAlACdOFNTONYOWGII NAME ANOAOORESSORMABIMTY MSUIWICEEpMOINO<DEflr?ifeLTAye,E?+ri4' - • • 8G'?iT•Mfe06E49ERXlCIItlpfPC04iMV- .r,r.[.ppYla _. alr ., R •i7:., :r I ,, t .. IA4MAANDADOV.490F4AEY]PIMSESWrCB '•e•ie .y, .v$ i?ilWigT ,}.NA vow=_MMOIFIDe. rte. `?TL1' AL c 'P fFi a W N 9830 _ .vim -r soM?.Ere'onePa:'°?°4`.fws'?iu.L Iv . NAME m aa??? f]r? NJ MPAI? NAAAE , . _ ,.:. ADlV1e93 .yyS.:. T,.I'RC IUWxtLTk ADDRESS 'c.. M wATL`tSj71'M111r1EII4•=T_, ,,,E;•An? WE,?pij ARRt1ESA^'.JJ'-: E9V•Y.?.SLnM90fWRWE6 ?w.i:Lr ENQTONERIATAfRC4 n51y 'h40i.. . »anp[,.aAa .1P? .moau? wuED ,? .IS[Wp : r.DIP 'PECONnA•I ;.p A]MNDER. McEMne. PULED I[ciael 1A?1010 rlmMAU.n pnpurLM ` In. ? i v .a erc1 .":? o[E "o aR.WErcI OtMEP'wP1tE-IN ? "-S?-,iB .' 7? t OTNEP WAITE•IN"....' ? ? .'•S? s? 70 - SNOW AgRnI er ARRDWMdRCLE - TSB::DEOISVDEe80WWINTHMPBIFRI_IliE13i T6ei318 '71{ ' :`1'i?'ar-'w Ace r'"Ni anu»e r., eaMeu» [are.wwr";n O ... , ! ?- ,...:r.. w °l?'2 ?Af1S? ?. -"i rr> 2: cL n q 7 L SY"f h . ro. '? v ?i ?D .? ? .•.a fJn t - I -11 ^,'t33i {t. 77777 VEHICLES POSITIONS BEFORE COLLISION - bDraw[! •vE»cu we F wpwu -ESMAMBV w Maur lr4P.n MD.ur r.,wED vo.cu«w•p ?. •:[»P:le N ! [ W ON STREET IeaIWAY 11A1al OR NO aV01t1 vt! ?»!O1_ E»'0E? vO »D DMTII`Mt ?/eOUp[ Y IK1!'•y,[Q? ??TT "wr•?}!'?i??v1 S"N:S )J?.IJi. ,.?.?1-F:Y .. ?Cm 101WNAS •059-00 Or? J ? ? ? ? D 4.P.. 1" . ' ^ ... ?.Q a<o!a.C ....< ..a•N?vP,..u.Wv,?N.• •a•`* ° w,.'?:+w`+ OIRECiIONr:Tnt:^:DIRECTION'r ., N.otstwANWAS. 10 9 WALK ]?WA-AY 3 0 s11OJWER '4C1=No1P s?'c:p"?. i e OnlEn » 1AE11C 'f '. Po+oxwP..cEiLLw;, fy?ruAt»eTtSyy 'Va!,[44!?•S$lPJCEZ Eolf!.. i1fitS4!IAi.F.IY:t O?BRAOy.:Y.2•.4a..A3All olaycnivS?rtS.14B4NP_51ti.ir 4th <.w.wl 1 .wl ?i w..al. K vu.cu IDreuaiaAAMWI rYU cv ? 1 D oo-o aT,Amo r ANEAo 1 [3 a»wnf } 0 1 ° oN"L! r' 0 -i ? G E war ® k1 1 ?o^v 7 ? .- r, 2 ? DAVM .? 2 $a stop saN ?: & 1, 2 two war ? ] ? OVF.RTAPYAp ANDFAS&M }4 !!?`` 2 ? 1•'tT :. ] ? SP,1w.r10 :. i ? Pu. ? ] : ? tw rvaN.. ?- ] ? ?AOR.vnLC 1:1 a -0 MAwwOlwra TunN x'1^ :' ? ] ? 3NOW A ? Km E L[YR! ON lT a?4 • IEAYMgPFD Y , ?I A` NfEPCr1AN0E 4MEq LETT1MN,T t l 4, St O ? 4 D; ? POOPMA4R1 ? ? • D n ` ° ? o, rYT " ' D L[oMMro e E ALLEY OME11n - S ? s' ? nAO.A]AiAllEn ?, S:? 0, 6 ? MMY1f1 LLTlEW ^` y,' 1. t!t' ?!?T4a ,. oAA +4 .,. P e TWO Ar s Iht 1 r ° ? sTWET MONf4 ? ? ..S ? M 31CNAl1;?A ? ? LL T'URr ? S ? 1LGA?q r,.y L•C fll i NwA.s TpLeu ?iciv"`?` ?6N?'O:r "'p ? r.Danccn nAO4ArN 'lk r ?fr.? Srofa Fon tRAFro ? !:. ? oNE1l sllaT ? ? aEFMAKO A ? r e ? xoPP[o At EIONN,?.{ ,' ?ar 2 .a;,{` OY?•?•O UX S+ j) •y aRstoRDON .CN v dy- , r r f! / r Y Q+,]°Qomoeo: ?as (?o ?oMnoAOwav? 1t a (1t,j' S AA » Q* SY?? Ir .°• ?'•o ?DVt pIWjlrlcJt r, Ya ?1] WI,d. ro ? D:lo ?TPAln. UNE'1M14' Y.? K}, Y] MtKSSM 601. ?rl.Y?IhJ.I?W w.]`t a1,YJeliiA+?tY :C ?'1r4.??YS D,t ITC ?. PMMEDM fIG1( ' 4« EN1LREq ''. • .-... '•.. f Mf1101Nt1 Alt .} ... - ? 15 ? ucNra r - ', ?, w ?' j"TPf ±rr Erq :.? I ?T? t ???,• 'r. ::T?'.'?'s r ?' ?`+.,?."r?1,J"Y" ?.-Mt? ' Al .RU,?u. .l'r ;F<2 ?R d+ngM -'?1T9 ?( i , . W O STATE OF WA INGTOIV WSR159,RIY.I.ED, N AyaT E •:?b•_ POLICE TRAFFIC. COLUMN NREPORT ?TRAFTICWAV o coMVU,rvrNUMtlfe IY _ r? PRIVATE WAY 2v pAlt ocai l D o« u DN um! covwr murvr ' 3 . r. $ Rls ?` 4 l us l7 NRI ?CFNbSa J r NO. A/o cnrtlo• reWA A l ? t? ?( 1 N Q 931 O N CITY OR,OW N NAMI S1 RI ti ORHGNWAY iC145 3 X ROUIF Ok StR[ SL qN # v MR! S LJw 00, INIlNStR .SIRFI104 e0AD ?I ON u ti7. - hOrv f Mt4EEC1 a WEf I% 2? 6.N ?[:J FO R1 f f v p e- e N-UN 519EEi n S1.1 . MYPOST O' 5, w '! avnNCE a9t , ,xoM 9[EERIIaC[ceoss sxenoR NtA4ESl mnf vos " '9 ? WI P I MAtS N 5 E W MIIEAGET DAGRAM DATA RAMP A`. S _ f IIII of CIXUSgNINVO V[ Sf CODE j I D. vIR IY. l IOTAI rN) NIA?Oyy NIN(D-NO VIII.- OSPIIUGE '? dgUN Y, P v[H Cl[s © .-KNY DAMAGE ONLY ?p[sUllEO 03'E°`16F wY''Dxo?" 3 irv .9D IMER CL3 NfR RI ff10R ROAOO4 PIfE9fNCE CROS351efR0R qOM 3y/O ? a qd OtllIC1519 UCK (NAM F OF-ECT -KIANDOWNCRSNAME) 51.0AMAGf RCNI ODING LAE o J S S IR r > 3? UNIT NO. I O9rv[q's NAM 1131 N9s, mIUDIE UNITNO.2 ? VEHICLE ? PEDESTRIAN O PEDALCYCLIST 4vE4sNAME: wsl N MI (x " i?Y . - s19lUAOD9E x i AIM (4 ,J 49P::) 7g b ? ; yxY 3 ADDRl. 1 Z t. 1 CI r 31A1f ZIP COIX PHONE NO D ? 8 uY 51 T ' o ' . or v u ?i$ !.? ??5 ayS` R A E z"IX P N c W ,. Y Z DRrv(RSUCtNSE S1AIf 5(% Af tlXIH I xvtNSlCENSC NO. S,AiE Ex DAr 01R H ,AD DA ' 1 V T Ma Pf- O[•1 ,J(? ? L J er L OCCU 110N f6PNONE NO r ..? S'SS 1G/G Yf5 lh IGHi Hf,GNi ri?0 'v l) E R nPAr1 MNAMEPNONE NO. (fi WLIGHt (IGNr 9 ?f3z -? .ezlG 1) CHECK FHa s:N UnROrtE OFANOINE9"t v ,2 nrt. O GHECIC (,!) ° iov a O ww v CODESp* 7 / s I roN E e ; PASaN EMP ar iF.N 1Nt CODES * a c a is 5 tx 6 [Z: I x FS V mMUr.p ? •M .tt ? u FN YEAR f L41 ? <"only ? +in ? i0O1 O Mn Ar e ? u°6Kr ? e"only ? _"I O MI. IDODGF?CNCVI ^ ngOtl l DAxlNOVA1 5lvlt lRDx.c ?/ E v Avu I D4E.CNFV) MOOfl IDA91 NOVA) -7 3 m d?oN? rYltl DR V1 ? l (//•!G-o [° ? "??• IC( H SI tN O . siA Au(R RAIf NO. -E H eEHC U N U . EN .? . b '? V ."•-? fHKI[ IIXMIr UI / ? ?J ( ' , l! • C?J gN NO A I C ,??_ I ? pt L -j / Z A /T y i V AlE ]i }.. = Yr I 'cC) 422r L y l r cl( DEN,I. A, - D 19,0 r R l A. R[ G151[4IOOwNl9: Wi IIgSI MIDDIF PNOIVE NO, f S, RIDOwhte V.Sr 11- MIDDLE + 1a 9 D 'J?` W lt?A?'Rx1. AS NO. j2.c"7e17 t y; 'J"` ' A Z D fssaowmR N A a w R - ?al ; : N AME IA-WOW NSUV•NCl CO DO AC(Nr E /Tj0LK e • D. 9 Z A m . O I 5 R IA y AN PE . %oI , u JcA c 'CEO BFI r Yr S' ftAMAGI •vU ? u I A rv , 1 r w Axwl j ?,. f I 15 •ror S 1C?OilOii v.tiq r..l. DArl t51 OAMAGI O CHA9GE R/ El RtMNNIp AWAY 10MD CNARGI ` ,(JTAWArRIVEN D 0p[MAINFD Y' T Oµ?idna ISr. DAMAG! I DAMAUDM f D vi * Sr ti S O Aw•r er ? WDer SHOO R a Y, A ' DI GRAM OF COLLISION: '.11 PltMlrv At NDC•rt rroR11 re -, slurn NeassA er R9ow ; I DESCRIPTI ? v ON OF COLLISION: ILnFSwPI[MfNlu 51RF1IP NeClS5Agr1 ?1 • ' v & s 1' ( ' , ..._ - ... _ : , t. ed 2 W G _. vYW?./'/ p .. o u / 4v6?Aa "t al" a J 4 ..: .. ?: JD lyPf1xA - ?CrT Tvr . uc.l °•Z 41'q.r O c'-tA e . 'VE-ST UCUNO G?. '-.J 7• I74-//LL-+J- F7?/L. v r. I _... .. _..... 7Y*?CVJY-Srrue,'1 l=d. uc i _ zecam .. .... 1 --- 5. 1 I R NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES I - 2 9 4 5 , OCCUPANTS/ WITNESSES NAMt: ' A l e ' ' It. A.C Al '"„"" RA "': u uiR. utn :'0lY k F (u 7) "? ? ' T ? (,u S I rA?YI,/ 1 153 O' :q '65.2yS / :?Pt?r 2- ! 3 t A O 137 ; ) ? yl, ! t n. U 1 Jn ,) N iPx eY AMe ?P7` OC O 5- ? ? ? 1 ( > ?.v? Luc • L. u ? 3y1? '- [ r « II I Atlwnl ! ) (. ?uP a P INI P M OAMe ?; ;RI oo a» o ,°... I -. t _3' ', t I t i. i+o 1 a ? 1 w ? ??r -Sw I 4 r:,i I R ( t-? ? ?'. ?- , • •nrw x lss SIq:AI.u +IVt• ?.1.7twrF a•wE? '/YTf' X i.5 N n ns .Gf NCY t ICU .1.CIS.??. ulm li. O•Me CJ'r`G ' ?rH6:n• O::» ? :;:,v r,tl(/r IcMD nna vlD D la Irolll •wwvlD er DA?t r ?fG , r I? P?'3 05s??'U ' I'Tj f 5! ?? a E y { ? n . , ?.? I ,s , ,, , tq,. -?D Iil sM?r^rpm"R9',7C y k , , l,r. k 1 '? ?r x? ' r ?u L?J ?L,.M1 ? t i 1 fh t i r w x ? t? ?r t??. r, . i Jsat ? .?t??i FY f } Y t', ffi Y ? I o U I •a of ,f ,. ono k i 1 4 i { i t, WiWR'AVYi4, s ! D DATEDFCOLLI ION OF COLLISION TIME COUNTY O CRY NO FHWP / y?Y i VR i SUN 1 Mql i't ] WEUA IONS FRI B ,AT IDS( MENO}1R1 J / 'J URBAN ' 9 1 I r ( / ? 1 l Y ?d??`? URAL E (iC / r. 5yx H%' COUNTY L-n z C) ApM LB. 11-1 ppUTE OR STREET CODE SELIION "51111 ROUTE p?ICOUNTV ROAD ?CNYSTREET ? r ' rr [,y ) E?/` ' V ?/ 'W "OTHER 15PEpFY1 f0 { f J ` J / Y4 ? CITY O,p.?TOsW'NxI ? PPEFI% EO My 05 i L N 5 E W N - rr 15 l J ?? ? ? , ._?• • _/? . / ? ? / "/ C,VF/ ..___._. A MILES ? ® ? ? ®OF--- T-! F`li V (? ? ._ J :C C! V A NAME 6NO.OF STREET .M ,lNTEftHCT6NGY,TTH: ITH: STREET OR ROAD LL RMIP DIAGRAM DATA T ON -ae /A,I ??? no/Pc? Pv/D ° MON WTEflSECTq 1 iE NON %RD INTERSECTING STREET OR ROAD OR REF• ACCIDENT O.. MILEAGE 't.. PINTER CLS. ERENCE ROSS STRE?ET ON^??0?OO N BETWEEN.... ... STREET ANp. • gSTANCE AND DIRECTION FROM REFERENCE OR CROSS STREET NND SPE IAL CODING USE "MILES N S E W MA[fw N[,H5 I }." ? ' Ga??o []FEET ? 0 E] El • COLLISIONlNYOLVED: ?+ EEE???'''??1 VEH CLE-VEHICLE ? VE CLEBICCLE ?o.Eq IWRITE) "HIld RUN SEVERITY No. HALED VEIIICLC OBJECT KILLED ..? ' • IOTALNO "VEHICLE FIN TRAIN "STOLEN VEHICLE I NO. D OF VEHICLES .a? " VEHICLE-PEDESTRIAN "NON COLLISION " HAZARDOUS MATERIAL PROPERTY DAMAGE ONLY . O T/ST/nRYUCHI?Ar EOF OBJECT STRUCK NDo V/ENFIfIS NA(NyjE) ,{ L? LOCAL ON OF ODJECT SYRUCH E oAMAGE OAT( J(allis ^ VE•7'r. `?[ R1?1S "ROADWAY FEEToo®o PO EDGE 'oO CD r F - ?- ^a ORIVERSNAME lAST .fIRST - MIDDLE DRIVEN NP E lAST FIRST MIDDLE TIT BICYCLIST OR PEDE5IHIAN CHECK) 0 CTT L R STREET ADDRESS-? R STREET PRESS Y' 9p v 9/o Gismo ,', f?cd 3-7 E CRY . STATE ZIP CODE PHONE NO. E CITY STATE ZIP CODE PHONE.: R Ji?seX116 _cuA. l?J3', R /?AA40 ruA. ? ?33y A II i N DRNERS LICENSE NO.. STATE SEX OAIE DF BIRTH N ORIVEnS LICENSE NO STAT % ) I T . E E DATE.OF BIgTM 0. A-7-/Z Ft/ ?Y YR o. J 507 PrY uA. f iBYa • ORrvF[LS OCCUPATION FIRM NAME - PHONE NO. 'j DRIVERS OCCUPATION FIRMNAME PH NEN ( 1 • ? ' [( // ?{{ ?L• ?3i/?C?f/, K•l?.L? T' dJ :- r XW 77, e,-," to i? CODES > nI CLASS -. _. - yAI SEAT PELT _. _ I'I EJECTION. _ CODES >.j, CLF55 -6- "I SEAT BELT_3_ ISI EJECTION- A1ugE fi yniJ FU RES C[ L . MA D MSCENE BV: TO iPOM SLENE BY n7 cA.LJ .? TO •-• if. YEAR MA KEI GESHEV.I MODELIDARi NOVAI STYLE 0 CONV.1 VEH YEAR MA.EIDODGESnEYI MODEL (DART-NOVA) STYLEI2D5 SON ) v (7e? 2?io Lr l Dar ( " v v L/aLJ E VEH C PLATE NO SLATE iRMLER PLATE NO STAT E Y . . E VEH COLOn LTC. PLATE N0, STATE TRAILER PLATE NO. STATE 6 J " XI t1 zCG b z 2. " C cc??i I O?/? 6 o w C VEH LE N11fICAl KlN NUMtlEq 111ETIF (` VEHICLE ID NIIFH:ATION NUMBER ODOMETER . L, 7 251. /Pl7 ?R38S? E S'111e L G //8cz ??03 !(?N L •[?1f . REGISIFFL':1 OWN ER-LAST RE fIRST _ MIDDLE GISTEREDOWNER-LAST F R I ST MDDLE No. " •Bt776 L J AppRESS C <NyNEq ADDRESS OF OWNER y 2 57 T/-c%JS /T 3 3 /7Y 22 ? 55kk . . Y ' T ? _ CIE Y NAME AND f550FIN5U CECO.OR AGEM wz-A•)5C,(10 WlScURS ANLtEOf?'AGENT - S> 9TZ %A?/1?1- NAME AIItOVE?55i0cf - jr•T2 ??J,cl£?.UQ :} ,r C E CITATIOEINo ENFORCEMENT CHARGE CITATION J ACTION 7Y A NAME, ADDRESS & INJURIES OF PERSONS INVOLVED coD1s SE% AGE STATUS wn S ti n[ i EJECT. C NAME: C ADORE S9 ? -?r ??sC?1J? 3 ['3 c:t C - ? ? •u G'1 z 1 3 i z P c ' ? _ 1 . S?G U FIwM WNWE ' I 9 C u71 c Nrp TO F . A NAME: ,4 T S ADDIIESS N. E n MO EDFI .I y: I S V mJU SCENE nr To •y W NAME- 4 T AooaESS M f " 'h ' i N I F. s noM D N-wgrts sciNr nr NAME.. To : . 1h A' ?>Fy S AopRESS = w 6' . SCFNf flr TD 1 C C 1151AIU5 1 PASCNGER ]BM: CIISiW IJI S[AI POSIIKx[ O1HE ) FIM-KW J INJUNY CLA55 11 INJUnY 2 DEADAT SCENE ] E B pSAnl N61NJURY 5NON MSARLING I.I SF AI PELT I,NOIINSTAILCp 2. NOIIN VSE CJECTKXT 151 1 NOT EJECTED 2 TOTALLY EJECTED T • D E OH[ER S 5 NIIN[54 2 . IRUSMOIp{iCYCIEI d ] 5 POSRKW UNHNOwN - ON ARRIVAL D AD A OKD NHOSPIIAL IEVKXNIHNJURY 2. POSSM1. WJURY ].USED A UNNO N ] PARTIALLY EJECTED d UNKNOWN IF y t , it 5 SEAT DELI FAILURE EJECTED , m TY ..e' , ii 1 ?M1?L?nI y YF! T' T y . , ? H tt 4?? A .( yM?lggNy'' ` F r F t t i rv, yytr! ? - '1"ii (? _ nF„teRl , 1511yn ,? ... ? L? .'"?4 ?tT'L nf? ?6["dtl'I?B'Sfl'rCEUniiEA (tl? r (.? 3 SIIPOE AREA OF SEVEREST IMPACT O/ COL ;. EY?' M INSTRUCTIONS DRAW AROWISITOSHOWPRINCI ALORECTIONOFFO ?9 y ,'. DAMAGED VEHICLE NO. 1 HIS EFACE F SKETCHING DAMAGE TD TRAILERS. MOIDx ETC .$ DAMAGED VEHICLE NO.2 1] T u .qr. .CPA II 5. F V '?I '(S ' F L F a F,I Ib e. O.r .T Owwlvln 1 1(, tl NY SEVERITY OF DAMAGE: VEHICLE NO.I SEVEPITY OI DAMAGE IOTHER VIRCLEI SF r?T{ TSA L OFDAMAOE, VEHICLE NO.a DIS G AGE J ? O V DAMAGE 1 ? O SABL NG DAMAGE J ? OTHER MY DAMAGE ING DAMAGE a OTHER 1.1. DAMAGE 8 f 1 H E S W j oUNCTI ] FUI-RONAL DAMAGE A ? N AGE ] ? FU A 0 NODAMAGE ]ONA .AGE A LI NO DAMAGE TOWEOB T ...... EST. DAMAGE TO ED BY (' i. C v '?- ESi DAMAGE TO 0 5 TO : - •.,, j?. 5 l _ t .T ; DIAGRAM OF COLLISION -1 DRAW ARROW SHOWING --T-_7- D[ NORTH IN CIRCLE 1 t a «[s a r r[D[s,x.x5 I 'F I T-1 ?. Si F? I --? T I ' I I I ? p.wK,SprvIDNnDA -Al I ? I .xE . 4Tnp IpNpH I Drv NlpaneLF Vrw [Le On .- ...._ ._- ' reD[s1PMrvrnlnseuoxe ' AxO AFnnc-un ax __-__T_:._. DESCRIPTION OF INOCATE WHAT PROBABLY HAPPENED BEFORE, DURING AND AFTER THE CRASH INCLUDE INFORMATION NOT ON DIAGRAM, E.G. DRIVER COLLISION DISABILITY. REOUCED VISIBILITY, PEDESTRIAN CLOTHING COLOR. CONSTRUCTION OP REPAIR WOPK, ETCI N 1•, Y - - 4, POSITION BEFORE COLLISION - [flax LEGALLY ED WA E EN. EDS. EPOS D TOR HIGHWAY O ON[DRE ED O. RE SING b C SING TI 5 .E '' -I L ? 77 2 1 IES NO NO f ff _U.G - 1 J t ,; ' J ? --..H - _ U r . PED EI 1F__l ' r' C O S,. n wnnr rw. FRO cpnn 1. 1 cpnN IS To ipwl M TO + PEDNICYCUST WAS USING ROADSURFACE : -ISIDEwALK 2 WEATHER rr F. WALKWAY ?SHOULDER CONTRIBU . .AR (^ ( L_-I R-SSwALK rG 0 TING CIRCUMSTANCES O 6r OE ATE- _ K BLS'CLE ROUTE II ?OTN - : ER EHCLE ACTIGNS - - . u . ICHECK ONE) DNO S] .: ICHECK O.Ej ,- ... .. _ IC NOE= HECK ONE OR MOREI DRIVE" . ,. .. 1 NO J W Z ,. NO'J VEn c[[ ON .I.I U I ."GNT AHEAD ' r Ir DAY C E DY 'L , OVERCAST _I J__LALfOn9 LD[W I FOLLOWING L._ QGLDSEL I n G E _ _ I? A. uJ? OVERTAKING L_J IS ASS NO 4 „ I q G LUF T7]I I .. - E-_ • A? E T .. .. G Ni N PI i ?L aj I now ]^? OwW G ( ('"I 1J•I EplECEIDI -LSTATED _ ? ? ( L...J_ gLO?ARKN S7 _L U G r-1 L NU I V I RN 3J E t ,ICE ?I , E4o.RL r I ?ID ?.? ?I 16I E_R vE EDV v __ISO U.tUPN - IS? r s I IDVN.T GRANT TINY "I Do E C Lk__ - - 4Q G I. =J1. l- r L_ J SLOWING III OTHER-CFYI H ER-ECIFYI H ^It?_ SIGNSGNAL O + 1. _,BL) M.IOLAl10NV1' ST.lF [] T ? TRAFIICFOR LIGMTCONDITIONS GIIfCK OxEI TRAFFIC CONTRO NO ]VEHCLE ' ENKL EU E.-.TYPEDOROi.IUD O.0 IC C - : VEHICLE VEHICLE CONDITION IND ]I ` i S SOBfl1ETY _, IL DCIt ICHECK ONEI N x r s15iEDATSIGNAL UB.? OR OP SIGN Pt } l, ry Ii 1 I SIGNALS I 1 ONLwAY I ! }jH ?}I {[DI . STOPPED ?a? ROADWAY X . Y _i'N/ nwruanT ! , OP _..__.I TWO WA- ..•..,•. ?A.____ E c rv _ c BRAKLS _... _.-I TY Bn _ •? ? :. . M . r SgAPTINO IN TDU T FFIC LANE I DAwN T r'J IEID G ]E nSRLE . . _ . OABILIty ?,I? STARTING FRO' PwPKED POSIT ON - .. _ _ I.W _..? __ _..... _-. .SI N _.. .._ II NG IIEO ...?. .-:. .... OAD Ar. - 6 ' ?L wNGF . NA H. P '.___ IL . -: ' DETECTIVE '. ] HSA.LIGHTS _ ...._.REAP NO. MYARLIL___ I HOD SOBN ETY I] i ?TIJI EH6 NG BFITERINO 7 Tq.SPFICI I..-, DANK-SIPCFT ..LJ_.LIGnTSOx. l I MBEII NC . _ ?- AILEY -_? W - THUS WOxN S.Coll, - A%". HAD NOT RFFN DRINKING fl6 BACKING DA s CET b' uc ao!_._ . 1 :6 Rmxw .. '? I- TWO WAY I° Drw LAx-LEFT I srny IpwFO DINDVCn CHEM. TEST NO - DARK STREET LIGNIY 1 I ICE M G Sf Cwf E-ONEl TO ' - - -1 E GIVEN o... n ISVEC IPYI I ' . aTHI .-._.._. ]'" __.,.... ' l A . olwiR lYfCN VI E - - DIV IOED _ --' NO DEF EL i5 n-? OIiItR -SY[[Iivl TL51 [ uSLD 1 ] fD % % TEST RESULTS Z Vkf HLAIING OIF ICI" S NAME A"AHK - -11 NO LICE U6/^?[II[1 • . D LICL AIIxIVS. ANCE OW )F? L ME NS MIN IRS . Y X V l511LATING OFF r<!n'S Nnu[bxANK IN NA ULI NO A [ uNl DI T. 1 .A IE RIP II BY U L P ' DISTRIOOIION ORIGINALCOPV SEND TO WASHINGTON STATE PATROL-OLYMPIA, WASHINGTON-8564 DUPLICATECOPS'. LOCAL LAW ENFORCI MENT AGE NCY'S COPY-TRIPLICATE COPY', INVESTIGATON'S COPY paw-m ift Y? 6 L ??? J ? M ! f ? AA? ?f ++88 6? A CJ D DATEOFCOWSION DAYOFCOLU SION PME COUNTY NO. CRYNO. fXWA A 7 I.0. DAY VR. T SUN I MOH 2 NES D LV EO A TNON S FRI A SAi (US -D- RI } / ` '?SO / ? UF.BAN E, J Z ?!s'G UAAL PON i ? COUNTY ?STATE OUTE ,®COUNTY ROAD ?CRY STREET O AOM CLS. PREFM ( UTE OR STREET CODE ScC ?,, (E','.r•i.„ ?OMEROTNEflISPECIFY) " IN CITYCFTOWN ? P f W P REFIx EO. MILE PO i O ! iLTT J?MIlE9 ? ? ? © L^J OF _T %n NrSrry? U [) •?\ `? / C' A' N 6NO.OF STflEETOflH Y. S•. yLFa c o d INIERSECiWGWITH: STREETCRROAO LL R AMP DIAGRAM DATA '? 111/1 1 O?iY ?? ?• % O/vo 1-11 n p T ACCIDENT I ACCIDENT NF _NQN %RO I I OAO OR REF NIEREEG TIN65TRE OR NIERSE O ' CRO53 ROAD N OETvvEEN STREET AND STREET CODE ys OLSTANCE ECPON fROM REFERENCE OR C [ISS ST E i R R Hs S uru?T PECIALCOOWO USE O MILE / ? g ? n QFEET N X E W OF Cl/4 rn r. C, .. ?VENICLE•VEHICLE ?VEHICL£BICY LE ?OTHER(WRITE) ?HITARUN COLUSIONINVOLYED: SEVERItt No.wuED. TOTAL NO. ?VEHICLE-ECT ''?VEHwIE-RRTR.VN ?STOLENVEHICLE . NOANUU ED . OFVEHICLES ?VEHICLE-PEOESTRMN ®NONLOWS%kJ ?HALViD0U5 MATEPoAL ? PROPERTY PROPERN OAMAOEONLY 1 GBJECT STRUCK(NAME OFOWECTSTRUCK AND OWNERS NAMEI LOCAPONOFOBJECTSTRUCK .. EST,*- _ ? OADWAY FEET ? ? ? ? RD. EDGE 5 MYERS-E-LAST.. FIRS! MIDDLE -ER S NAMEI?ST FIRST MIDDLE (IF BICYCLIST OR PEDESTHIAN CHECK) R C?JoM Jrn? T.l,.,, G>;'//,'?(•, R F16 ?i/o,J STREET ADDRE93 STREET ADDRESS .. , V . J J lf?.- Q E ' E c i 4 n N CRY STATE ZIP CODE - PHONE NO. T > ? 6 A CITY STATE DP CODE- PHONE NO. /? rS r ' .? ow s..,c CcJ//.03 6 3?5• 7i 3 i f -i.,, rrr_ CdC. S•1S/s7 2d N D-ERS LICENSE NO. STATE SE% DATE OF &RTM N CRNERB LICENSE NO. STATE SE% DATE OF &RTN 0. 4voo- &1Tnb9 G/?j MO. DAV YR. 7a`i^S O• tc- r - ": nit??3icF ' 4/A /yi MO. DAY YR a 6 S7 I. OWNERS OCCUPATION FIRM NAME PHONENO. 2 CRNERS OCCUPATION FIRMNAM P NO. CODES >113)C-L= TAI SEATSELT ISI EJECTON CODES J IOI c- TAI SEAT BELT (5) EJECTION / NATUREOF INJURIES rJKC wTURE t URIE$ %. JSL iROM SCENE BY: FROM SCENE BY' TO VEH.YEM MAKE( DODGESH ) MOOEL(DARTWOVA) -YLE(200.--I VEH.YEAR MAKEICODGELMEV.1 M OO ELIDART•NWAI STYLEI20RCONV.1 . v' 7/ L2J??t / J LOrAr.T ? k E. vEN. COL , , l10 PLATE Nn STATE TRAILER FLATE NO. STATE E VEX. COLOR UC. MATE N0.;. STATE , . TRALLER PLATE NO. STATE ...:.:..: H H O V LE.IOENlIFICATION NUMB .... .... ..: t.... . ET C VEHICLE IOENTIFICAP NNUMBER E S?6Z/dam/!{ C E Ga A/ C 75/ 3( / l 0 tvH ,G/ . . ' REGLSTEPED CANER-LAST -.:.., ...:.. F1flST. :..... --. :.:...._ MIDDLE HEGLSTEREO OWNER-LPST.., , • ,,; ,.:... FWST .. :.: .........'. MIOIXE .. N SG.J«? N O. O. cS?r? ... ADDRESS Of OWNER, .... .. .. ? .. ADOfRE59 OF OWNER -' ' 2 -E- DADDRESSOF B+SIIRANCECG UR AOFNT„«.. _„. „_., -EANOADDREWOFWSURANCECO ORAGENT .,.R:. .. .. CIIM ..: i:.. ._...:. .... :........ CRA NO. '... ENFORCEMEIR. CHARGE ... ..:.- . . A ACT ON _ ADDRESS & INJURIES OF PERSONS INVOLVED NAME CODES - 2 O A 6 , SEX ADE STATUS W E ECl. C NAME: C AoOREss: U p NAIUR Of REMO EOFROM -u-. To A NAME: N T ADDRESS: 5 c. 1UFs VED FR M VNlAIRR SCENEev. TO W NAME: T ADOREW: " M N N UmE4 RCENE BY: S NAARE S ADDRESS' 5 p F . 1 B sCEN P, 11)3TATU3 I2I SEALPOSRTgN {JIINNR". C 0 R ? DAI O PIO E 3 O 1W1 ; PE Esf1 D%:tCUST 1 tOTHERPOSIT10tA T . SCENE EA ]DEAD ON AFRNAL NON D U INJURY 11EVIDENT N S 2 DUSM0T011f.YCLEI ADIEDW HOSPRAL j ).POSSItlLE IrUVRY E PYATHESS A O B do&n& UNKNOWN R.NOTINSTALLEO LNOTEJECTED 2.NOTINUSE 2. TOTALLY EJECTED O. USED D PARRAI.LY EJECTED A. UNK1101VN / UNKNOWNIF 5 .SEAT tlf LT FAILURE GECTEO mI M1 i le m+ r l Ir? I DAMAGED VEHICLE NO. 1 I m IS SPACE Fpi SKUCHx DAMACETO TRAn WTORCYCLS' aj DAMAGED VEHICLE H0.2 I a Nona Ia Nom / ?-- ,i. R0a1 b ra. FW `"s"?r a ITj ,s I"'" rs nlnl. . _ .: l ,s Tlv. ,n.wa.ro.rrw. 1QC]" ASUNG MAUE: ACV IE NO.1 SEYEPoiY OF DAMAGE:IOMER VEHICLE) EEVEPoiY OF DAMADE:VEMCLEN02 OIa^AELON DE ONOD M.V.DAMAGE A 1NOOAMAOE S -IND.AV DAMAGE ,QDISAELWODAMAGE T0 RM.V.OAMAOE 2 FUNCTIONALDAMAGE (DNOOAMAGE 2 2[]MFUNCTM]NPL DAMADE fNO DAMAGE FUNCRCNAL AMAG 4LJ 0 D E a NO DAMAGE EST.OAMAGE E9T OMIAGE - EST.OAMAOE TOWEDdY TOWEDBY TO S TO S TO ? .... n .•. ? S ,SJJ ai DIAGRAM OFCOLL1510Nio aE" ?.•! y i I I '! I 10IJ„c.?.:Y IR,I .T I 1,- r v. j - DRAW ARROW SHOWING .EP.MUU° I I I I ? NORTH IN CIRCLE FRD DW.y y: I T T 1 I? /?1 `u,'e.:irnceasiROC,w ,z I 2C %f< & 7 I+ I a I I 1 /I I , t I r DESCRIPTION OF,`*r, •. COLLISION _,•.,`OJ '? Ij"'+s INgCATEWMAT PROBABLY HAPP ?&4TY,flEWCEDVL4BIl.riy, p ENED GFFOT1Ed1RIN6 ANDAFTER TH E0E5TRVN CIOTH?HOCOIDR,CONSf E CRASH.INC RI1CtI0N OR WOE WFOgMAGON NOTON OAORAAI,EQ ORNER REpNf€WOR1(ETCI. Y•, , .2 ?27r-tel.+?a -•,?, PO ONS O • VEH .. ..r?HEADED MRE POSTC0. j A'Y'ti•t?'ti1?. r,w1. NO.OFLWES . .SPEEp4 VEH IFPM O WONEdRECTION oOe LEGALLY WASVEH ON STPEETTH,GHWAYNAMEOR NO. she NO OEC EiC REA&NO L?? pEI91N9-0G r ? PARREO OCCUPIED /? n :- NO YES No ?Y ?., All ' PED. n ? D PLOIACYCLLSTWASUSIN O: I?SdEWAUt '. = i.. IWAIAW ,?sNaulsEA / ''[[ORS AI_)c °?Cross OR W r SMU°I 'e?ic9c1¢R?wrE "77. ns E i°vlE,Oa, i--70__ . ROAD SURFACES I fcA ao A - ,•yt WEATHElI;?,- nA•E« o,E, CONTRIBt •. ? 111NOS ANCES'<? _ - ?p„`. .,;n '. ..T'+?, .,wa.Dmrwyn.c]EA a - , Hn : vrHr•• , Mo n + aRrmn : ] aRYD, oawl A .2.PA?A. a, ®, nR?AUHrAI1fAn [} II J Dm 1,_ I I.sf]Ie,cecs wsf r_ ? ? LJJ!'J s??wfD?umED AwL _ .] ? :vw - '= ?? CX Wfr ] ; R.ND G]p D;G,' ? ?,C mc?ER ?M? ° fE Y ?30 M -. J (? Enow s? o,DWw L ? "a,senl'r'°wrsTArm ?°? ErrAn?nro _ 1-1.°?PNMW L.1 fTia? L?.1 IOMUxoruM _ ELI ? ICA _ a J AOO ._--.._?_ ?ET?EEO _ ?? eYLR)1 O -I1e? OPFECiM EOW1•. - ?0? M MNAN __?°?I O ° ?_.____ ' • ,° ros+csRO' r .... _ .__ ?s? slvrnu ._ _ K CVYI OM[e vtvY? I?e!1 Pe ? ..?? OTC I_TC sv?ii°'A==--Z- ?(-'?1 lJ'^? ,OiOR10-'-w ?'? mArE'kD'? . T HTCO CONDITIONS L10 Ir+?LGt 01W ,TRARFIC.CGWFAQL: Vl,tlE ? ru.a t i„TYPE OF ROAQs ] ICPfCA ONE 011 MG,IEI 'VEHICLLECONDITIONy YDKiI ICKCN OM 0? a ,,;_SOBRIEfY"y,•?y"yy,;, VLKtE IG,fdOliE) ?e? srDFeEO AraDrw. O?RWn S (? aDNME. Q -- 10 d< Ar ? C0 f PlrW ?e? POMWAY , CI d6MHl '? D• I I']2 TW AY -- D °N?f3M ?1? NBP o , . ?,O? ' ?,L war, y,_L-L.. _. - I?'_p ,gin - 'p'} = 1. ?„? A^;,?od o,,, wE L]'?[r] U Ll ««= ?'_j °?`+wNn ? . .. ?u? MwOOSnc,° °"° {{ f ?°?' 1u.v, ,nHnoR - _ is ? fLA? ?-?'---A.4f„'-- I 1 E ALLAY 4.J_?_...----- -?'? ? ,n, H.DNDr BCEx MrrcM ` ?1E? .]tlWD ( I wH°1iem'r ? ? sM.- L 1e? „'W°xW"»ri r ?E? o,Tw. "? "° CHEM. TEST-, .. 1 w i . ? ? ..,. _. I . m°[[r Wwr! I ] ,GM'A„I 11 I eIPAMHrrn ?` ? - -1 r 1 1 1 I T[SrOMH T ? _ ?u1 ? ?. f ?'we J- `J•,? ?-.-.._ O-• f? ??_ ? ? wLp[CIf r . RIr PfNYD ;Y S ?.. : .:?, ,' OrhET19,Egp '-. f 1°IcMOaN?ROI'? ) uldalxD .-^..-;6ne11iarea?Yl J % % TEST RESULTS I: ImunaAlwoE.crw]N.we,w. u uY /. rt^..JC iJ eAV°e HD rY PO,KeIAVMeN]D route urwfo w,cE cru)w i Al ?- AwE ti/? :AOE«D p70 PneemarWDarctm HM/f ]AA+w ,MO°fHO n AcfM:r Tc ?• ,0 ^• w]roewr,oEr DArtoP AEPanr 7 77 wrlanoer arc j OPr: SEM) TO WASHPJOiOH STATE PATROL-OLYMPIA, WASHINGTON ]S- WPLICATECGPI". LOCAIUWENFORCEMENT AGENCY'S CO -TRIPLICATE COPY: WVESTIOATOR'SCOPY T2_. "E8 1 I i -q ""?perFpPd. yy. .. rj T c sit' Vi t . - ? Jr ? s r? 1 d • ? JAL v? J { J• 3a` uJ?k' 1 ASY T : i T OLLISIOn M D Y YN DAY OF COL LIYION anOE O PI A N ILSF UNTV N0. / E -77 O ? ] B [/ J ??? nD OOG Q [[[,,, DURUA COUNT 1 ? STATE ROUTE COUNTY ROAD ? CI Tr STREET Z C) w0'4CI3 FOR BTRE ET COD p TPION V j' ?SO ? OTHERR"ECIFYI W N L E ?IN CI lv DR iOWN N 7 [f E d. ,L6 - O Dr - r. Tbcv?1SEND ?`-?`?? ?? w ???? ..8Z A T.R E6.0 9T HIGH WwY ,. ERSpC}I HO W, H.STHE ETOggOA LL DI. Lz; - I O INTERSECTION GR--PC' C'CO ?6 C- ?Pd r T6JtlER TPEET O >f MTEw Clt EFERINC CROSS STREE O N _ OETWEEN $TnEET wnD STPEEi I ANCEA OOIRECTR- IN DEFERENCE OP CROSS STREET -i w 1I1E9 C DIHO _ QFEET ? ? ? Of ?^ ?• COLLISION INVOLVED: ENICLE-V4HICLE VEHICLE-BICYCLE IGI .THE WRI TEI ? T.H RITr E(}??I r?J (q?) K LLEO VEHICLE-RR TRAIN YiOT.I NO. I?T?1 O LL 7 ? ? ? EN E Lk µ EO ^ OF VEHICLES 1 d VEHICLE-PEOESTRIAn LI HON-COLLISION HAZARDOUS MATERIAL .. .. .. I -.T1 .-AD! ONLY El OOJECT STRUCK INA.COFOBJECTSTRIJCK ANO OWNEwe NAME) - LOCATION OP OtlJECT 9TwUCK EST....AOF. r? ?ROADwwY FEET ??? 3 OgIVE0.5 NAME ST -LA4T FIRST IOOLE , D ^ .,- _ OnIVER E. FRUIT, "DOLE 11-1-C uST OH UESTPITN UIFCKI I] IV D 66 J 7 R STREETAOORESS H :.. STREET 436 S 2 r, V E CITY D „ ... 3 E , -_111-01 - HONE NO. E CITY.: rE ,;; , ..LIP COOE ;HONE NO _ R `7_• T?GI>USE?Q LCJft. g R DPIVERS LI/CE?NSE HO. /'., __ AT^E. SE% RATE OP BIRTH- OFIVERSLICENSE NC), ., ,.-:- STATE SE% DATEOAY Pin rR. - Mo. M IF. O• O• DHIV E'R/S /O<CU;ATIOy _pIpM HIWE. ..: .,.. ., ?. ,., ;NONEN pgIVERS OCCYPwTIOn. pIRM NAME -.. .. PHONE NO. CODES 1]I ?IJaSSY Ia, SEAT BELT "EJECTION CODES I]rcLJatSY "')SEAT PELT ...... "S EJECTIV IURIES F L , [ _ O ED B 7"- A A? STD • IND. ErvE P VEH vEAN uAKE10000EL e 1 OOtL Owgi-NOVwI ST L N.-LOn V.1 u KE k Aq w H. YE -CHEW M OF LI ART-NOVA STYL61]DR _LnN V V E [IJLC(?e. ?5 4 ? V . - .I H EH LO LJOPLATENO.. ATl. w,LERPLwTENO. Si E E vCH. COLO. uOPLATENO, STATE-_ TRAILERPLATENO STATE. H I (•` VEHICLE IOENTIFICwTION HUNG OOOMETEfl ICL IF IC.AT,O UMBER L C SK 3 L S K p E Z 0 i?3? r • L REGISTER DOYMlP-LAST ,.. ., FIRST ..:. MI oLE q ? .. _. AEGVTEREO OWNER- .): rIRST .,, MIDOIE .N U I I?1 - L r N O, .-Or-ER :.. - .. ..... ,.. . ... _.... O• ADOA[SSOF. OwnER ,.. .. _._... ... Z N.ME AN. A..... Or IMURANCE CO OK ADEN! nAME A....DRESS OF NRl.ANCEC , OH AGENT C HMO¦ .... ... .. - ... CItATION NO. ENPOgCFMENT ACT... AROE _ .,. .. CI T.TION NO. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED cones _ a E% AOE STATLL4 T EJ[CT. C N .YEI C U N OORfss: .T... OF [MOVl. FNOM p ieeNE ev u TO A H w4e N T nio u ;qoM Ik4 W .Me I npru: N. n[or vtp FnOM E S S r• N '• NiVNO ROM UnrP4 rM T O C ] C • S ,??O?1 sT1O1,?N BIn VCLr3T w IPA TIUrr ..... Ir [. O ITION A4 ] IEU3-uO tORCYCI[I i INJU IT CL NO INJURY ?J IOiwO Al S CENE ]. OOIA.. ARHIV rlO IN nUS;IrAL ^ LI O y A OOM ?oiiARili.n 3'l VIO4NTI INJUIIY OSSIEIf JNJU IIY r (FI SE.T HELT S NO', NNSTAL L F.D ] NO k ]USf.O U3 OwN A'... 141 EJECTION NOI 4CTE0 ]. TAT L EJ[L lEO ]r R' NiLLr lJlCTFO A n ww IF J s E . nNf33 UNKNOWN s l •. rnartroN ` w arFMwnf r Jiuto ? u -T ^3ix pqJ ti? 1 r G ? a I){ r r JJJ w?_vl 1 :L f I s, ` pr I, ?1. 7 7 1 r R I SHwDEAREACF SEVEREST IMPACT. ?I - I a?L t_•JT r?? 0. I. INSTRUCTIONS: 3 DRAY, ARROWIS) TO SHOW PRI`?CIPALOP TOY OF FORCE. - - --? - ?j J, r DAMAGED VEHICLE: NO.1 _ u, s+aLE Fy-,. src_TCn .w D..wG mi _.N,. ,u.DRCYCLr - DAMAGED VEHICLE NO. 2 J -'-{ r ]JNa r2. Huul , j.1. T-11 7-V 7 i.: EPrTr CE'cAMZGE VENCLE ? E NO. aGi. IOTHENVtHCLEI -R TV OF CauwGEvEN CLExO TC' Ors' dur.c DAMAC CE ] ? MOO =EO>A?ACE t CQ7 ?uNCrrow? oa CiuE .' DD No oFr,??-E aMACt i'p °uxcr oHA? o.u>„E - ] C,? DnIEP U.v.owMwGE Ir E ? LL.'DI:1 ?T ?I;l?-?G.a.V Es'i. OaMaGE T ESi. °zu..Ge r u EE AMAGE ? • Iri Y rll.tc In `. 7L aowE s a ssT.o ?'? 1 1 I DIAGRAM OF COLLISION ?¢- DRAW ARROW SHOWING L.. , _ t3 Cr/?-?/? ??f.?•?E- -? / NORTH IN CIRCLE - 1 '_. _ -sue urRxLa.c.Ar f -• .. .._...... P ._ .. -.... -_ n T -_ E _ ! a ? RuRRw (3 A7 _ v 1(} j r! ? - J' ?,` /?,/ _ ? r T i axD.1-eHLMLrvON _ /7?,?. DESCRIPTION OF GTE wNaT PPORadLV HaiPExEOrd O W T ECRa5+3,rNCLUOEIxFORIAT10 IOTONOIA OR GR E.G.OHrvEq r COLLISION DISAaIUTV.REDUCfo WS31LITV.PEDlste,?9iS.4L ac?PE/:.f`L?19IaN REPAIRwogK, Erc.l - $••i h.I.ll_1 (V. C.c??-- ... /IGJ ?:? tICYk LI„15? D _tiJruG(?1,`?-va_r_ _`ra tlb?Ft- f? °' ( r_7 EG?. P.S IU A.ttL)EIJ7-'('L' c/?..Vt CA It'7-r/[1?-itT-?'iEI:L Y` T I crl.=-???Vtfl_Y? sec; JNrG lrlttcA..Y?lL / s tG?- (?^?c ` T t[,? tC L - ?i? L._ LU.bi/L U? IVE L%ITt D ([ t:,PS CA f ?_-_St el-V& E NF i. V 'F-+C`J-IEt; EICn-... i.lt__uJlliS_.--s-.kcA)G t"..EcfC G JZ.IJ5;1c'. of C? !` L1-1 lft$w_ - ti t15 r'? n,, 41f POSITION BEFORE COLL1510N rGIOFI LARES -rDs VEHICLE M E rD - _L H L ,HEADED ISE POST OI0. UY ET Oq HIGHwzv Naxf OR NO. I•IONEDIRECTION r r P E sH. "F r r SigE N r NO INCP1ENO 0 CREASIxG ^ PARKED IXCW EO ' f C 1 j///`?K ?A _ CHEYy L I? ASE- `Y` F ?C ...,.? ES NO '!SL _? T s r s IO. a Up, l 1 ED ALONG CnO55rNG r OM TD RO IMO rt ASU 1 S f T OuLOER f CROSSEYALK S CROSSWALK 3 OCYCL TE OTHER - - F:u^.?•aa URFACE C FCONf, Sl WEATHER K CONTH13UTING CIRCU (STANCES - wr E ? r I CH! O CHC O fl P.]v 3y5A, O ] -VsR 1-1 OF] OCT tI I c0 G Fn N6 3I?xP ?? f y Sf G ; EAO C'I I; S CRY .\ CLEAR CL Or E fHtE OLLOw N01 0 ?G Ei NO .60 ERC,ITT-. COH TOO CLOS£L? ] SC [sG -NO 'N .] -T P NG T uG5 OF E01 °' OVER CENTEP Lq Et X] =T TU 1. Al-Y ] SNCY - SNOWING ] f CEE GSTwiEO S rL:MG O OCA E a G - ' -S LIMIT L GNZt i LE TURN i. 4 ICF 4 iOG 4 E EfPEEDRlaf. s O. UHeOPER 1 tY[R } '??Et11 3 3: .. :.. 3 D orewANr m. " D sgeewxu Taft L t!« r R - ] O fHlttE 3 CPA UO LrGNr xlT a SLP D OTH _ I' fN -1-1 S OTHER ISVEUirI OISREGANO STOP pTSGS`- dEC11 'V.f? - 41PROI11 I T , _- + • _ •] 'jig.,'- IT SIGN SIGYaI VIOL,i UN SOIPEO rOR _ W Tq < 1GHT CONDITIONS RAFFICCONTRO f TYPE OF ROAD VEHICLE CONDITION } r fCS T>•,tl IW.7 vEHICLE ?'] NHlCKON[Oq LRIRfI yl 3!\/ f l,GtE ?'4NrR¢CKxpQQjyy? $GBRCIIFCKONEI E `.' OP OP9 GNIGNAL ` - t •,. 1 SIGNMS CHP NAV 10.] IfaLO'ITI1iED1 `•'I+ T ... ` ? 04rlIGHT /.] L ].. Two WAr OEFSC-E U1JKIJ?LL,TU ° ., PCO INO IN' X GPL l? RRAKf3 IMPAIRED TT" PAIFIC L1Pt • ] catTN ]' llt- PROM'. 'Fb. +" ?% • YOT VUPAIHFO -: PKEOIOSITION 1 DUGS .' RCHANGF ] Di PFRIV! HEO SOERIlTri MlRGINO I[xTFPINl1 ', •. _., I _ r I _?. ..-.. -PFD .. ..__'_ LOO nwuP. HEM LIGHTS' UNK. - IT ? TRA/FILY ' PK•STP R .S AN_ G E ALI.V NE O 'a - NAO NOT ___ _ &? LG i20,1 _ -.. .? _.. OH SHOO BFENOHINK LG• S - ?CKING ?. t -STREET E-• RR rwD wwr.LEirl 3- py lLmuF +F nIRV [rT? C EM.TEST T „ 1 1. + TTSO{I _ SIGNAL IN LAHFS r L Y NO.T H `r X OAFS-NO GrfICLPI OTHfP ISIECIirI 3 SIRLff IIONTf i FLAGMA•y r Sf PAR,IID h /` 1 C • TLSf GIVlN f .? , HLIUSED I F ?' U, , O.....Y[CIIVI- \ ] UHOlvi0e0 OTHlH ISPtCH r. 19 !fTlST TEST RESULTS 2 ,q SrpANM1GOSIICFR'f HANf ?M M1K, i,OGt NO LKt-A1CH'CO+ PuLICl aMNryFO M,RN"WfoULANCL iIOW m ]NaD li eoe0 - _ ci)ACT ?5 Si Er rr lGl r f HP, D R vv TG Leq a SN+Mea ANK oel NO ceacY NroN Unr3 .re w.PDNr, avfoer uarE II t 1. ,II -• I P'LICRUfHYY.LNF SEND YA:NINGTON STATEPATR DL- OL PMiTONORSU{ T•AVif 4-0 ICAT[COPy: LOCAL LOCAL LAW INFORCERCFUEMENT AGENCY'S COYV -THIPLICA rE COPY; ' LYVESTIGE5r10ATOH'S COPY W 1 J T c a •, A.,,i,.I.'+.?•r5 {.t'i, I ,??;?.?? ? {lY 1 S I' _. M1 q,q C? 11,?IV¦, 1 1 t yd 1 .e ,rl, w? xw•xnv o' .7 1 M I VV?51-IIIVta 1I? PAC[ 1 of VOUCC COMPLAIN( NUMBER UNIFORM POLICE TRA 'COLLISION REPORT '.e f al "t B? DATE OFF COW- DfYOf CE VISION TIME S COUNTYNO. / CITY NO. FHWA UN MDN 1 2 IU D WE " RIUII 3 r 9 SAY (USE 240p IfOUPI > ?/ _ ?Q/sD l(? ?LjFia. URA( COUy\1iY L/•?/?(???[ r ?"j []STATE ROUTE WCOUNTY ROAD []CITY STREET O LS PgEFI% ROUTE OR STREET CODE A . CTION = ?•'l1 "- ?OTHER(SPECIFY) BU ?.C, L CITY OR TOWN S E W ?IN II N PNEFI% EO. MILE I'O i C y..? Ip 'ff//?-MILES ? ICI ? ? OF. -._. -- V //?? Q T O OI?. NAME EN OF S`fl ON ?H INTERSECTING WI/T/ry?,1?S-TAR LEEPT/O/?R flOA 11/?\l! V ?.VNtE Np1 P21ERSE ION .. U. O RAMP DIAGRAM DATA N ?, BETWEEN . .. ._._. . _ STREET ACCIDENT MILE GEE.. CODE INTE r N %'fl0 INTERSECTING STREET ORROADORREF. ER CLS. ERENCEC 0515,STR?,?TgADa L?? STREET E EfEPENC E ORCROSS ll?? 'CE pN EL SCTINN F?M g5' (( 1ip? ) O MA S n ,, SPECMLCOOING USE O _ LL JJ I U ED t IG? 0 A ryryII COLLISION INVOLVED: VEE..LE-VENICLE ?VEHICLE BICYCLE OTHER I WRITEI RUN SEVERITY ? ?HR6 NO RaLEO TOT . . OF VEHICLE © uV ?VEHICLERR TRAIN _ __-__ []STOLEN VEHICLE NO INJURE. ?VEHICLE PEDESTRIAN []NON COLLISION ?HA2ARDOUSMATERIAL - PROPERTY DAMAGE ONLY 061ECT LTRUCNINAME OF OBJECT STRUCK AND OWNERS NAME( LOCATIONOFODIELTSTRUCR EST. DAMAGE ? FEET EICIE30 DRIVERS E T FIRST ? TY RIVERS NAME T MIOOLE DRIVER'S N AA -TAS FIRST AR OLE RF 1 D C? c aP, B ,?A? ESS R STREET ADD 55 / ? ? I -TE ZIP COp -- p--NE -N5." E CITY STATE ZIP CODE PHONE NO. R I bG(JU?56d (?ILCQ?>E GUAM NSE NO. (?E SEA DATE OF BIgTH 7J S Htl JAY YR O. - S Z i ' UPATION FIRM E PHOODRIVERS OCCUPATION PH NEN . E7Jt" 1-9u?NS?,i9D 'IC ?jo, CLA55._. _ TAI SEAT BELT.-. U'I EJECTION CODES 71JI TWA RY NATUREOF C 55=_ 14, SEATDELT_i -1151 EJECTION-I_ VOUHIES SC NATURE F OVR ES ROM ENE AR RY ' MANE( ECNEV.) TO MoDE?rRT-NOVA) STYLE 12DR.-CONV.I EMOVED f FROM SCENE VEn YEAR BY MAKE OGE-CHEVJ TO MOOELIDANT-NOVAI STYLE I2 DR-V) E R h LTC. PLATE 0. C,?1 {? STATE 1o TRAILER PLATE NO. A. STATE E R VEn OLOUC. PLATE NO =X:y STpiE Eq PTE NO? STATE C E H. ID NNFICATION NUMBER Z233?81d??Q(c21-2 ODOMETER 1g5Z(, c e VEHICLE IDENTIFICATION NUMB R gA?Z I?gb58 ODOMETER DI K. o. REGISTERED OWNER-LAST FIRST MIDDLE a,-wont) BkU- ? -Ao o flEGISiERED OWNER-L i FWSi MIDDLE -,'I AiA KEk p YI I) ADDRESS OF OWNER ?t 'k"le- S OF OWNER ? ???? A ib NAME ANDADDRE5SOFWSU CECORAGEM (? ` ? t F - t DADDRESSOF Irv SURANCEC0.011AGENT I-_ ruw?c?0 1fG P-dA- 1 r• R ' /Joh?E CrU OE I1?` CITATION NO ENf O b,Q _ I b6 Lq? A RCEA•E CTION NT Cr A1G ?.T ClipilON N Y 1 ? (? E I o6-?-/J -5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES - 2 y C SF.Y AOE STA2"" TUS "4. "T EJECT. NAME' •.LFICI {)/? O? 5 . S 8 l" A I 1 C F yy ADDRESS ?pl? `r It{5(p/ ?A=Lq 7Nc ut,AS r „q ? I IIREOF IIE DFH OM N R ENE TO N NAMES V2--:WA . .-LpF/<.a\:.K Z Z A.OHESS o ?? ? i ' ' ] 1 s y A- , A-?NU2?l3S- i] - ?s?-r?r B UkiA ?_l?1/t?-E pR NIURNFS F ? sceNT nr m T „°o?E'Li;oCt1(EbJ?Es,tµ~ .L, ?Ai`wr 4 -? ` i N r MnGIES z M a LD r, EciNE BY E 5 N AME S A DDRESS E. N INO .A _ r .. ( ((STATUS Irl at Al l'O.LIION R " I-0INJUNYC"' C r. PASSEF MDESI. I AN AN 1 NO POURT S 05ADlINO IrLNRr O eCYCItSt 3 r IOT.111PO.T-1 I 2 DCADAI SCENE .DEAD ON AN.IVAI M1 NON DISABLING IENDfHi HNRr E o"'cE SS e i e I i M f ' O U R OYMI A OIC.INHOSPITAL E POSSIBLE BIT e . I i( O N N l I L I Z I '-' NOTINStALLCO I. NOT EJECTED Z NOT III USE 2 TOIALLYEJECTEO G UHMNOWN D PARTIALLY EJECTED 5 SEAT BELT FAILURE A [UIECILD If NKNOW ?,?pL?p1 ?A , I?1 l .?E ptTl7MMAF?PA'?'rR/"--?Anar,1.R?? I :I, l::` S .I I -...----.,.., INSTRUCTIONS: . - ]. SHA DE DE AREA .. OF SEVER EST IMPACT CSTIMFACT . ? G, WARROWISITOSHOW PRINCIPAL DIRECTION OF FORCE E D VEHICLE NO.1 zv ACE FOq IKETCHNG OA.- TDT-ISFIS.MmogCrcL DAMAGED VEHICLE NO.2• i I6. 16 R w rav r 'E E VFNICLEN01 DISABL E TNEnM V. GE A O NO DAMAGE SFVEn1iYOf pAMAGEIOTHFnV C E DMAG ] ? FUNCTIOxal pwlAAGE A lJNO pAMAOE DISABf G GECEEIIICTNEnMV AMAGE ;P SSJgFUN t ND DAMAGE TOWEOB TO DIAGRAM OF COLLISION E DAMAGE TOwFO BY EST. DAMAGE S TOWEU BY _ EST DAMAGE f TO f I f I. IT. DRAWARROWSHOWING - -- , r.ruruRlz -.A.COnrnou pxuwAEn M. l mxmr ore uee r.reNleoxsrR -?. I i.•-, I j NORTH IN CIRCLE ?_L _ _ -. I .. _ UmraN AKIALmcT ' ? Loc?i?ra Ouvu ro xrm I r ? I ._I ._ _ ? '> sxDwvtNx:t[ rto[srAraNm - I I - ou[crrosrrDxsArlMracr' [ INPW.KD.AIE[YtNELIpR -^ -T- ' I 4 I I I 1-? 1? I I I ? I'4 r ? ? I -r ?- 1 T? T^ I ; I I --- DESCRIPTION OF.- COLLISION IINDCTEW ROBABLYNAIPENEDBEFORECURINGANDAFTERTNECRASNNCLUOf O TIONOT IAGRAM EG.ORIVEIT ,DISABILITY, REDUCEDVISBILITY,PEDESTRIAN LOTNNG COLOR, C.NST-CTIOYORRE R.WOFK.ETC.l J, i.-?1?._ -.. .. . . '± Yom- -... -_ -' .?..17v:1..•_ _'.___ -!!?.J..1_L __!_( .__w.?c_1..::SL_1-'._S .. •1 ;,. ?_ ... __? y--h' ------,-L_k I L-_.L.._ •. :1.. ..mil, .' POSITION BEFORE CO VFH. EADEO M EOST LLISION F A r DIP ON STREET OR NIGNWAY A FOR NO. ONEOIRECTION r VEGALtY IwrS VEH NO. CREAS NO E E TH W . CREASING ED OCCUPIED RK - _II ? ` El I n ?I l=, YES NO YES NO _ MP - r,_ ALONG D I _ R nn . _. _ ro p C - ST WAS US G -7 ?IHDEIALK I B T _? 1 ]i I LOEn -0 LK 6. R wLK 6? F GNATO ] OTMM . ( W R NH AL' SRRONE( A E WEATN IC (CH - CONTRIBUTING CIRCUMq iANCES S DRIVERIVLHICLE ACTIONS - ECK FI D ER I < fCKONE OR MO EI " ?w ??? I.DV (' DR E A DROE] GOING 'Hl G D FI 1 OR '? I?'T'I' CLEAR.CLOUDr ? p1-11UENCE OF I LOWING - PfGAROEO WARN_ ? OVERCAil- 1\LCONOL 1?1 D00 V Jri I Gx/SG ' tpVE D 55 O .2 { WET i RwINING _ _ -'.... . (? a INFIUE.Cl OF r I FRC r APPARENTLY EE p](-- M 0 1 1 7 I DRVGS I J LJ L U FIGHT T RN L sNOw' ?;J_6?or+NC __. U n ` ' e D esrwr r. o L oc '?AR ?1' J M S ) xc 1- D - lJ _E p4. D I c L I. ' KE • FOG - - .T L . ,? RN FDING S [ I JROPED O 11 ?-- {.IAKIN G -?-.3A SPFE ?s?? I pF E -,_ C v1 -•n (FYI F 1 OTNERIiiC ' I - T V P. _ Sr r- n DO DCLE _ I _ 1.. 1 STO bGO. ? L D L B.L ) SLTOWRINO r M r61 EC 1 ' I I L S 0 EL -2 LIGHT CONDITIONS RAFFIC CONTRO KNFCA 0.11 ND t vDDE P ASS x S I -- I SG ESG G ] N HovIDLA ENC E - D T E T C rvo ]' TYPEOORMOR VEHICLE CONDITION SOegIETV AT SIGNAL I EGR ONE OR MORE . I ' C ` V IBL D Q r1 II [G A -- ' NO F K ?{?,vS EN ICN EC DNEI O CLE O y -1 1 O f AY N ] 1'kC?Nff1 +l?TF01 N0] I 5 T0 E IN D 5-- IT A R T Al ? "? v DEfECT E r? 1 NvDABILITT I_ Rai' ' ]. I.... DA 1 SG D ..._-,- .., BRA%[5 : G .F i S-- E ] I i ? V ' J R I?TTI? ' - O ?• I? 1-0 N •' I C .nCDSyiNG . _ . L.G I ES ._ -_ NOT. - POS.T.- t'-'r CTIVE I]' nEFF J 1ii, DfOBRE I]F--1 MfnOING IENIIIHNG I 1„ NP;RAMPGC . - LAR r LIGHTS F 16 1 _; .. TRAFFIC$ ! L^ O RK-T RI[T 1 7 fLAfNING I LILr I R15 W0 , HADNOT. IIB? BACKING LOMi[ON._, _I A.M. L_ L-17 \ 011 MOO .. b •I OwRK_[TRFlT -? A S f Tq .. ! -- . [: eftNDn xG TWOWA- 6 H 11 z CHEM. TEST L I L? - T O E Tp V[ •' TNfR IbrFC rYI ?.'.l .I 6T FETIIGH S I AOL l F - ]r -7 NO I]I D PLO ,? 1 'DEFECTS I I T ST RfrIISfD ?' _.._ - OTNER IV[CIf YI ?4ic OTIEEN I6vEG{FYI ? i NOM... % TEST RESULTS T ' • INVFifIOATIN Or IICLR SNwUSA RANK ,. IN L ( A INO Oft C[Pi NAMFb K N BAUG[H0 001 NO pLK[perwiCHEO nATr ". ]fm A OENty UNIT OLIIT AIUIWfO ANCL 1NwFf IC fLOW I MrIDeD Ih X . J bO IUli. ArF Or Nl ^. f B 0 l[ DISTRIBUTION'. ORIGINAL CGY! SEN. TO WASHINGTON STATE PATROL-OLYMPIA. WASHINGTON OBSOE DUPLICATC COPY LOCAL LAW [NFOII LM ' TON 98 . C ENT AGENCY S COPY-TRIPLICATE COPY: INV ESTIG COPY ?R`°?5:"^,'RI'7iEE N1f2dYTS3^S?RR'?'.FFiRC'7"S?nElBrnn?,.IIWwwF,>ernew?.ww-..?.-.-_?,__--.___-- v4 .3t 3., . _... 's.. O GATE OF COLLISION DAY OF COLLISION TIME LItt NO. COUNTY NO FHW TI YYp MO. DAY Vfl T ,, ?? lo SUN MDV 111(5 WEO IHIIN FPI SAT ) f 2 A, 3 t 6 5 IUSE 2100 HOUP) rJ1 } J - / ?I ? ?? L/ / OuRSAN URAL _' }p,e ex 1 i EE C ?STATE ROUTE OCOUNtt POAD ?CITY STREET = O DM-CLS. PflEFI% ` POLITE OR STPEET CODE ClION , IF. '. F } T ,rn ,• r ?OTNEfl ISPECIFYI N ? ,f .? L ?IN CITYORTOWN ' W PREFIX EO , MILE PO i ? O - N S E W 3 MILE9 aEl ? ? OF-?OB?.--??-01.i:,+9l LI -:=t • O - ? . F U... J . 41 , r - - AME NO.OFSTPEET OR MIOHWAY •r. I T RSEATG CBM:-STREET ORPO D - O - • r RAM DIAO-O TA ? ' v '.T'. 1lLlcr Rand ON iseove Road -`"-I r ,.?: r.- '" 'r•'' a "' I • O NON WT ACCIDENT E E NON "MA %RD CIS- NTERSECT N U, 51-1 ON ROAD ON Ei ERENCE 8059 STPEETOq ROAD , .N.. BETWEEN STPEET AND _ 4frREET STREET AND JuIL AGE CODE µq u„ r4r '.:•? ' - -• 'NUr oq 'NIa PL IA COd OU9E ?y;m. H ', ... '•' DISTANCE AND DIRECTION FNCMREFERENCEOR CH _ ' `?: OMILES N 5 E W .5 OFEET OF (PITY --? -- ?VEHLIEVENICIE- - ?VEHICLE BICYCLE ?OTHER IVIRTEI ?HIT .RUN -ND KILLED COLLISION INVOLVED: , ?VEHILLEgSJECT ?VEHICLEPR TRAIN _ ?STOLEN VEHICLE __.NO INJUPED TOTAL NO ^'x . OF VEHICLES= 1:3 VEHICLE.PEDESTRIAN - ?NON-COLUSON •?HAZARDOUSMATERIAL "'""-' ?PflOPEfltt DAMAGE ONL Y OOIECI STPUCKINAMEOf O[UECi STRU KANOOWN NAMEI'? „ '. -:.:. ":-. ., . LOCATIONOFOSIEGTSTRUCK =-E,f- - ESLDAMAGE - ?ROAOWAY FEET ? ? ? ? PO. EDGE 5 --...-. OMVERS DMVER'S NAME•UST,MRSTMIDDLE:1!f.'B,K:YCLISLOP PEOESIPIANFHEC IO?'V-'-1 - D JGI4!SG?', Charles W. Garth td. •_R STREET MORE59 - ._ __ _ , R - STREET ADDRESS ' ._. :V TrJUrL•3l t : 03 o.J n -Do C" ifou$e i nrj;I 4rET+? Lu. svilE..:_r_...J ZRCOD_ 1.•7PHONE NO' E CITY ..^OT-OiL .:.OJ.'_STATE .?I_.nO.I ... ZINC/QL. 07.Pf{ONfi iIO E L r iy:.e. , R. 93353 >25-3697 ojr • IR. , C't rE=cuLj.I1-7n. - 95325. : 437-2743 ,I r i'5rdl,5iidp n ..?SE%. TEOE &qTH ..-., STATE DRI FRS LICENSE Nd . .. IH N STATE N 3? I / A J j j YR , OIWFAS LICE SE NO, J ,. I M DAY MO O DAV J Ml 93n tin. 222 - 11 O. y ZZ n N , jo. e• 1 DRIVERS OCCUPATION.- FIflMNAME ... .'. PHONEN 2 DRIVERS OCCUPATION FIflMNN.IE ?]Or+4ie9t Under-SCE: P ENO IS ,p' 1 Retired >osb.L D_:.ver I{arvesters Fort Townsend. tin IwUR 1 I I'+1 CODES > IJI IIJO 10 CODES IDI CU55- ° SEAT SECT EJECTION-- CUSS SEAT aELT 151 EJECTION i. .: NATURE OF NATURE F Stated nCne INJURES rossible sprained gist . INJURIES `pMOVEO R ?fNF SY' TO OM SCENE OV TO e ` YE DRt:ONV.L: U ??l VEH.YEAR MAKEIOODGESHEV.1 MODELIDANTNOVAI - STY'LE12DR'CONVI - VEM YEAR. MA%EIDODGE-EV.1._ MODELIDAR F .? y A V 1S7F ' llnzda ;vY}- >ta tFfL V 19G2°? "ford - F-10 STATE NO STATE E P T ?T 7 IA - VE FOLOR. E .E VEH. C ON '. lK: PLATE AA. STATE TRMIER PLATE M0. STATE t XU 9709 ,! n. H "Blu D A 6 f '- F NU IGI N -N C IDENTIfICAT10N NUMBER ETER . C VEHICLE IDENTI _.., ILE E E. . FlEwTEED OWNER-LAST _ w FIRST I MIDDLE REGISTERED OWNER-IJSi..:'u.•, .FViSi ... _I .gin H]MIDGE..Y . Same as driver ..nr,+.e .. c U ns driver -'' , • o. AOGRE55 OF OWNER ._.k_..__-...: ..:-. ..__.._. -'. AOORESS Or OWNER '? NAM ADDf1E Oi.ISURANCE CO.Ofl AGSM :_ ,:.... ... ,.. NAMEANDAOORESSOFINSURANCE CO. OR AGENT.. ., I:..«.'..:._L....?•J.?>.:.J ' . ' . •... ? Gran Inou. Port Townsend. kin. cn. L11 State cattle. r • None - AcrroN aona - . L... ..;:r. {,'...;. . _. ... .: ::.,- ADDRESS & INJURIES OF PERSONS INVOLVED"" NAME CO DES 5 F 1 . , s6z ADE STA1 9 EIELT C NAME: t , U . P NAATU EOF RkMGVOC0Fr10M TO MAIMES SCENE V , A NAME } T AOMESS , I S E ERDFNOM RE Sf x U TO T . N RE6 +CI W NAME 11., ':.1 - AD° M T IN ?---'- EDrP AT UFR SCENE By To E ALIE •, .. " S s AO 1" - .' M E J. :•ro.. _ J •r 9 6 ur.or-AT VAM M- -7 - A '- .r6 ,$ 8' ScrN I5IEJECIKYI S ATRE I J , 11151AIUS 2PISAFEJGTq t]ISkM WLtION T% J "'.'U',' LASS OINJIIriY 50J ILIIIG INJURY 14) E L I. NOT 114STALLEO •_ t OTEJLcMD 1 J C O PTMSIH AN RCYLLGf t I I OMEN PO`010Fl "U` MOI-YCIE 2DUDAi SERENE D DE.DLNl A.N"AL I t OEDINWSMIAI 5 ON DIS-ING .", rBLCNTIIINJURY1IJUPY T POS 1 2NOt NUS, - J USEDWII ° UN%IlO 10tAlLYEJFCtLD 7 J PARTI LLY EJCCIED UI KII OWNIi ( .I 1 , D 5 DIM. A wII.ESS I T A ?TK)I UN.NOWN - 5 SEAT DELI FAILURE _JCCK, E ... ._. I '' I r c r , L I 1 : L,. I i I 4 Is f 1c t.. ?, , .° yy•??`?, "De ,?,? '• *? . ..+:6's`1 d....:: +hnl ...iu°k[•?1•e -+rNI ? . Y$anua w:.w _.. w.a.Sl£'SI _ ??" L•r I "',. CR1EEyDAMAGE I NtACH BO%, CINCLI INE N4MULH OF EACH DAMAGED/ YrEXAMI .L M' 1'. y 3. SNgOE AREA OF SEV EREST IMPACT. ' P . •? _ INSTRUCTIONS: DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF F Oi 1 J'DDA AAGED?VEEH?I?CLE NO.1 THIS SPACE FOH SKETCHING DAMAGE TO TPAILERS,MOTOP s, E]c.I DAMAGED VEHICLE N02 ?., /r E"'_ 1]L'" Is T,u? • I lFl 1. Rml n, ! L !c=,? _ rF r Is ?rVnl v 1? •• t 16 U r•Irrri•W I I ' ruin rl r II r• r • I • ]. WrNU nNH I 4 } SEVERITY OF DAMAGE VEHICLE NO.I SEVERITY OF DAMAGE IOTHFR ECLEI SEVERITY OF DAMAGE VEHICLE NO.] F 1 1 ? DISABLING DAMAGE ] ? fOTHER M .N. DAMAGE I ? C SABLING OAMAGE :CI OTHEN MV DAMAGE IOOSABLING DAMAGE pp SF yt'j,Y I ] ? FuNDrIONAL DAMAGE ? DAMAGE ] ? Pux ? NO DAMAGE ] ? FuncTIONAL DAMAGE . p r°io onM.ce AMACE A n 5, I TOWEUBV• EST. DAMAGE TOWED BV CT ST pAMAGE TOWEDBY EST. DAMAGE Z tt 5 a'. TO S CO TO S TO oING wner '. DIAGRAM OF COLLISION S i R ?. I Y ' 1_..:. -HDRAW OWGCLE h ..1 .: igi? I-? I NORATHRR IN/ f I-1-j' I stop' sigi_4?_LL I I I1 i O AB 1° aK NP T. B.A.LFw- I F J_? ?-r-?• T-? 11II--I i- I ({ I I ? I __7 iI I? I 11 ?' ?I TY kcR .e I I D r T. .I N A -`.-? I-_ t u -. mow DESCRIPTION OF INDICATE WHAT PROBABLY HAPPENED BEFORE. DUBMD AND AFTER THE CRASH. INCLUDE INFORMATION NOT ON DIAGRAM,FG. DRIVER . . DlfAel TV REDUCER VISIBILITY,PEDESTRIAN CLOTHING COLOR, CONSTRUCTION OR REPAIR w4RK. ETC.1 COLLISION r I Driver of Veh 1f1 informed this R/0 that he was approaching the stop sign and was slowing, .r= s"',' down totDRT_when Veh.,3 stomped acrosg the street_from him with his-high beams on and'?he?',I ' was_.blinded_for_a_couple_of-seconda_andive_failed._to_st-oo back far_enough and,when Veh #2 R# ` ent-by?he_struck__himjn._the_-left__rear--witb bi.s_right_fronta_V_ah_? was not_iJL-?lyed.in } • .Y t _the-accident .-and -wasm-1t_on_the scene_when._this _R/0_arrieed._ ' • '+_? -- POSITION BEFORE COLLISION v[HICLE ....... D 9' y .f?Nf HEADED MILER '-- ----- - ' NO EA NO OT [ F REwsING ON STREET OR HIGHWAY NAME OR NO. ?'? n ^ J- Old Discovery Road ] n [J a a Miller Road 1S I ED ??? OP R q i ED]OICYC ST-USIN E e IF G. 17' S-NALK _ 5 G _ )(1. E.-LDER KL I CF RK- WALKWAY EnLK S( JLnO Z ROADS. CINEACE.. ICHE 1 WEAT ONR . -- n ,.. CONTRIBUTIN G[KCUMSTANCES C EC E OR MORE/ I jL NI ?OAY ' OEY s ?AEBCA3 D DR NO. NO. DE L E C ? iLOwINING 00 L - I ]I, NET A ' ] n RAN-_ PI I Itl nFUCS uENCE OF B o f , - I] sNOw _Fjs-OWING _.ZTATED n]n YCD IN _ - O r.. ?tKn ICE . 'GO F lELl REAS EASE SCDNG PE I n10 s?i B -I ED D n rF c NT RIN . N. _U r?., I R acARD ' OTHER IV¢cNw E enfvl - - CI6r f •J-s. eoyG 1-J- ?E]` MGN/°GNAL $ GNTIONDITIONS ICH[C O EI RAF f'C FON fRO ,„ENO ?E...TYPE OF OAD R VEHICLE CONDITION ! f (?EI I SIGN O /-I C ECK ON O ! O E WAY na ] ?S € ?I gF ri AA G T ' ~ -l a M ] WAY 71 - c Iv E I DA • I f , ._ ..... ' 1 rr ??L SION 1I. E IBLE ? I O ;f BI [f - T I Pf?s G . ? ? J LID AM[G _ NA FD GH TS HIIII CLIGHTS AMFOR D ' ? ( (' (_:4}?. -- S 1?y?D.- j OA f f!T _.tIGN SOFT _- 4 I B .L SIGNAL ' EW SIP/ITNtGHTf ^ ?NC N _ ' ^ D E NO DEFEGTs 22 r, , t _ OigIR IYFCrF Yr' y. nwi "DL ' -- ]OVA r Of D'. Y Oi PFt?Fv - NFH Is xvIfTIGAtIMG Or•I Deputy W.C C[R S AAMLAnANK . Gebhart DGL 6 Lr[E Dr rltp .12119: 2 19 193$ L I INVfj c c r crH s N.t r UrANA xADCr NO !N1 HE I JCSO OISil1 "" DUPLICATE C IN_ ORIGINAL CGAV' SEND TO WASIIINGTON STATE PATRC OPY LOCALLAWEN FORCCMf NT AG[NCY'SCO11-TRIP1H ?F OTHER TO {p ER Ecrr E 0. ?-. 'Xr5 ° z¢?sGORDED WAR STRAIGHT a AHEAD '?).? Z. BITTAKIN . ASS ND. ?IAL_1 ASLE RCRTLY EP I?'7 n I_.1 D KIT TuflN ' RKING C115n_LDG O O CI LE MANG ITURN N L--I L E, CT_VE EOII P."' ][? Blinded MAKING L ?J? ? uNRN EXISo iiowlHa -LBr? OiNFR IS TEtI L I' LJ OWOLA ON ?TO TTOPPEO FOR TRAFFIC VEHICLE SOBR.E... ? ICECK NEIL -1 fJe? a>OPPo sGNAL OF STOPS CN STPPED IN ..A.- ?? MPAI.E. TY ?IOL--I TRAFFIC G-NE AIRIT _NOT IMPAIRE? ?11? STARTING FROM PARKED POSITION 03 uBD SOBRIETY GI)J TRAFFIC/ EFNTEgINO n C DRINKING ?16? NACKIND 110. ] CHEM. TEST l 1. r-7 TF6T GIVLN OTHER IBPECIFYI J lfsT REPOSED n [ _ 7o TEST RESULTS Z LI AHCL IE EIC PLOW cI AIR IMPEDED _ ..... 1 40YED !,42 RIVmO' ,.CO 0 0 copy; rI NIX'? iv°l"U I J1-. p L?. rI r+. S r .y7F a. , 1 I L {.. ? I I I 4 1 ` y ? 41 •S "1, DES Y ' f C 1 W p> - 1 _ AM` PM . ?. u LI?.iT ?:?C.yxuriLL: '... CO rY'..,.:.::.. .. GTY FTO '.. ,*. a MILES"+. ...:i::ti:G .T WK•:: ... ,... :: DMCLS// mEFD Out[On//91''A. OWE:. SECT ON• f?l' 3Y AK Wcwl n0 ©® OF ? R,. .?o GVENAMEOFSTPEET, POb ORHNDIWAY „?..., '_. NI EPBECTWDYATH; STREET OR POb .. - : P? aED jf `i MLEPQST,vT ?' 1 ? C7 .1. 2 rgNINTEPSELTIONLDCATN]M CO.L 91011 G4?J? --co-p? -E /E O. 1/ /f BETWEEN STREETMD STPEEi MMCyr.??,$ t+ lL,•1•r?• L ??jiyJ?h?.{j?"r+.l,?,v??• Lt '.fir?'A '=11 - hLil>'. 3 /e.T V ?-19? i? Fa.ewWE © ?•? PAAn xOr xbMAEr-iaNEO[n1YwOLAx 1 YHEasLCNOx. ©® FE O ' WT?. TL NON. %RO WTER CLS .'O _ k{'P CIwOTPFCICq POAO PEfGFIK=OCaOSS Itw<ETOR ' - ,.'Y= ? EHCLEVFHCLE ?vEHCLE3CVCt ? 1nEa-111 ^ / W1u5CHwVpvLO 10NLx0 ?YErKLEf 01- ?VEH .1 VLrrclf3 (,' rtl'11 -_ ?Mx ?Hir Rw EW SPEC COOEUS? i ?t- Vr Jj r pMECrsTAVCNI : OWHEROFOB OWECTSTRUCN IxwVeOr • • JECTSNAMEM rT???? DAIXIAM WLOAT AlY ?lJ EPoAD roroNevAriquECT FEET • .. MI.-E FIRSr NAME DRIVERSI-ASTNM[E. I GTREET AO RESS. II01f1ENO.M0BO% .. . .. -. w=- III COWYOH OR ECaE iHw. TVN vDI30xs WEaE A 1 FUTST NAME MIBOLE ORfVER9LASTNAAIE STflEETA00RFS3 ROUTE NO.MDBO%NO.,, GTY STATE ... .:. DPCODE pta?TION CDLIS,iON RfPoatfWM CITY.. STATE OPCODE DLIVERSOCCUPATION; ,.. MBEP STATE SE% DATE OF&RM AGE DRWER9 LICENSE NUMBER STATE .. DATEOF& TH AGE .. - MMO UAY YE.a ? . ORWERS LICENSENU M F MY YEM .. SODYSTYL 1]LW.1 . VEHICLE YR. MANE ICHEV.DODOEL L(NOVMD '. VEHCLE YR. MAKEICNEV: ODD3E1 MODELINOVA-0MTI': BODY STYLEIR DNI: .:. _.It 14 ? NO._ ......STATE..... E .. ., :-TPAXiRPUTE LKEN9EPUlE NO. ST ' LgENSEPLATENO. .. SLATE ` VEHNtE gEMIFICATgNN0. - I. Ilaee MO0E498 NEWER(;. '.:.. ODOMETER IMILEA0E1 .. VEHCLE IOENTFgATgNNO, (IBOBMODEL98 NEWEPI:.:.... OOMETEf1 IMOEAGE PEGI4TFAEDOWNFA,?...•ILA9TF•IST; M1DpLENAME) ?.. .?.yy:?OgFIERSLN;EN9EN0 „.,?„ PEWSiEPEDOWNEA,.::; Il/STFIRSi?MKJDIENAMp•_,iro. .?_..OENVEPSUCENSEN0..:?._i, M PI E :. (STREET CDYANOSTATE) OATEOF H „ - .....-.:.. M O ERSADDPE99 ;. ,, :",.. ISTREET,CT'ANOSTATEI ,; PATE ?BWTH i NArlocost nAHt9 FVENICL DANApEO .....r ;:',: -. ..••.. ,::: -:i.. :tp IPyAR VRVGIE S PMTS OF VEHCLE DAMAGED sm.-0WST - ... ...:...• .• .... roIKPAgvEwrAe.. WAS E AUTDE DIIS T WSURMCE O YES ? NO LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• covERAGPbf wEFFECT Cr FOR THISACCgENr 04 VOL'R CM NAME MDADORE590FLMBII]rY WSURANCE POLICY HOLDER,;:.. ... , .. NAMEOF Wg COMPMY - 4 SUPANCEAGEM 711, 1, - ,.. UA&Utt POUCY NUMBER' NAME MD SSOFLIAB1 =P 5 2 6 7 1ST W.NIPY -. :. - fNDINNRY IVSESEPARA EPfJCRTFOKMdrOHAt•tENA1&- .I4E: 101- NM1E `} y` \ ? NMAE [ -. _ •? ( ? ? wwEO 11 ? ? ? L re • ?+ ??? \ ' . C ADDRESS L /?/•I raj }(/?V? p [ ? p ?IL+LMV= .. Zuj --- A=T E Gi? M -- -LLLII ? ' Q - E OFwVmF9 N a `_-!`^.-.?I,- LJ?1?V_W - I =) I _ _ a ® F ctom C.ie mctam \ ECdJ Moxer.0 . MwE MMNNLSTDNDuT E S :: -: ... : . STATLI30f Y ED F E-TAPPLIE9 STAR90F-IJ >C A VEHICLE OLrAws.O NCx LA].LM1Kt P04ti rE r•I ppl ; IN VEN1ClEm ro? Q 11 l WLLED 1#Y= HLI NE?wOAI 111 T F"L@7, 1((E rmvl NO ALLIED Iwv' 11 IMr10m Dy p?ETCI , pFrN.lLCI - ?FE m 13 J? B .' ... ?D•f la Lr RI1FaN .., ? FJ? B T? ER .I SoWNORTHWARR WWGRCLE VYMAM O ' vKYC [d M '.. OE9CNIBE BELOW WIMT HAPPENER.IReFEfl TO YEMLZE98YWWBEM ,:.. i:?k:.1 d w ?A OuTwelHAr xerLEera ?• 9( a0ir1 I?iOHw°Ci? H?utFf M A] ? O e 1 \ V ? _/? 1 _ (]_(?/'T? ??? /f --LIJ?.J -? -?.I..V?.A-• 4 F?••? ?\.7?f? KH VfKY( A•n • Mw P?.E?r?;T„n.HfL3rMN.Dw ?,? Q?" ? AEI _-HOnwA ori? CouanfiNY? - ?_ -_- j /? ? Vie. _eorrie?' .,:1=;:?3-.:_f?_-6r_??e5 MPILIDA.K>..wA. ? - pw[N1i1f uoM s DK M04L. F.AF1D rn.cLl occwD ?i,i, ?amfK VEHICLES POSITIONS BEFORE COLLISION TREETORMWIWAYNMIEORND Pa1CTKY1 [s ' b 3 M) W IIX,C• O NS VEIIKIC H ! f W O ? C, O O" E ?"D:,o °T b IrDAA ? ? ? S ( I KRFr O ? D Dr1Km ? O O 1YUnm,H ? O O ? A- el?o]Ma FRoM DIRECTION TO DIRECTION n +uN B OTHER IY OESi11141 WAS l131Ir6 10 SIDEWALK ]?WALKWAY ]?SIWLDER 40 el 'WMK s? [rai IgAD SUa FACE w[M.ER LIDHTCONCITRO 3 T-ICCCNTROL KHLCNORI TYPCOFROb DOVEPNEMOIE biN%A9 ...,. •., ICWCNDR (wuOKLI '. MCl a1 v N IrK [ 1 pT g ? I KIHTAD+1 v K V N1Sle Ly b. HO] µ,. rA> EIZ1D Ate" 1 ?,AYLiGIIT ?r11AM?WGNAIS o l ?ONe WAY C) 1 ?DQND arRAKwr NIeAD t ? TWO WAY ? i ? 0 tR1ANE OANO PASSND 1 y[I f Y P ' sqN ] U- I-Io ] a DAWN f i0 ? yfte ] ? -14,40 IIgNT 1:r11N D 91GN O O ? ` A wl, - ?ygYArq ] ? DUSK a ] ROM a t? !Er?(DMK 9rNffT HTERG[ANDE • ? M"NG LEFT TURN r1 1 ] ? S.pIY ?mo ? ? e a FLAy,Pq RED ? LJ • ]]?lUnT30N ALLEY AMP( ASNND AMBER ? e ? ALLE ? 0 ? MMWOU TURN OMK sTRf Ei ? E ? ICC F y L y?o".ER ? E ? a GNT30rF L IM[G1Y1 DN.e AY. .te / ? ? e Q mow-4 a a a LEFT 1 ° ? ?,I- a LXL'ermKE f?gxrs a e ? Mau TUR. LME3 a 1 ? srwfo FOR TRAFFIC nIIASON wRrgT3tfw0 DAHOfR '. Or (N ? r 0 OlrgLR4LMMMl 1 ia MlG Y 6TOPPEo AT BKWAL n?A.CMKOV•VNw D]1Ar[Ib..f LT<1. l^r•p ? s aOf ER, M[G1Y ? 1 ?SEPMATEO ? s ?OR STOF MON T W •TV••=L `? --- ? _ ? p?0 ? 0 ? STOMO W IgMWAY u,?rT,?n9 0? sTop ?;qn ? D gT VFC volo ? to ? ? k . C ? T ? ] LWD TR FI IF FMIE T w1rVd3 NAMe Y??ODREIO ?x TMF GK :?6eLw w ri4N J... d...w ?+111I t ?L4T ?eTdlaryuy ? i ?fV? C] IT a IT MM I ND F ? EE ? TM". .1? mM4eL* l TRr 4fitII?^ T ASYFyry?, 1rSR1DRi I3lrbn:^; p?ACSYAIAT[¢DA[L, "?4.? 'mT77 yfLtW,y.. ?M1N."'? - R Y 1 !.: ] l J y. ... ,_yfW_t •AIP x r d. Y M.F,,._ E tir??i `I- NnrynyS 1 ¦?aelM - f I F 111r 1 ] 1 !L' 1 l 1 11 {?.? ? II I I Y 4JR w? A ; aA E i3 - ---"?' TIMEOFCOLUUU rOFS ? ? 4,1 = Er `r[,N sw ,A1 w[D NNR F Yr WD AM GI '' D vM • D TI / CDyNO' ElV•""RIIAlf COU4TY EE 1./ (i iY. iL1Yp1 s0YI5uf MLE6 CITY, TOWN GMM ?P (7<iri.. N J,[LC 4i t•'{jAAq (1' E yn; 1 ?•- occw9f tJ ©D OF w !'"'-U /:J.:I/?y?w ?? ADMCL6 PREFI% ( ?o F?oZ AD /DyI/T /jTJf})DF ??q _ ? q0 GIVE NAME OF STHEEi, POADOfl HIGH W AY WTERSECT Wf, WkiM SiREEt Oq ROEO l PREFI% EO - y `? ? (l ILEPO6l: NON INTENSECTgNLOCAigN OF COWSION BETWEEN tlR E ANO RAMP DIAGR AM DATA V !i ? ? TroT O © RALNDADCPO55 a PTewuaE n M ' UrosTOR DfNNFVWG um- TFRS f ©® W cowslW wvaWD `E-Ipvfwclc vfnclf pvfrvrnf e?crDLE .I N CPD ? w05r Er OP LIABILITY INSURANCE INFORMATION-V HICLE NO. T AS THERE AUTOMOBILE UADIL I I1-H-CE COVERA } TAME AYD AppRE550F UA&IfTY WSURANCE POUCYHIIIER GE W EFFECT FOR THIS ACCIDENT ON VOUR CAR ?YEB ?NO k r nM'%=? / ?! •Jy J, ('j `) f• -E. ?i"f I AvO ADIXI r? C Fw rJyyAME OF UABIUTY IN/6URANCE COMPMIY, jf .. - sr j -1 ? ? ?/ N<+1 ??J`2 ??' I JL ) -? Cam?/".Et` I .S?+uy ??: K? r ESSOF UA mSURANCE AGENT , / rnr 5rM[ iP BUTYPOUCY NUMBER v TWJVlY ,:.. .. AGE 2NOINJURY: N SEPARATE nfPDRr FOR - r _E - WAm fsl AGE ODRESS __I -Al D -0 E NAME ADDRESS :Iuk F M SEX ? STATUSOF NJWEO NAVE MARK F A ST CHE THAT APP u b,rp br, oocrpns ® MMPs Q p p awvfn VEHICLE P[DC51AKKiw ? KILLED DcwefWD ISEVFn EI LIES S ?iUS OFINJUflEp uon oSAerwD roSVDfF N+ipi1 IOFCPO`?Ev pPAS..Erq IN VEHICLE M AFK FIRST ONE THAT APPLIES dSAbLwG drD15Aluw0 Pw?iunU KILL ED ISFVENfI u .Wi wf ?(+r.Irr wA'1[ u ? 50 6 ? pPF 5 NO 71, ?rvn:w <, I I 1 [FCOM EICI ? 50 1 I:f A' NOW HORIH BY AgPOW WCIRCLE ' « O c? 60 70 SDflB OELOW AT IIAPPENE REFERTOVEHICLESB UMBER, ?/,'? 441- . pn ncLf vfpfs tIoE LTUAS,%w w "ERlwrarN ifw Lis ? p uxwc iwu. pvrar? I / .., c o / LeE : -(o/iJ 0 '... :. r •- J ! N .: iECT "TRUCK .. _ -. wwE G<OwfcT9TP N .... . . OWNER OF OBIECTSNAMEANDADDflES3: -:... INLOC TIC Y ?®.- .C.6L N P _ ,. ' I. •. FEET E.. IERS LAST NAME FxpnE rrv,n - fIRSi NAME MI00.E Tw]cuf5 A- wfRF wvDLVfD • • .. DRIVERS LAST NAME '.. .. FIRST NAME ..... MIDDLE . R" L . N :ET AD ROUTE NO.ANDBOXNO. - -AE I. tnw IA / 2 lil-16 `y",- , 5? PF AE 6TREET ADDRESS .. _. .. _. ROUTE NO-AND BO%N0. (fi r ,' .. STATE LPCODE DRIVERSOCCIIPAnON - I-- -FAIL AfP,n,rL c0uL5pN ITY . .... .. STATE , . ZIPCODE piIVERSOCCUPAt10N ;i . I x EflSLICENSE .. - „ / STATE SE% ,PATE OF BfliN AGE ?/liD- ? _/?Y_A/?C.? J EM 4 *?i k ` 3` ` , 'sJ ORIVERSLICENSENUMBER, STATE SE%' DATE OFtlIRTH AGE x ? yI ! F Pk s AE YR. MANEICNEV: DOOGEI MODEIINOVADAgTI /BOp ST EI2 ) D9 F DAY rF P BODYSTYLE12 0%) `? I •{ -PLATE140 O BT AT STATE E N . TRAILER PLATE NO. GTATE ?JZz 3. Q? // UCENSEFLATENO. STATE ATE O. STATE STATE YN LEIDENTIFICATIONNO. 119CDMODELSANEWERI OCOMETEA (MILEAGE( /L YEHICIE IOENTIFICATIONNO. 11968 MODELS( NEWEgI DOMETER (MILEAGE) '. }2 R lER OWN 1 TFffl T-MIDDLE NAME) DRIVERSUCENSENO. .GISTEREOOWNER NA,"aT FIR6T MIDDLE NAME) ORrvERSUCENSENO. I u 95A E55 (STREET.CI TE) GATE OF-H OWNERS n A ADORESS ISTREET.CRY ANp STATE). DATE OF BIRTH y - ^` k' w p,r vEAA • OF VEHICLE DAMM:EO J , CJ?v fsnxArzpcos PARTSOFVEHICLEDAMAGEO rJN ? , ,T:c !L' ? iV C// rD re?wP VCN?1Kp .... EsnuAffocosr '-' { I R? yc) a ;? •.rFrfW..v„r.. r 1 t VEHICLES POSITIONS BEFORE COLLISION nK1[ ? ro IrLAn P S E II1??JC ON 'CT OR ? ? ? . ?y rDIM"I ? ? ? ? ? ? a ALONU ( - FE..w.AN WAsu5Wp 1 ?YDEWNK '? . RoApF Ace cf u.r WEATHER LJGHTcON01Tld: v[wc.E ,ft ! ?fl ?DPY Il DI cf:,,°°r°," 1 ? DAYLIGHT ? [ ? %Y[T Arw•q t ?DAWR 2 ? s 1-14 ] ? DULK ', If SNfIW ] ? E. f ? EOO F ? 04 Pig tpPr '.l r ? • CJ 9 ?S : 5 OTMK 5 pAP. AtIITEi ?IrJ'(C/YI [WY 5 Orr } ? ? !R i i 1 p p MCIFY [f y? f IK•Nt5 WAI DANO[n " ? RE A f ? l ve .LM ' [O.nr r OI[P FC nn ?-fl, " F *P R ) ._1Iff I f h I InD _ AM5 wvrrv:cLE _ .. _-'._ wv[sTaATEDev aFF ?Ar NAME On NO owfcinN w ns rP rD nai occu.aD ?sIMF ?DI O PrP ? ? ? ? ? ? p q C! ?rOUt[ 9b?0?OMn 9P ( . ? ? ? ? ? ? ? SnFR F wNKWAY ]?WOUlO[R A?cAboiiwxF FROM DIRECTION JO DIRECTION S?cinlu e?OTHER 11 TRA[FICCONTROL IcrYC[pKl TYPE OF ROAD DRIVERYVe1 AC 1pN9 rf rA w '•1wgf Icnfc, Ufw r I oNE vTr•cu Krnc?Dxi on wlKl EI ? I r' ? I' ? I ? YGNAl.9 OWE WAY ? 1 ? ?r 1 ? OdNp 9TPNWIT (HEAD ] ? SLOP SIGN ? rrfLD SIpN k. M 2 ? TWO WAY RYBLE ? 2 ? OVERT-IXIANOPASSIND % ?rLArwwp NED ? ] ? ROAG 1 . ?Wtf RC RRNIOE AMP( OG I ? ] ? MAMWD Pggi NRN ? • ? MAKING LEFT TURN } •? F? ? ! ? fLAYr NO AMRER ? 9 ? " I ? 9 ? MAXNG OTURN u [ ? ? WAY, ? LE n lUm .AOVnwD ) ?Jl!'f i OFF ......G,M- ? LANr! 9. 1 Ar OF o ?[ ? omrn a'farv ? O I-AlIm . sl0rrr0 AT NaF U 0 O° OOrr, ` .. .. ? 2 o ' ., . d r i V• r DATIOFCOLUSION_^, _:.WY CAWJOAFR ? IIMEOFCOLUlgN ...? D T `' Eln u0N n Mwu PM CC :iiYt10{ly CIIt?Y`tq, ?,y:;u'4?yµ /.Sa??.Wf. ;;:rl'T hL 1'TC] 4- ? A E .:,.000nTY :' C1TY•iONTt:i..-'". ?, R^E9,NI© ?.:;Gtt. TOWN ::.. _:?.: ` IE I l © T , ? 1 ? • O?MC}LS PpEFllty MCIX1S?nC SECTION. i?p ? ?('3t?. . a : 1 C P rl OF 17() L?I Y v . ; ) :!::7 , ... .GIVE NAMEOf ST?EET`Pd1ADOfl HIGHWAY :,._0.1...., wlERSECTNO YATM;STREET OR ROAD; ?,A_. PpEFl>?; EO ?• MLEPggTy?c >?§1MfY,,I?Y?Iy?,+,. NO INTEflSECiIONLCCAIgNOFCOL SIGN(/ // PFTYIEEN 1 (/ - STREET AND $TRE T - MMptytt?,??7p?IiAgG.;?RM 'tn? VW?d" 1 pATyA, .Tyt(?l f? rTIKk•,F?,VAS10L"YJ E ? f O O© NAU10?0[gSYw MLLf05, OPIDENrP NOUNwAxK NON %flD Cw0 .' IT?% . ©L'I o rE JHi r YS NTER- CLS.: ? Rs: EnENt rr09S° PUL Top AOIOT ^ ,r/a ,, ?sf, ? EIKIE ?vE IKYCIE ?O,rvf llxx lU - o vE SVEOCODE USE _+? „? ? ?..,. ? .B1kCTSTRUCN O[OVEGfsrRUCx OWNEROFOBJECTSNAMEANDADDRESS N- LOCAT INR 1-l IO -4 EET fIXll O OWNERS LAST ttAME !FIRST NAME A110RE qnE r , R flK0 C MVERSLASTNAME + FIRSTNAME MIDDLE (DR C 7YrT J1rlnP Uti L'A l UInkET AOCRF.SS flouTENO.AND90%N0. c c1 STREETADDRESS ROUTEN0.AND5ox N0. o?? 1 r INxnEDNA ._ CITY STATE 11-11 ? e 4 c! IlJR a ` l!! DIIERSOCCUPATIO N Nuz-le (till sEPABAre caLUSOx PE OAtrDNA CITY . STATE , .., , 21P000E -11R3000UPATION DHN EPBLICENSE NUMBER, _.. :. STATE SE% O ATEOF&RTM AGE .. ORNE1E9 LgENlENUM BER . STATE .. SE% pAtE 0F8 :pGE. 1 q,7 11 I S M ? g F}n •?7 M F MD wr ME E1IIGEYR. MAKEICNEV DOOGEI W MOOELINOVA-0Aen BODY STYLE 12 DR) VEHICLE Yfl. MAKE(CHEV: DODGE) MODEL (NOVA DARR EODYMUE120R1,.: Pi V Beef -fU-CCNsEEPLATE., STATE TRAILERPLATENO.,„ ,. STATE LICENSE-TEND. .. STATE.:,-. -. TflAl.MI TENO.',. V&nCLEIOENRfgATgNHO. ,,.' I19SBMOOEL9FNEWERI _',. ODOMETER IMILEAOEI It U 2]3a-72 ; VEHICLE IDENNFICATIONNO...,:.,: IIGNIAOCELSSNEWERI.:. ETER,(MILEAGE) HENSTEREDOVMER_...: ILPlTFIflSfMIDCLE NAME)_T;,. pflNERSLM.ENSE NO.. REfiISTEREDOWNER .. ILASTFIRSTMIODLENAME); ,;_,. ORIVEfl.R IJCENSENO ,y 0WNER9 ADONESS (STREET•CTTYANDSTATE) :,, •:,, PANTSOF VEHCLE DAMAGED DATEOF&RTH b E OWNERSADDRESS . .;,ISTREET•CRY.WDSTATEE :_ ?•,: ?• CIA BIRM;:: uJA Si ,.sE4n ht R l : M It .:.:.• :-•: P.. ??L. JT/1T?CL?P. AvE?xCrtA Flll0FVEHCLEOA,IADED... -.:,. ...... '• !O VfNtE°` 1?Yc .Yx.A1 fF? LIABILITY INSURANCE INFORMATION •If-I ENO 1 Wti` EGREEI EFFECNEFFECT FOR THIS S TY WSURANCE COVERAGEHIS ACCIDENT ON YOUR CAR OYES [I NO Y . ?( ?E AND ApplESSOF IIA&Utt wSUR.WCE POL ??LOER .. ., .. ..:', UTYINSURNgECOMPNEY?;.. •. : ?• :.•.*. : .. ...'... . t . Y 4 -F &pp 51. ,T J SMrE T I CLUTr C m jQmaatcn NAAIEAN ADORESSOF WBIUttIN RANGE AGENT -:' :: .•.: .; r k ::5lAt! .. j-1.1TYPOIICYNUMSER.. ' Ir A 8 - lo- al ` y&- 7 "F l - - 1S T wJURY - AGE 2NDINJURY IVSE! eRFPgI fOn KwAIwAAVtS1 _. _ ' _. .. .... _, -:. ..., .. "e.' , Q , • :i NAME NMIE nuUREO l > Y? J , Y I• - ADDeESSO SE% NDORAES! BER.: Kr ADOt,Om f E" [Y 6TATU90f wJUREO FIRlf GIE TNATAPPUES 55 , - 'Rv .E. OANEn NVFNN;LE 'z-a G7. P?0(xG[p 0 Q MAAK FIRST ONE RUT APPLIES STATUSOFINJUREO ,- KRLEO E ? wVEM CLE q NG,GSARIq 09.'A ANI O MiE OM ° Op fR IYVFnfI IE? Y rri. t?. ? . Py . ?F[MO,pAN NO ? 5c] s? 0 f p NM WAwr U I 7? ,CI ? ArI NO I a. nl :Yn roll! 5 7[l ? 8 N O E,V. ; _ R ,•„ ?t F,,. ro?[ZgR?In?RDeE lrnEE, S`: ??;;°w \ \ ®\ ?? A ?s . ?aY/ D PENEOIRE }_{EQSICR/S y[-4f'ET ONyV1MIAT yam,,,, 1 , ?v ? ?y? +. FE, TO C S?CJ1:.LaKY•_ 1 - W_.! .I,I.O •011 ??F?_-kl?n oo_?ko ?IlLH-c, r rnU lei+. C ) t -F A MA.,EA. f NuPAlA [KH v!H t! A?Mgw •. .? W11CMxp MA I I VEHICLES POSITIONS BEFORE COLLISION T (` i ?? ? Y'o I?'a^ ?L?`? 1E [ell 01 : I ? ? ? 71f i ». ???? • t L ???? a a q 1U'1 NIVAM1 U`Yq 10 •J[MWJLK ?{ ]:. I p.T nuwrACr. wY.1- Lx f ' LK.NrcDNanar. - & '' 1 NI dM t 1 1101 DAYLIf li :? 7 W) ? 1 ? ? M,v ] ? N+KI ] ? DAWN 1?' 3 I 1 r t 4 _`,y ' ? 2 ? NLT ) ?'hOYMrq J ? 1/.Ow L ) ? pU ;K B p o r [E! , 'rypqy I Y 1,. J f ? YG4 ? K ? CC ! ? OI r111 ny n i r A ? ! ? DARK S,RIk, 9 >` ar n nr T ?]TL 1 w oti?& r ',??tc 6?., I F c , w or Ax VAY NAMk ON 110 Ow LrilE ? t Kw 1111 y PY Coe, climl.a ]WALKWAr D?SIIOUIDEn mArfgcoN,na Frvta oxn ?I I l•?1 LGNAL4 ? ] ? 51UP :AGN ? J ?rn1Ox ? A ? rLAI'MeID ? ? ? ? ? .10 a"D! ?oM"D"x Kll. IGNr?tPr I! 1 YxC L?•_,?•M•VKMOKOrI[Mwlnfl ? t ?ONE WAY ? 1 0 G0IAO5TRMWITMICAO ? 2 ?Two WAY ? 2 ?(YARTAMMOANDPASNNO ? O ? v04ME IOA ? S ? MAKING NIsHt TUnN ? [ ?INTFACI t -F M A ? MAKING LEFT TURN R AM ? s ? s Or1.m IJ'lGlvl uuililrgdr ?Arwo WAY- ? ° ? MAKwn u.runN 1 }• 5 ;:- ':; nTASOV rOp f7lSrrNOOANG[R ° ? sTl K Lgtlt! [J ° ? M AL ? ° ? It" TURN ? S ? ROVANO V I 1 rv I ? rEE ^, ? I ? o' FM RAGMAN IANE! ?{`' ?.. vrv?°Yt ?f. ? I ?BigWfD FOR TRAFFIC } (L?a? kc`k'aLF1CLJ ? ! ?O,HER. P[GrY SEP--- R STCPPEDArllGNAL ,I T 1 ? ?• ? ? ORSTOn SI (Y II ?l %llon ON ctTcc? rnr+ ?c? -?erz 1 eCrJC uay 9 ?SrOPP[O WROApWAv ? _ J, y (t. C.I tl1E - pupa ? D TNO uNDmoFO ? C] 0"AR le"MILAN 1 ''.'I _ I L I?t Ul. I.wiw n r o. a r_;M - • ? ' Nrr G T n i fT?Y - '.._ TY T lJES r CIT O ? ?Tr? I-?l LLCY,? C?r/ 1?? 1L /J Nyd. D A?LS PNEFIx x?.2w T. . _ I' ,V N E ST ? 'R ., qY..,;T.: _ .TERSE T }r'/. E6T R ?? INTEPUE ,ON LOCCATIO1 IF COLLL.ION l/ AEFIX E ST /?•?? x WEER ? :REEi 'P aORaM OaTA _ r. _ ?' W? x, •xan exosaryo?wo nWS,«xlrel nN.Nne L.NOw.n, s I r wc- o - we6? S, .. 1 G C E.E. G i . ? 63 ' n - %? a Y} J EG j1UCKx^ Y'IN, c- _, OWNER OP' OBJECTS NAME. DDRES CA „-, ,, ?? a `[. 110 IN N, N J q.'O LAST. E( P T _ME a..l- (DOLE 5 PI .n o MOOLE + & is Lh' ' ! EFTA H y. ou NOr ANO;BOX NO. ST ET'A. r .-,`?. +?._.- ?w.., _ f R. .,., r.n.-• o TE.? A.yo . a w '? kl' CI ..%19.wd:.F,JSM_'s C:;_ IP.000E -DRIVERS OCCUPA ON, sroxnnx ... .. .,. -..J. r.. DO U T TE .21P,000E DRIVER9:CCUPATIO01 - y_., ... Fr` PTJ {'• , ER LICET ENIf TiE % ATE RT GE, EE%OAi 1 °Et s a ?? vcN.cLw-,R: MA^ OY 9 LE'.'.1 N.I •EL .rte- LL / •_._ .,..,, ,.rw, vl M_OOEL.. J Rrl. 8 T LE ?f?o_wJ - • { _'-`-•-" J MAKE. Icwcv:o IGi?.tIJ ,,.,< _ F?le?.'tde•S?-a-/)cr.,l?/ LIr. /% Jl 4.P _T. .sInY:T_ 6y?• ER PLAT STATE ICE La STATE J':l LE PLATENO y .STATE; jh?I? +r VEHICCLE.IDENTJiK.J?T(g/y pO?+j r,j, BOr?oo.i JlcweAl °DOMET.(Poxr.uec VEHICLE IOEN ffIOAT40N NO (I I.- Mo t tr Newnx1000 TERI.-e s Fk`tr. L .r1..•a r 1 >?J Ci l .? 5 y.? - - 5- 'G E j GJWNEf{,?, waT-?r 4 cl ORp 1 E- O . REGIST REDO R. HO Nr ,.:. d 1 i }`i YH/ Y/Y9?LYI OIf SIl ?1 J .. .. .. DRIVERS IrICE .E: 1 yT MT[:O D WNEHS °RE59: ..._.... .. .. .•...?.....,.. - E P BIRTH 11 'A; 7"F ' ARTS P_VENKEE(PMMAC, 1 'YLS PA TB;OF,V EHtG1y.E,'D?AMAG(E,D. T^T r.?. ,t W,,.,v,. , S Nur S ARAN - ?. w sr A v, GE LIABILITY INSURANCE INFORMATION VEHICLE NO 1 c E , EFFECT FOR cao6NTGNV Rc a YES [J No A° LSS j' U L'CCTf,YU{n C /1 Ry (? 1f I! ,1 ?/ q?T C JIMY/C47 (1 +?l'/6ry?lAN „OF TV E- O A _ w ^^ AO E99 _ plJt81[fYY UR_?C AGIW - .?r" -?`a 7-t -,-?-YJ S f !.4 C uS--C L N R f' D M F nK ?E?N [- °i ? T TUS PI MAA FIR-ONE THAT , APPLIES our 4LE ~VwrTTU OF NUED ,MARX F14ST NETHAT APnl E° nA -,r ya yti. h VEH CLE LLEDY ? : N VE E o . o v«ns YYY•• `• "" ILI -' I?rwa bo -O r7O Il(1'll ? N? I?O.. ;eve11el Nnrf6? rN lo. 7N Vr 1 $. ?^J (L_J7 O T Y O I HC E E•C U • ??- ` , ,}D .. E BFLOn WHAT HAPPE O IREPCR TO VEN CLES DY.N RE+ 4;?; ,. w 1 r A l"4, L7I r' t H C? I rY Crw ,rw, x.? w. N.w.. nN `\ \. :y " J. wuwnrn T..N Y.NKLY .,P aN]w I -IJ?. < r. _ / Jr,V i' • + VEHI(t CS POSITIONS UF.FOHt COLLISION --T- --'n?-71 IFAnE'D r'. sr G?ATD DY ry1T'?[ LU E W Or RE[T NOIIW AMP. ON N4 NnR fn.Asr w« ? 1I.-- L.J rn, e" Y' } 1 t NO. 1 f o'rwaJ Tl w;:? ®?. ?? 57 J<. rE I?J rnr No rNVr..rw, P ? ] U NJ _ 1-1 rl I t K {' - rHG TD - ?. ( i _ _f J CJ ?f l r? l7 $ , pt TAD q F :WP.. R I L O r-ornm6Ls r ? NLn =r c A TINS ??,? d7 sIT [ 1 ) L(1 .11ALI ( FrGN •'w I"?EO?( WAY •r r? 1°O,NC. 6TRAIf.IIE AHEAD' I f II' r F,I IAINING (-N f •r uHY TJ/(;? { JI ri 1 r1iI ?A '? l? Il [. 1 [. [ I: J _-, TAD WAY I.J ) 1-1 OVr.RTAXINr. AND rADRIND { i r (-? ! 1. l \VT'T ,11-J SNOWING ] [. J DII1X rJ [ I -LD NIGH I f_1 MAKINf. -Mr TURN r ?, , 4r 1'i Ir J'' L'YJ OW A`J 3 [ 1 E. [ ] [ J 'AIMING run (r[ 1 a l l I [ , I [ I" f M-11. L[Pr TURN "±J. `I ; • [ 'C r_1 El II LA.' r 15R i \ [., :1'L MAKpIf. U.TIIRN 'fy , `. ?',•} , % AI 1 rJ, ° [ (7DIID vw DY wFTE i 1 I 1 (J r ; :.I A1.1 I x•J 1 r7 D, N '?I , ••? .., rt.I / (•' J (1 1 : N TRAFPIE , ?? y,J I raJ !)r I.12 [ 1-) (i C] _ n eUDgAL 4'', J [ J t O I I RO AANAY / J' r 1? •J? Ct,I ,).i77 ICS /% !"r. _. -1 I, LD 1 J [7 ?r' ' ?? -I" NI a 74fr-, w`i„r ...?,.N- ;'•'.?'-''rMrJ.a ?!. A i Nu- t +" ?? 1.-' 'J ??nn YS o,'-'?..1 +"? TOM 4Y? r? u. ti r •9. F• Y`: .141 STATE OF WASHINGTON PAGE OF No. +Y ? ?? kR Cl1CE COMPLAINT NUMB" `• UNIFORM POLICE TRAF COLLISION REPORT . t D GATE OF COLLISION OAY OF COLLISION TIME COUNTYNO. CITY NO. FHWA *-R .T `( 4(IY YR. T SUN I MDII 2 NFS S VIED A IMUfl 5 Fry B SAT USE 2I ?MGln1 3 J / ` ?U N URAL COUNTY ?STATEROUTE 0COUNTY ROAD ?C'NsTREEt Q ADM 'CLS. PREFIX ROUlE ORSCREETCOOE SECTION ?•. . ?OTMER(SPEcIFY) IW Z 3 f _ L N 5 E W ?IN CITY OR TOWN W P REFIX EO. MILEPOST G19MIES_??00 oFp•?- ouJ,LsczF) w4. LL Z• 73 BLS {, N0. EBNO.OF STREETORHIGHWAY /y,? INTEflSEOTINOLV1iH: STREETOyFflOAD o765? ' LL O R AMP DIAOflAM.- T I ONI"h ?/O kE•I-(--": /Z 6Io? ?es ..1 D NONINTER1EGjIjKJ- ACCIDENT IN TER NON %flD INTMSECTINOSTREE ORROAOORREF. N • : N DETWEEN STREET L STREET MILEAGE CO. I Cls. ERENCECROS?TREETOfl R. O (J 15¢ DISTANCEgMOI CTI NNF90M EEF RENCEORCROSSSiREE ET S PEC.-C---.SE 5 y?! tI JF?? CR# I 6 BNPAFI Gi?,sa LO ?FEET IF O LY NlSc•ov9-K -l COLLISION INVOLVED: ? VEHICLE-VEHICLE ?VEHICLE•DICYCLE VOpEFr/RITE) ?HITBRUN ?VEHICLE O C BEVEflRY NO. KILLED - WECT ?VEH%:LE-RRTMIN 1 ?STOLENVEHICLE TOTALNO OFVEHICLES ® NO.IWURED ? VEHICLE PEDESTRIAN ?NONCOLUSION ?HAZARDOUSMATERMI. ® PROPERTYDAMAGEONLY OBJECT STflUCK(NAME OF OWECi STRUCK ANO OWNERS NAME) LOCATIONOFOWECT STflNCK ESI.DAMAGE ? S E W ? ROADWAY FEET [3 [] ? C) fl0.E0t)E S . . DRIVERS NAME-LAST FWST -01.E DRIVER-NAME•LAST FIRST MIDDLE IF BH;TCUST ORPEMSTRIANCHECKI ., D oI D R t iIn ct- R I STREET ADDRESS _ .. ,.. STREET ADDRESS - ... .-. V E a _-31 SET v .., R CRY STATE 21P CODE PHONE NO. E CRY STATE WCOOE PHONE NO. nuDtiSvn c tJAt' 38S' /6//f R N DRIVERS LICENSE NO.. STATE SEX DATE OF BIRTH N DRIVERS LICENSE NO. STATE SE% DATE OF BIRTH O, (? ?- LY.'Y YR. O- MO. DAY YR. n ? T •?( DRIVERSDCCUPATION FIRM NAME PHONENO. 2 DRIVERS OCCUPATI N FIRMNAME H N NO. CODES >113) CUUSS 141 SEATDELr 151 EJECTION CODES > IDI INJURY CU59 14 SEAT BELT 151 EJECTION NATUREOF IWURIES NATO O V D FROM SC NE BV: TO IWURIES REMOVED FR EBV• TO VEH.YFAR MAKF (DODGE CHEV.1 MODEL( OART NOVA) STYLE (2 OR CONVJ VEILH. YEAR YEAR MANE(DODGE CHEW MOOELIDAflT NOVA) STY LIE (2 DRCONV.) 1 v 199y deli ?'?m ,Z 7` zdR. v E YEN. COLOR LIC. PUTE NO. 6TATE TRAILER PLATE NO. STATE E VEH.COLOR UC. PLATE NO, 9iAlE TRAILER PUTE NO. STATE C V NI L IDEN F A N NUMBER .- DOOM q (?• V HIOLE IOENRFICAII N NUMtl .. M R E g?/ 225. 0 7 0# s - _.. a NEOISTEREU . AST VWST MIDDLE REGISTERED -LAST FWST MIDDLE N A4 aA Ak A. a N D. ADDRESS OF . . ADDRESS OF , OWNER .. : - ' izs's 5" /ro pj4, 17 L195 2 ... : .. . . .:...- ...dl,.,:v 1 NAM ANDA RE O W -RAMC CO.ORAUE- NA.E.0 AOOREES OF INSURANCE CO. OR ACEM. C E CITATION NO. ENFORCEMENT CI"OE ,,. _ •. .. j ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODES - ' ' S , S E% AGE or ATU9 N , „ EJECT. C NAME: C ADONESS' U p NAIUH IE EOFflOM IwunleA SCENE RY'. TO I A NAME N T ADMIES.q _ $ NNlaf9 i•JCFNE RV 1 TO t 1 W NAME'. T AGOTESS N NPPIT : SCf NF Rr 11 M T O 5 Nu•F S _ ADMiC9 I 5• i IAl I-A (?r'- If ANf nv T O I I 11Afu] I/I+LA I f I•U:,IIAAI IYCU': IAIBLAI MELT IYIEJECI%JN I t: P.VOIKIM ' N Pf i 19NIM - I NO YANK( C DISAIRN011WRV I. NOf INSTALLED I. NOT EJECTED A 1 D O . . A 11f 2 DF An Al s"CNE Npl pSArv 11X1 l NOI W USf, 2. TOTALLY EJECTED -y \ !DRIVERFOAITKAI OFAUOIIM rvAI f NO II W 1 0-I. ; n . f NiI JU I Y ]USED . PAMIALLYEJEMFO OIO ICYfLC11 DCDVIIIO•yfTAL 7 PUS,AIIIC YAlfli UR Ol'IN A.1111N OWf S STAT 101.0 MHRF .JCCTEO IH IM tl 11 ' `? ?..: 4My ?Str?k' " A .? T4, µi'1 t. ? v',.l t R Le . :+4" ' ;.? kIM .,? ..49 ??n >I, ?! ?kar vti? l?8. 1 fMuR4iu IdIr.A+ I N k? a LYZ:M ? s4?7J, VEHICLE DAMAGE TIN EACH DOK,C'"CLETHENUMBEROFEACHDAMAGEDAREA. "' 2 SHADE AREA OF SEVEREST IMPACT A'wPlt r®? , ?? ?nl x k _ n ?YrY' r a G dr. 1 R 4- INSTRUCTIONS: WAHHQV43)TO SHOW PRINCIPALDIRECTION OF FORCE. Qom, - - DAMAGED VEHICLE NO.1 IL ISSPACEFWSNEfOHINGDAMAGETOTRAILER%MOTORCYC C.1 DAMAGED VEHICLE NO.2 _ 13 lb d . o 131boE :? ."" 14 lbNl 14.A-1 {{{p. }I 1a. TrunX EA, Ia:T- 11 . ? - L? ` IB.UMercwKye ? E 16.UnUwerru°a 7.awlwR v.wamAn SEVERITYO OHMAGE: VEMIClE N0.1 1 QDIBAWNGDAMAGE 3CIOTHERM.V.DAMAGE 2 F n.nONALDAMAGE NOOMIAGE SEVEWtt OF DAMAGE: (OtMER VEHIGIEI I QDISABLINGDWAGE 300THERM.V.DAMAGE 2 FUNCTIONALDAMAGE 4 NODAMAGE SEVEItrtt OF DAMAGE: VEHICLE N0.3 10DISAWNGDAMAOE 30OTHERMV.DAMAGE 2 fUNCrONAL DAMAGE 4 NODAMAGE DY TOWED Sf.OPMAOE TOWED dY - EST. DAMAGE EST.DAMAGE - TOWEDBY TO 3 r, ? ro ro ° DIAGRAMOFCOLLISION Ro- I I ' I DRAW ARROW SHOWING NORTH IN CIRCLE ECI-1.1 I- ? ?? inrF S anusLA?mca ? ? V I I I I I I ? ? : I I IcevArcncaAViRG4cnu ;x - '?? -I -TC I I _ ,-1, ?•w L I ', I ;' ( 4 I I J i ?- I I - AbLEPoW1uF ACT t6 I E 7?1 ?1. T."?-_. A ? F M ' " ' ..?rD«LEYeH°LE A4OAflENCIX3i4q!°?F -}- C?' r i ?y l I ? .__ ek I rf r I f, H _? J c ? ?e.CKP DESCRIPTIONUF .'COLLIS'ION BNDICATE WHAT PROBABLY HAPPENEDBEFOREOURNG ANDA gSABIUTY,REWCEDV DIUtt,PEDESTRIANCLOTHINOCOLOR FTER THE CRASH. INCLUDEINFORMATIONNOT ON DIAORMI•EO. DRNER CONSTRUOnO ORREPARWORIUET0.1 Vehicle A was ZB on C.R. 40 (Beckett Point Rd) failed to negotiate curve, left the roadway traveling 117 feet, struck a tree and vehicle rolled over, D BEFOREC .- EH. HEADED-- MILE P09T ppA .... r. -( N0.OFLANE9 SPEED. VEH WPAR013 ,,ti-SY.LLS:t_n..v?1e.?'...=.haakA'A"..??x:.t tt*J ?•?h/. iF AS EH. ON V ONBTPEETORHIGHWAYNAMEOR NO WONE DIRECr LE NO. .. WCREASVq OECREASVka n I? L_ _L?. n I- A-0-12 P AgKEO OCCUPIED P k P-Ff ?'1. 11 1 w G ? ? ? C' K ? 1/0 IF _._._.. urn _...... YES NO YES NO _ ? ? ? - c n -' - __ n-iii ??? n - PED. , nEE Dn ?RwAr On ° IKE nr 8.E Dpwll.iOwl PED,scvCUBr WASUSW O: (71-- 7 r °nbHWt?eR 4nC-"- LK °ncNRG45 ROAD SURFACE;; [ CK DrID ; HracWEATHER,),y- ICNFCK OKeI CONTRIBUTING CIRCUMSTANCES ,,,•y,yy?',,;r, p M-K CA.. On EI x .olwcvvDwuecrrow .-,-' ,L D I '. I 1 ND x I Ho (? J 1'? 611OOU1pWOMAHGO ? 1 ? arr aww°e„nwr-- °"eor uRO[ WFL ea ? wr I_ °('l an nAruowN°a O FouDw r L 1 --.•- ? - ' 1 x r^ oW vrr • a ? - ,K%11 ? WtT ' ? 4aL-.__ !:-! RwM - • LU=HLID. O?v EEHC l1rr=- r 1 ? 11 I=G— ? _ ? l ? - J PqH N - L 7 C_l°_ ? ° '0_ _ f 1 ? ' L 1 f - F ? m f `1 rAwan J L J ?LD l FnuRV ' r ? n ° ? D° __ F F 4 ?r( rco --II LJ ! R L 1 °I J- _ ( Ie °E°'e[c rv°e LOUT L -_ ? ° ?? u.rum _(?1'.?_??? •_?-__...-- _rolun ? r-?---- ----- -'11f-' weDARo -?-'--?-? orO.,D?IbH,- _G°C.1.----.--------• ??.? alDMq OrIEAI?eQ'rl OrKFRIYLWry i - eA+IgHn ?e?, rASaHO MWEOANRarOP ?_11x[_? aMn.snKU 19rECr n°?? n°n'".+onurronrn 1- (?7 L...?TI..J iRM'O FOR LIGHTCONDITIONS KH[a aRn , TRAFFIC CONTROL ' A o r Nrrow aaHCLA:,TYPE OF ROAD, . No > ICr,EGt or.a Gn MarP:l _.VEHICLE CONDITION . atnKLE oNe o SOBRIETY,- h K Are« oK '--}e? ar°aion°.aLiOML'' i ..lop - ' I.J 1 .. , eKwwa L_l l DNe WAY ----_-- ?LO 3 1 1q. } nF V CGNrMBUtfq R n -' ? a ? ROARwAYN ee N[ n C_l C;10? u1W UWe 1x4.-1 Cp !___ I I.?.. G?_...._-_-._- L.?L'LJ PTAMLO?Mf9?IMON x oust (. I I s A.M. 1 h ? e E] nra 1 1 L-! Inroeaa mr ? irwrlKOlwrewrw ,nr ? {T . . ... . ..__ -rd ..,^,? ?? .__ l I_f-,? OnlwgOM -_ ..-_._.. r Af ? br[npaNrruKl > - r J16 -? PAGfbN1 Irwa ° F_''r- ?M.. , wrwu1T [1j. L7 oea°oHwn rurco ar+[n CHEM.TEST X . w[ 1 LACwr I 1 _.4. reo I-a _ _ ,_.'rrarw[R ? ! _..I. Dna nrrxc rrl ' GnsRlwierry MNMnC aK N.D,nprO ° mFR 15A[cirvj--- To Yo TEST RESUI.TS 2 nUr IA INUM rNW b {14 A[?WAIUrN.U PCa NAWU wIT Mo°I n o '.'I' ` ,K r:(KarWleAAhK PYt[rq .XtEwt! j rMlalraMr? LO I?.IOnt ?Igv1.601 PAIL ti r5 ?. 1 •.? Lam... r.. L ? M i 4'JW'I:v'; F• i av 'L ,; t x z ,r ?' y'LN141V0;1 I dt@'6r' a '- f I ??Qcw9 .4f i 1 ?1? rk? L C y I I l ,L 4 b l 4 NY T ? fj ? e ?, r 11 ? I L r; ? n 1 ' i , d( * I y I' it 1 } 4}`er+4 i? f { T r„„ S, c x : 7 ??- y STATE OF WWINGTON W3P 1,91REY 5,i,1 PAGE 4 -•? ?\ 1! ?. CE COMPLAINT NUMtlER UNIFORM POLICE TRAFFIC COLLISION REPORT ? U DATEOFCOWSION DAVGFCOLW4N TIME LOUIIiY NO. LIEY NO., - FNWA A AfO OAY nYR. ., _ SUN I On lul5 ,'JIEO 3IRUP 5FP'eSAT IUIEPa H0 1 T ?U E L cD 1,7 rv ?-?-` ?STATE ROUTE gCOUNTY ROAD CITYSTREEi Z O - ADMCLS. PPEFlA ROUTE OR SiflEEi CODE URAI ScCt:CN • V OTHER (SPECIFY) C i? ?q 1? LITY GH 1011N //2MILE$ la $ ? 1:1 u OF ?' PNEFIA EO. MILE VOST O O ? tat . .TAME ANO OF STREET OR HIGH WAY INIEPSECLING WITH: rREETORROA0 LL I HAMP D AGR A T / u ?? LL ° I AM OAIA I ?rB QX} ?[SG. , O NONINTERS ALC:LEliT TE NON A.RO INTER tERSECTIN631R E OR ROAD OR REF. N DETLYEEN STREET AND S BEET MILEAGE CODE CU'. EREN CHO$SSi EETORROAU DI$TANCEANODIRECTION FROM REFERENCE ORCROSSB-l ^ u•TPEm SP CuC-(OUSE. ?MILES N S E 5v ?FEET ? C3 0 OF CO COLLISION INVOLVED: ?VONCIE-VEHICLE ?VEMICLEBICYLLE ?OTHERIWRITEI ?HITARUN SEVEfUTY T TOTAL NO ? VEMICLE-OBJECT ?VEHICLFPfl TRAIN [:]STOLEN VEMICIE NOANJURE WURED L "O OFVEHICLES ? ? VEHICLE-PEDESTRIAN CKNON COLLISION ? HAZARDOUS MATEPIAL PROPEHTYDAMAGEONLY l? OBJECT STRUCKINAME OF OBJECT STRUCK NDOWNERS NAME) LCCTiION OF Oe.IECi StRULK --- EBT.DAMAGE ?POA DYIAY FEET ? ? ? ? 5 RD EDGE E DRIVERS N-E-AST FIRST MIDDLE - IVER'S NAMEHA$T FIRST n1100LE IIF &CYLLIST OR PE ESiP CHECID , D R c /4 4A L? O D I ET A RESS STRE R STgEE OORES$ v Al /=/FL.d v ER G Y, $IAIE ZIP CODE. 3 P?HS E NO. RE CITY STATE ZIP CODE PHONE AA. f J + N . DRIVERS CENSE NO. STA E SEX pniE OF BIRTH N DRIVERS LICENSE N STATE .SEX GA TE OF BIRTH °, 1) -1?44d A MO. DAV Yfl 2 O l °- O M. DAY YR 1 DRIVERS OCCUPATION AM=_ PHONENO. 2 DRIVERS OCCUPATION FIRMNAME PHONE NO. CODES > Ul cusps MI SEAT BELT 2 ISI ELECTION CODES > of IWUH CUSD Y I .- SEAT BELT 131 EJECTION - N NAURIESOF I WNATURED S q V D F OM SCENE BY: TO MOVMOVED -MOVED FliOM SCENE BV: VEH. YEAR MAKE IDOCGELHEV. I MODELIDART,v AI SIV-1. .LC-l VEII. YEAR MAKE(OOOGECMEV.1 M TNOVAI STYLE 1200.CONV.l . : y v V 4-jjs Eels 2 / /, v . . , H vEH. COLOR,-, ; UC. PLATE W. STATE TRAILER PLATE NO. STATE E VEH.COLOH UC. PLATE NO. STATE TP.VLEP PUCE NQ STATE [?LLU 2 ?IJA _ -- I I I. .. , ,;?;,tl . C NICLE NJENi1flCATWN NUMBER . .... ...,. <<..:.. ODOMETER >,- :-...; .:., (?` VEHICLE IOENTIFICATI N NUMBER - ....,. -.. - rl.a, : ? • OOOMETEA - ::5 :r E.... .33 iD Mo?/7 l0 E' . . ... REGL'TEHEO OWNEfl-UST .•. FIRST ...-. :._.r... ..... MIDDLE REGISTEREDOWNER-LAST -...'. FIRST - '. . AUpgE.;: o. cr /s ca! N O. .. .:.. . . ALORESS OF Ow _ R ADDRESS OF OYJnER - -...: .. ., ... NAMEANOADDRESS ECO.DRAGENT :.. NNAEANDAODHESSOFINSURANCECO.ORAGENT... CHARGE ,., ORATION NO. CMA UE CRAA NNQ - ?? `? ACTION - ''J NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES 2 J A $ AGEE w EJECT, C NAME: 1719- rll.?A. W / ? C A DDRESS ? . U N P V ATURE Di REMOVEOFPOM WRES' SCENE HY: TO N AME: L /G N T A ^ DDRE95: L? !C AP/(.ElIT° 1 An/f ?. / / 3 l S I WURIESF H f.OFHM SCENE. DV' TO Y I I ADDRESS NATUREOF FR M N N U"E4 RC[NF TO ( E NAME S ADORES' E, N IF'1' • 3c M ro I II I31 •`E AI10 3RIfY J ( ITI I I I C S A ('? ?SCti OL RY ED ^ O T I5 JLCTto O B PfCE fA4 OG\CU.f I \ T OnIER POST dI I C D E D DEADONAHIINA S+tU 4 In" I E ' i ? 5E ] 2 TOTM D D ! DN IER L - . pU' \FJTCPCYC'. Cf ? L I a D:FDINHOSIIIAL V I DEV .IURY 1 P0391'L•. --PY USED NOIVN UY+ D PMITMLLY FJECTED ? A .-All-IF ?. E :'.tNE SS 6 ] :, c,;ICri U':WIOWV I B 5 SEAT DELTfA:IURE , EJECTED ,HI r ? + T? I' fy ? f - 1 IRa _ u TXE NUMBED OF EACH DAMAGEp AHEA ? ?` VMMIULL'-UANIAUF 'C" "'POLE INSTRUCTIONS: WARROWISITO SNOWPPNCIPALOWECTONOFFORCE : Q '{ M / N DAMAGED VEHI CLE N0.1 IUSETNIS SPACE FOR SKETCH.INGOAMAGETO IRAIIERS, MOiOPCYClE3,ETC.I DAMAGED VEHICLE N0.2 J,IMgO ° . 'A :- Pool I IS.IboO i_KV.i??I73f" d. R°pl 137?rIl,a.TlwK _ FROr ;S. TIMYt 18. UrMdMU,raea ,s l b.lk'drMnupf rr „ lr.amNra .. v.aWIMP EE'lF.HIIYO .DAMAGE: VENICLEN0.1 SEVERITY OF DAMAGE DINED B ', QCLRABMNKIDAMAGE 3QOlHER M.V. DAMAGE 2 PUNCP.ONALDAMAGE d NO DAMAGE YEXICLEI ( 1? DISABLINUDAMAGE DQOTHEfl M.V.DAMAGE 2 VEFACLENO.a ' SEV1QERITYOFDAMAGE: DISABUNG DAMAGE 3QOTNERM.V. DAMAGE TOKEOB/. EST. DPMAOE _• -'r ^' FUNCTIONALOAMAGE NO.-AG"- - ,•,? TOWEDBY CS ;DA: E 1.?V• 2 FUNCTIONALDAMAGE d NO pAMADE RCFNEfI?Y AM AGE a r0 :Y,.. ,,: TO $ TO $ DIAGRAM OF COLUSION Er>E v Aw Apwr s ! _}_? _ _ i ;q i _< , I I I ( I I ' I i I i VI 5 I-{I-`r?-}r - D FI , r L ? .-DRAW ARROW SHOWING NORTHINCRRCLE oo r! ! ' _ 1 I I T_I rwcaNaTRpc°Nd"ORC.I"S A ?a I=, r r l nr - K ETa, z4?FRDeAOI.fFaXroF __ I ! I I I y"/G2?.T.A1. `?7 --i ! n i r n , I paalECrraO"crvrlore i`iMdPACOP . s?xcwucaAaLEYEwdEOR' - ?_; I L ?I I -L?-- ,_ i -!-l _ r ? I-L. .. 1 ? ! ? I I I I I I ? i I I r1?1 I I I I I l l l i! i l I i'i ?'v' !? @r5 'TO!r' , ( I I I I ( I I I I ESCRIPTION O' COLLISION (INDICATE ME AT PROBABLYHAPPENED BEFORE OURINO ANDAFTERTHE CRASH,INCLUOEINFORMATICN NOTON DMGRAM,E40PNEA. OISABIUTYCED VISIBILRY; PEOESRiIAN CEDTHN O COLOR, CONSTRUCUON OR REPAIR WORK ET41 - 1• I J?.__Il _f_?_GL L-/,7 _!_?-' _L'?i'lil?-• / +? _ _ J _ . : Lc OSITION R O VEX O,E-I•:_?,•,:a.:^.:-i"'7.'.•`f. r>?a+.:?yi,A;' 1 1?y?,?,'„??, -NO.CF OW ES `SFEEO9 V XIG `• I PAPK HEADED MI POST pIN ONSTREET ORH NCPEASWLEG DECREASUIG pAY NAMEOR NO. IN ONE OIRECTON yrE LEG- WAS VEH. P MXEG CCCUP ED ?'''7 II'?'? N S E w iJ - J YES NO _ NO 17 •-' -- 1 1 - E,N oN . I-i Li U L `r te Cdw ,d COmrtRI mI 2 FIG. .- ? PEWS:CYCI-TWASUSUq. (.7 rfipEwAUI 'nwAM,w• 9NWIpA Ar (CPO 4wlux ` CROSS °rm°ECrCiERwr! ` ?I IOn£n ?i?• J '1-J f I`: A ROADSURFACE.J t4"?r,WEATHEA.•3; _ CONTRIBUTINGCIRCUMSTANCES ••-+-?L C ECx 4.fl _ IaNEaK ONE( 0? (ONECK ON! CA MdrEl .• +?"'°'-?? ?} M VAr . ?1© 31NANTAIIIO pLNCEOE ? ? °? D " ? ? c ? . ? L _-A ooNw ? ?r? L_ cal. ? ? pA?D A? ?aa a ?I w r a w ' . - - ? r , ] RNNwo ?x? swfNCeoc ty? cfN,fR • _. - n Y ° ?'? ~o a- a*o - ova SEEaTArep> a M<.o J .J rsc a Cl ? M nu ... - C IurnRV i I ?I Ice . u- XLLJ cE dNOAEwt .. n °I•'-? .nNOPEn (^ O -A L? o-o ww _ ?_?-L^'a__-_ 41 Doer Eaa? ru ? , ? omRrsofesn n "°° ( r:? ewro sw. l? J °o"Ka --Qr? miRC°r°R LIGHT CONDITIONS yTRAFRC CONIAOL;.?' vu.ciE'(;ATYPE OFROADi ,VEHICLE CONDITION. ;Y,;,.;SOBR; ETY =.d DRATDrawuL V KTi.4 I_ NOj?KN¢tE NQ ICNfCK ONl GR AgRfI VeNKE! IG pN ° r 1 M ! ('? ° Q ry LJ Y N0. 1 Cl?pxr°NB?TOC, L. w ? E r • .l (` , ( 2 Al - ( ---?T? f:_rL .• ...-- 1_b _ _ DID ?AitJ °.'.:.' I.? V P i... / ' rr? . `tp. MV CIMD u r--? a o NN Ij :_.._? 1..-1 I.-L . eu _?I cPrcenK - , 1 ?-7 ... Ro.la ?II:J'vAIwEoPm H J a ? caE Q. ? ? +«a ? ? ? N..ae I? ray ` I °E'fin,ay L-1 L?J ? ? ': _ . QuQ _? ? (pHR..a : - _ - - !r °isa.? Ian F,AVwp. t ::rrMa -? .oKO?r" Q1aQ lACxEo - ^? ? .___ f I..... J_ °'.. ^! I NKwD' " • _ r( CHEM. TEST -?: 1, A< j , n nMOwlww:ea? ue n wsiw.wNCT"' - I Na s ^ F-j ,rnaK,. '.. o IsPfc+n rr -. _ . ? _ _._ . , ._. r Cf? °L J o I j I 'q ofrfen I j nsraousea 1 '' < 5a y1 „R .?. [AP TEST RESULTS 2 ?q '.?C ('T I E?KY?aA+,NparcenaN.?e EKV. a.meNO e x i < `Y X '*S!arc s WEEP ~ //} N? uy areNeP f.,wr,eo I o„cf re ? !. e?ro AN a.Do N'%Y UMtON dat °pti. OArE aEAIroNI 4vPdlEDa1 ?,l, f_ ??• ?•+ v? .+..wnAA Arr. +LNO IC WASXINOrpN IIAlE PATFlOL-0LYMPIA, WASNINOTON AASOd r' WPL1CAlE COPY: LOCAL tAn ENFORCEMENT AGENCY'SC[AY-TRIPUCATC COPY: NVE371OATOq'9 COPY -, y t r,7, 4 r: j4 s , ? ?V? 17WwC?? h ?V I at O OATS OF COLLISION DAY Oi COLLI610N TIME COUNTYNO. CIFY NO. FNWA A E _ DA MO. SUN OH t E! WED 1 FRI bAi 1 M 2 L ] i ! B 1 0 I ?C < U } J Q 9AN ?11URAL COUNTY "STATE ROUTE COUNTY ROAD ?CITYSTREET Z ADMC45. PREFIX "011 EO1111EET000E 6ECRON "OTHER ISPECIFYI LW / 1 (D2280 CITYORTOWN ( I E VI ?'. ? W PREFIX — MILEPOST j Ir/? ?/ Fj? .. J N W 00 OF 1// C MILES IC_1 / v R. I J LV A G' JI N F T M LL `? REETORHIGHWAY A E O.O S IN ERSECRNG WITN: 6TREEf OR ROAD LL RAMP DIAGRAM DATA T ON J I Q NONWTERSEO QN,. ?J?SGQI?GRY .P O I ACCIDENT NTEfl ON XRD INTEL CLS TERSE TWOSTRE TOR ADORREF EflENCECRO S STREETO AD N . BETWEEN STREET AND STREET MI E AGE CODE . • , Q DISTANCEARDOIRECTIONFROM REFERENCEORCRO6SS T 'ET uN?n EiN! SPECIAL ODINO USE l ? pQ MILES N 6 W ?p ?j LL lys C l,S? , .. J ?(7 FEET OF F.SGOV t IDQ 'led C ?VEHICLEVEHICIE ?VE ICEBIC CLE T EPIw RITG ?HRaRUN COLLISION INVOLVED: ? SEVEHItt NO.KII.LED 17GFL TOTAL NO. "VEHICLE-OWECT ?VEHICLE-RRTRAIN ?STOLENVEHK:LE D NO.IWUREO OFVEHICLES ? VEHICIE.PEOESTRIAN ?NONCOWSION ?HAZMOOUSMATERAL 4PRCPERTY DAMAGE ONLY OWECTSTRUCKINAMEOFOBJECTSTRUCKMDOWNER NMAE1 LOCATIONOFOWECTSTRUCK EST.DAMAGE "ROADWAY FEET ? ? ? ? RU EDGE S DRIVERS NAMELART FIRST MIDDLE DRIVER'S NAMEIJI6T FIRST MIDDLE IIFUICYCUSTORPEDESTRIANCHECKI ., R s e( ?o R D ' 6TREET ADaiE53 ' STREET ADDRESS V Sod 3:2 E CRY -STATE ZIP CODE. PHONE NO. E CITY STATE ZIP CODE PHONE NO. R Tm?lsp.,.? 'A. r8S111yZ pli n H OWNERS IICENSE ND. SLATE SEX DATEOF BIRTH N DRIVERSLICENSE NO. STATE SEX DATE OF 8IRTH 0. o Go jSAN113,710, W? ¦A ?$j e, Fvl .( Vi Q, M0. DAY V R I MNENSOCCUPARON. FWMNAME PHONEN0. 2 DRNERS OCCUPATION FIRMNAAM P ENO. CODES >, CWLAI N I11 SEATDELT ISI EJECTION CODES >13I IWUfl CLAS r IAI S SEAT BELT 151 FJEQTpR "TU E9OF If11lIP1Es REMOVED M SCENE BY: TO REMOVED FROM6CEN DY: TO VEH.YEM MAKE IDDDGECKEV.) MODELIDART-NOVAI STYlEI2 DRCONV.1 VEH. YEAR MAKEIOOOOECHEV.I MOOELIOARTNOVAI STYlE 12DRCONV.I v S8 C'4ev ac za[,a. p/y v , E VEH. C UG, PLATE NO,. J 6TA E TRAILER PLATE NO. STATE E VEH. COLOR UC. PLATE NO. STATE TRAILER PLATE NO. STATE H J h4* p w-4. H Q EH NR - NUMBER .. :... .. .... ODOMETER ,... O V EHICLE IDURTFcATION NUMBER E AA? s v? E A'7 ? RE RED OWNS NS -UST MI FIRST D DLE R EGISTERED OWNER- _ FIRST ,..MIDDLE , o, s A ove o. ADGREW O OWNER .. .. ... .... .. X ... S OF OWNER NAMEANDADOr1E FINSURANCEC OR AGENT;, ,., ,,.. N AMEANDADDRE390FINSURANCECO. CRAGENI' CHAR CRA INO. .. ENFORCEMENT HAR _ .., I A .. ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED' CODES _ D 1 ! , SEX AGE STATU9 N Y ELECT. NAME: C AGGI U P NAIUREOF • R MOVEDFROM WJUmFS' SCFNE BY TO A NAME N ADMESS' S NA nR, Ju :FSF SCENE RV I TO / W NAME T ADDRESS' N P AnFS SCFNFfr 11 TO E N AM[- _ S A n n[ss E. _ _ ZW ilia v_-- rrrN>nv T D I IISTAI V': .1+I rtl,Unrv JIIwURr GLA:u MISEAT KILT I GILJLCIKxI C J (HOER I nowun IS MSARUNO NUUNY I.NOTRWALLLD I.NOTEJECTED Q T 1 EM TWAN N! CUSI 1 I'O Illdl ) D1 11 1 1 UT A.., RCTIIE DC DOHA RNAL ANON I[VIREN TIIWRRY DUST O OTAILV EJECTED 1 rARTM Y CTED Oi f . 1 1 10m. nUC lfi 1 LED 1 DlNIAL OVIN . ).PC.afunik I- UN T : LL EJ[ 4 UN NOWNIF 1 t n rD:;Rla Ur. OWN .,, 9 !RE AP DI:LT iNLURE [JCCIED L Cry 1?` -------- ?5^ u( b.1f _ ... u tµ .? Ar A , ?4 ?yµ Bd VEHICLE DAMAGE 1.IN EACNf+O%.CIRCIE TIIE NUMBEflOF EACH DAMAGEDAPEA. rrn .vim=?-QTY. floc' /.1 ''f' OFEREST A INSTRUCTIONS: DAMAGED VEHICLE NO.t ^ AWAR OW151TOSHOWPPP- ALONECRONOFFORCE. Qj ' -IT IUSETHISSPACEFORSKETCHINGUAMAOE TO TPNLERS,MOTon,C.S. ETC.) DAMAGED VEHICLE NO.2 1G Ibotl ''7 1].NOwI t 1 MNr I?r'?? •- 1?1 ''? ' 'w ;S.TNnIk .. .. ' •__"]- a ' ? 15. Trvunik 18.UMwuerla°+ 1 1II?V? ? 1 T B.UMrrcn?nW, SEVEprtY F AMAGE:VEHICIE NO.t 6EYERITYOFDAMAGE:(O (HERVeNICLEI I?WABUNG DAMAGE 3 UOTHER.M.OAMAGE I QdSASUNGDALIAGE DQOTNER M.V. DAMAGE 4 NODAMADE 2 FUNCTONAL DAMAGE NO DAMAGE SEVEARY OFDAAMGE: VEHICLENO.y tQDISABUNG OAMAGE DQOTHERM.V.D MIAOE 2 FUNCRONAL O0.NAGE A NOOAMAGE-• Z FUNCTIONALDAMASE TOWED DY /t • G S Dh 5 EST.DAMAGE - ES;. DAMAGE p Easy / h EST.OAMAGE TOWED RY F. • 5 I)J e TO DIAGRAM OF QOLlI510N_ O. S S V''/ I _' - _ I _ - ?- ..-_ i- -4--- - - - TO _?.. •_ _ DRAW ARROW SHOWING ?- NORTHIN CIRCLE r Ea°wFFM AF.S ? . _ - ?'_ OR M/ fPDALWAY' ,aAFy?O„PDV f I I I T r ?? ME,D' 11DDA FaDe•DLEFDNTDF ('' ? Imo' t+ ? I ( (?(? ( ? I ;P nm *' { r j ' 1 I -t - t y ? 3 ? Tf t T?i i t-- owFrwB.uEa? I 1 I I,b I , WAI Acow9oN 1 rl _ - ' 'r • I, ' DESCRIPTION OF1'd _COLLISIONi'+f.°L ^ ^ T"-T {•!" (INDICATE WHAT dSAaUT7EAE PPOBAB CEDVW LYHAPPENED BEFORE, DURPH3 ANDAFTERTH BIUTY,PEOESTflIIJJ CLOTHINOCOLOR. CON9I E CRASH.INCLUOENJFOR RUCTON OR REPNfl WO MAT PK. E ION NOTON OIAOflAM,EO. DRWER TC.), SUB,Tr-XT 4rAS TPAVLD.IG ON CAPE GEORGE, WHEN A DM-R RAN IN FRONT OF IM, 1_t. EA,eRVFD TO 101 .. v^-GMAYaN+s J _ [,BEFORE IN ONE DIRECTION PoSr[DPEED9E LEOALLY IWASVEH. MILE POST dR ON s': EETOR HIGHWAY NAME OR NO. PARKED OCCUPIED VEK HEAOEO yp, WCREASWO DECREASING ?? ? (-1 11 (-? L : y I J 1 F-1 r C I? N B O NO YES N YE9 e v- ??11 V•'?HCP FZ e?r .l !` ?U ? - -- 6rPEEl Oaap,nYA W CpINFA ° M 1 .. -- ? 1 PEG. pE0/BA:rCU5T WA9 USpq: tL ?9oE l .... •• yl. I 41 16NDUUxa •L.ICMUw/ut °i C a•uFDit i? -_L ZT. x:..K..c, cN cK ONe ROADSURFAC,'f. 14-.WEATHER'Vi',;. 1:L.Ww.Lm.,: „,CONTHIDU NG?IRw--. NCES;;',?, y' °tA 1^ iwlR tc^c[v,R IDNEG _o a Ta r -, oRVEA DRVea .• NF.:.T}I '?- t ??" ° WANT AHEAD t IM, , I M ! .??,,°?°. °m ? CJ • Q Cl .qC APDfD ?UUA -. r y OYE'iAaM° . _? L?7_??,?BIDE,>r . ?' j?_? ..- _?'°f__l "?_?°__"-? •:? C?., AND.,,?,? . - - _ _ . _ 1 --- -i -Iyn-°IM--. vYWENCED, ?,r, CUIIFA-' -(?I r? ?,( I RgHr fUM .J ? ,J L L ?- -1 C?i? EM.YI ,? ENDwMO J r? OC OnC YMrIwO n4 dM°?WO,O. _-.- (? O C?CE?rrATID F10 ? IERNMI ?]a LJ l ~ u L7 ? . Ll C1 . ? ) ( ! ? Q p^^?? oiFe HE Ea _ _°? u uwv n f 1 w - _ . _ (E]_ - - o Taw D•AD G?'t ? ° CJ m°ww° Lu ? OODW- - --- _ O,HD115MC611 D l?lf<U'rl 1 tt 1Ewa°n0? omeAlEl'CCIm ErOwEOF- ?_.,Fr? : nI'n EKWSIGNAL n.n 04MMIN ra'n 'a OFP[D AT EKWN. LIGHT CONDITIONS „TRAFFIC CONTROL? vcl+u i(TYPE OF ROAD VEHICLE CONDITION;: y t:BRIETY,.C."::;+ _?c? -...-So --oN I °R?'tE N D" p OAR N5r2- VCIw:E! t L J d10xAA ND IDNIw b,I Da -, I , MS n r] ON! DDrrr , q E IpADwA, r-i w nN , ?I wow r L °?N E c..___ lJ l _-- r_J+oCj i?'•"I-FIT .. ° ? y ? + wwv I J'i s411 1 PUEO roer a°"° ' ?J Nr. ucH?S I I I ? __ _ 4 iy 17 ?? ' ) .. , ? r _ aD r l U 1rWIC1 fN I ]DI JH N% .. .... • ( ? D.Iw st+en ? 1 ? ""^° yoN . ... _ f 7 .. ov.uo° r I•n IIE?EN"DDn`N.wo I??+f o•aw0 I ?EI i 1 ? ? J , - ?Gr 6tnM J _ . _._. +uwo CHEM. TEST ? f I t>? EFF r 1 l? Ga nM F.c _., l On,la ryYt I ?? ORC.a -' I ? M flCr! ? ? TCST PEIU4n I one.AaA•fan' .;Nµwrw c ari1Ra 2 , I j DrAwv,l { x x TEST ResuLrs ?? ° - l nxA:EN wnA . a f u??M,. .o,?c nvc "?°r .v o E ? ni urww H'?tl c? t? wI ??4 ?•)rY JO F /D ?/£i7 7? /s ;, 2 E? ? F MC I,Ra y M Ir w Ia1??-- +u,%:G pC[r.r. W AIa++OH"ar T4' A. TAM r< N0. Ar•IK.Y 1 OWN E SalTt F IiVA, f ., . ;;;, x_ A MY PAGE • ` ?? 1, O 4t No. 6 UNIFORM POLICETRf?CCOLLISIONREPORT PD1i°E0°"'pLAINTNUMBER .,, ? _ .- "n 41ATC SIO TIME fN ? COIINTY gpAD ?CITY SURAL ?CT' E W?IN CIiY Ofl TOW ? ? ®pFy?O.HEET OR HIONWY O ?_ -STREET AND MLEAGE IMC C? ?NLECp S ?ORRO? s DSiANCE ANp DMECTION FROM REFERENCE ON CROSS STREET---' - TREET CODE 4//FF ? .Z,..}? ? f? d `•? ?MILES N B E W GC0.9Q 4G E ?{ PE 4G0 OU E -a FEET oF?C?-.PQ?_-C??? ..pal ,HS ( f,,,`• y ?r I ,pµ• l .? ' VENICLE •VEHICLE :fe COLLISION INVOLVED: ? ?VENCLE-BICYCLE OFTENO VEHICLE OBJECT ?VEH CLE RRTRAIN ?OTHERIWR iEI _-- ?HI}6RU1 ENONO.- URED ICLE. KILLED ERRY VEHICLE PEDESTRIAN NON COLL S ON ? ?HA2MpOU5 MATERIAL ? OEIECi STgUC-(-AM EOPOSJECT SrRUCA AN00WNER5 AMEJ PROPERTY DAMAGE ONLY -• y> !? L LOCATION OF, a Cis RN?CND, E . e R E4 DRIVERS NAM! , T. RpOi : T PAM?yE,.: W OADWAY FEET ? ? ? EDGE 3 ? LI ? ??. J D '"A,: -•--_ RIVEflS ME-lAS1 FRSiM°OLEy1f BN`4CLIS, pq PEDESIRIANCNECN)Qp?„+?? LEUU2E D E Yuw tir _A.:.- STREET ADDRESS .' ?•:-'`JIfNJL+ ?'' R. I?q ' •i I I"1L/MA LN. ?Jp STREET ADDRE53•+ ( - I EV ? tK . crtY .' .?11 EE,, ;t v s N ` NEWIeT) $OX''79 / "1I/717Lp?a,LDDSVA v oryE NO E crtr s nrE ry?pj?y? R 'GG R COpe.__ PNDNE NO. A1TO .J y 3 4R N ENO.,_ k :( DRIVERS LICENS.STATE.-. SEA DATE OF BIRTH 'N O.' r//+ DRIVERS ...BE .O. .S1ATE SE%? DATE OF &RTH?i,.y d5 J U' i ?A F MO, DAY YR O ... _ , ,? 'I DRIVERS OCCUPATION PHONE MD. DAY YR G Z DRIVERS OCCUPATION FIRMNAME , X'?py TECH. T E/1S0/L) 6E/uH1NG Yy CODES ,> OI _C' AUK IA1 SEATBELT- 151EJ Ai NATURE OF _ ECTION CODES > IJI IN.. ,1,SEAT BELT EJECTION FR SCENE BY UR ES ;.tl O E ... s VEH YEAR M NEIDODGFLHEVJ. MODEL IDAg TO T+/OV Fq AI I i STYLE I2OR LONV.1 -. VEM YEAR TO E IDODGECMEVJ MODEL IpMT NOVN '. STYLE f2ORCONVJ ;,;:J 147.7 V r.J ?eA MARE Ba?r 2t?2 - _ - E VEIL COLM :,.,. LIG PLATE Np-- SLATE... TR.VLER PUTENO bTATE. . E .- _ -....- ?- N ' VEH COLOR LIC P TE'NO.•. STATE TP,V ER PUTE.NO.: STATE..v.,?:,,1 .? 1 lvN??c- /Y1J98 kill C VE LE IDENTIfIC TI N MJMBEq. 00 M1IETER I 1 • - j C VEHICLE IDENi FICAiI N NU DE ODOMETEfl ¢.?Zlyy,s; Ey- REGISTERED OWNER LAST _. FIRST,. E... F I 'NJ LIDO {'? N r HU. MIUDLE r NER - LAST r J. 3 .'YI ?_. flEGISIERED OW .;i FWSl LN O N ADDIIESS OF pvm q ? ? L O . •' , 0. ,.? ? ° 1..-.. ADORE. WN OF OER. I v u ...Y '??" NAMEANDA SS Of SUgAN ECO AOEM. ••rt 'J? _.. •' ,'./.c. ? NAME AND AOLMESSOF PiSUflANCE CO. Ofl AGENT ?? /EEn?ro CIIATgN NO. , IAfl E.... . CN ORCEMEI X-7 I ry' NAME, ADDRESS & INJURIES OF PER30NS INVOLVED '•?? C00CS : ; ; , - .. _ r• A ,. NAME - •. ...... SE% AGE STATUS p, ..? T EJECT.( 'C C Af1pRE% NA7UREOF F P IHAIRIE9 SCIHF R°FROM - ..` t?, ~ •,Ar NMIE, TO .Y' ?T AoDHESS P ya 5 °a k P mRCss tt:. Rc7RMNdveurHw .. . , '? r) to .N r NA U V.DiH M 6 'NAZI[ SCENE BV TO ) S ( IIIS ATUS RC Nf IIV ti '- f ARDOEM F O t; M1SSI qM R ItI31AI POYIKIN IJI,HJURYCU33 10 ' 1 Z 1 hl ,''k ! Ipl Stal V SpLSAOL NO MJURY HI SEAT B[LT -L - 1 yS I31 [J[C1gN 1 pIM? Dc "' EEINf . 18u5 Mmogra[ rr, I D S N[SS ,, C._t.`. .- APOSITION U11ANpWY1 (DIED ,= IOSf TA T.POS"r <B?E VNUR J/ S. LfI/nNOVn INSTALLED E c f aY ?• {1„` A "?.11 r•Y! ?'oRN YIN CJCCiCO Y?ArbELtFghl?g.t: cPCCieDI. ? I ail{ J 1 I.P 1 f• 1 1 F''?l ? ? ? . I { i I J {.? ' '1 Alh t 1 ?t M1 vii 1? SM 'I?`w1??3•dr?' : PL}N 1k? d 1 : 7 ? jt (,?'( Itr ?J Ark' 1 Yk?F„°c' ?nmMSr:;i,?M ?, n.:nppad9 _-»n.- I? T'ftL y Lk 1 ? Pi ? Nit' P z } ? r } k :. a? ?T TarxY R- VEHICLE DAMAGE 1, , N EACH BOX, CNCLC'HE NUA- EXAMPLE - FA. . ]. SHADE AREA OF SEVEREST IMPACT' I r• t] INSTRUCTIONS; HAWARROWISI TO SNOW PRINCIPAL DIRECTION OF FOIft Q? , ,• • DAMAGED VEHICLE NO. T x SmACE FOR SKETCHING DAMAGE lO lFA-RT.MOloRL ,E,c.1 DAMAGED VEHICLE NO. 2 ` L9•. rr T 31 • > + 1 A 0 N s - II 16 um 4 r n. a.,,? x I Ia • F ' > a tw SEVERITY-OAMAOEI VEHICLE 1 - HO " 1 ? DISABLING OAMAGE ] MADE ] ? FuNdT10NAL DAMAGE . NODA TfVERITY OF DAMAGE: (OTHER ECLEI 1 ? O DAMAGE [I OTnFN M.v. DAMAGE N OTIONAL DAMAC F MAGE ] C. Q NDA O SE OFDAMAGE: VEHICLENO SAEL BL NG DAM E O N M V. OAM cE 1 ?R-T NAL DAMAGE ? MAGE • Da ' •:°I TOWED BY I O DIAGRAM OF COLLISION TOW ED BY _ ITO ?1- EBT. OAMA E TOWED BY EST DAMAGE TO DRAW ARROW SHOWING ?- NORTH IN CIRCLE ? O u? K T' CDITIGLB -DUAL - - - 'I I I I _ PA., I r3t - - ;:L.-I - _ - I DESCRIPTION OF (INDICATE WHAT PROBABLY HAPPENED BEFORE. DURING wrvO AFT ECq sH INCLUDE wFORMA On auc EG OPIVEn COLLISION_ '. DISABILITY. REDUCED VISIBILITY. PEDESTRIAN CLOTHING -OF:d___ IRNQRnEpw,HWGAK,EyC.I -J it vc o`?• .a;r•.r? i' .?z?;??I L '.T!OSITION BEFORE OLLISION -L - IN OrD+eEcr N EE Ds /A ... '..... EADEO HA A MILE POT( EIR. STREET OP 114 Ww NAME ON 10. SAFE O L WA E x0 -"-- rNCR PAR OCCUPIED f . EAS PEASNG- KED,- N B E. NG I.E. ? 0 C I_' r1 1 1 s L . L4 •' 1- J rEI ^O L_J EJ YES O f C C I ? C A 0 ' ° ro K ED-CYCLIST WAS USING. 11 IS .1- 2 IWAL-AV]I. ISHOULOER-J ICROSSWA Sr -MAN TW ?BrcvCLE NOUTE ]l .l T- ROADSURFACE- FCK ONE, . I. ,WEATHER.;.. IC EC 0 E .,..,.._,_..... CONTRIBU C TING CIRCUMSTANCES NE OR .-I -"? LR 1 DRIVERIVEHICLkADROll 7 OR MG DR},v ER 0.1 [ RI 1 O 1 VE} IN. DRIVER O Ell 1 f-l DRY ^-? CLOUDY CLEAR. ( I' I ByYERCA . (?I OF E _L'_? LOWING HOED w?q i IG IO S c TA E OVERTAKING LLL?"ITT? C O 35 O 1-? ! 11r WIT R,WING hO N f] DRUGS-FLUFNCE Oi = B?, ?VE CENTER 1 :-1 A ARENTLY SLFEY LJ SI 0'r7 FIGHT flNt T ] PROW ] w,NG ED NG STA]ED Yf€041M .LJ]? If- ? S GN?GTO ?f P P-HD CS? L _I C=w _ a.C 4... ' t CE '' I O4 G NfAS. EK[ ON IE .9EE PEED ?-I 1 - En MPRO I,_.. .J Tu r Oq o€F D HEFT TURN 1 GE? yTUp4 ff 77 BL.J. -_ B I TO VEHI FANrRM _L.?wl T 9.EDC4AI H L? ?BLJ D OinfR ISPfC,FYI (H[R (SPECIFY( O L.?BL z,= E. f 1 JI>rJ E'G M/AL"" rr 11 I, IBu POT. O 0YI Ofl ?}? 1PR fIC CONDITIONS ICRECK ONE RAFFICCONTRO NO.ivfxlCLE fr E'- TYPE OF ROAD ENO] (CHECK DNE OR MORE ?-? n VEHICLE CONDITION C ''ff,? tt VI ` ' gII ? '',SOBRIETY' ` ICN[CK ON[I f , 0,E] SlOPEDAT SICK ?, OR ATOP SIGN 1 ?I? SIGNALS 1 I _ CRT WAY- NO ] f' { DI xo. ) ?B! ] p0 P-14 _LL2 U4XT L.Lr?3 ' WAY _? t D.' G "Y' `DRAKLS F- ?) BD v t J APAIflED_ ?r1 BTARTING,N I BC TRAFFIC L J - f 2, p ?•( T4H_ . ROAOIS BIf .?.]C 1 H D G TS -1 I 11? NOi 1MfA1RE0 T- 1I I IAnKCD PpTIITION ]C DU • ".? f ASNIHG _ R [0.. r ?EI ' ,NTfPC,1ANGF LOOGRAML _.". -?] O C IvF AIR I-?ND SORHIETY u1]? MCRGINO IENTER,NU 111111T IGHTS OI ASHIND .?a??,_AMOER _-_ rr '' (( I? U?,L_, ALLE__,"- ??J_. OILTMOOIIL.. ( INc -`I I Pf[N DRINK ((??' LJ,3? CKIN6 ir, DARK-ainefr - ((-?I'3,'--1 nR HCNAI._. BIB Trro wwr-LEFT. .. 11_. TURN LAnfs ? (-1aE?t ,.FF.IrRC,Nw(u S-: R MFM, _ _. rnvER CHEM. TEST. xD.]... .__ .. .. 1-1 0 '. L_) L"J I DARK-MLI B ' !I f._F-.^ r P/ OF KF _ EK7 nD I Sl/ LEST GIVEN OTx¢R ImEC,FYI ITREII LG Ti - IN Aq a ]'._.. DIV F ) I NO DE FE CTS Tf ST N[f USEU 1xlIiY1CN V1 "? - 'R• K L _. -- ?. ]C WID€u 'IWJ O HISaFLNYI ..x. NEST RESULTS .2 - - nvFSII A x40. •rCt H'3 NAME ANA ' OGf. NO. (.ICI O:NATC,IID ATN I' ]ADD , PUL:Ct AIHHVtO ANC[ FFIC FLOW ]00 BIVIFD ]f R0 Df HRS X NVISTWA11N40.FFLIN iNA AR AUG. 0 1 <Y TUII DI51.6 Uf 1. 0 01 /NUVEDBY DALE A, WAS,I,NGTDN GgSDf OUPLICAT[COPY' LOCAL LAw fNrOMC[MENT AGENCY'S COPY-TRIPL'CAT E COPY: I NVESTIGATOAY COPY 0 I Aid` 1l+ ?°S A Al" 1 ` 7 T / I 3,n+ ' MAR 1 'l {l i!, AI 'I r?r 1 (IF, i A ?;7 T b .. y D E DATE Of COIULION /?/p .SaY 7 V N pAY OF COLLISION SUNA(W IIIfSIEp HLFN i 1 -1 I 1 1 I I 11 I r IUS`F 2:^D II URI J CITY NO ?- illWq ?UFRAN Iy NU W / _ Uggl ?STATEROUTE OCOUNTY ROAD ?CITISTPPET Q ROUTE On STREET CODE ScC TION ?? dh ?OTNEnISPECIFYI N / ` ?o L L E YI ? IN cIl.R TOWN N /J . IAIlE FGST 0 i p? -- ' Q E C NAAIFjd NO,OFGTPEET ORHIGNWAY TERG INECi IG WITM'. GTflEET -ROAD ( O 1- .IA. M DATA i T ®?? Jr I D Al-? RO D . A CC DENT SR?c Qq OOR REF D TER E ? D EIT YE EN STREET AND STR=Ei AILEAE CODE C CPO . ` I DISTAF:CE ANDORECTION FROM REFERENCE OH CITOSSSTREET Yi! ?MLES N S E W CMi?9 UE SE F y .. T - J / ? /+ % `uZ Ot? \ _ , ?fEET OF :.. .- IVEHICLE VEiiICLE ?VEHICL?SICYCLE ?OTHERIY.RITEI ?HITI RUN SEVERITY COLLISIOA11hVOLVED. ?- C.LLIS I I O ?VENICIE ObJECi ? VEHICLE RR TRAFN ?STOLENVEHICLE / NO LURED d ' OF VC HICLES ?VEHICLE-PEDESTRIAN ?NONCOLLISION ?HAZAPLOUSIAATERIAL ? PHGERTYOAMAGEONLY ORJEGT SfgIJCNINAME OF ODJCCT STRUCK AND ONNERS NAMEI LOCAT ON OF ODJCCT STRUCK EST.DAMAGE E W ?POa]f;AY fEET ? ? ? ? = RD ECG S Oi?ER5 N,IME L:ST FIRST M1IIOpLE O.1 Vc RS NAME IJ•ST FRST IA DOLL:?u'GVGIIST CR PEDES'--_•[M1?t'Chly. D / D AEI/d L1?T //7 Ji' S flccT ApOnE55 R ST cET AGORE55 - es? x g s'? 6 T? f, x 9 d E R CITY STgiE ZIP CODE PHONE No '. E CITY GTATE 2:P LODE PHONE NO. R ?? ? ' ` dcu/9 ! 3 5 3k S D 9 : TY? Nrd r, as3l/ N' pNNER ` S Cc NSE M1O. STATE ,EX DATE OF DIHTM N DflNERS L1CE115E NO. ST TE SEX PATE OF EIgTH D• 1 M O D Yn ???? , ? . O. MO. o Y.. Y CI / o' ? ? ? G? ? ?_ OHry-gs 0,D 11 P 'ION FIRM NAME PHONE NO EH ?ALyf' 2 DRIV SGCCUPATION FIflM NAME PHON NO. GG Y 'l- A oG/? o br A? GU j5?. F _ . . f CODES > IDI U55 IAI SEAT PELT IS) EJECTION CODES > MI IWURY IA1 ATUR=OF CLASS SEgi DELT 151 EJECT10FT = I NJURrES R M VED NATUH / /? ? r INJURIES p iH IA SCENE VEH YEAH RY: TO ?R0415CENE RY v . MANEIWOGECHEV.I MODELIDANTNOVA) STYLEUIDg.CONVJ VEH. YEAR IAANE UOUGECHEV.) 1 MODEL DART 1 N '/) STVlE I2ORCONV.) V E f C V dG / 11 d /Y . H VEH. COLOR 1JC. PLA E N0. SiAI iR PLATE NO. STATE E VEH COLOR PLATE. UC. NO. STATE TPAILEq PIAi O. A T E46dJJ STATE - ys !? I ooeJ '? L C vEHI LE IOENNFICATION UMBER ODOMETER (?' n VEHICIc IOENTIF gilON NUMBER CWMETER E i[ saRS 9 a y? L E ? O / N- lIEGISTERED OWNER ST FIRST MIDDLE r V REGISicflE00v/N'cR-LAST FWST MIDDLE N O. GG I N O c `/.?. r Ul/ J//??? J , ADORE59 OF OV NER ' :S ADDRESS OF OWN C q ' E A J FLAME ANDADDgE55 pFINSUMN N INNSS URANCE CO. ORAGENT AME AND ADDRESOFF f? q CHARGE NO . ENFORCEMENT CHARGE --4zL ACTION NAMEF ADDRESS & INJURIES OF PERSONS INVOLVED coDEG _ 2 D A 5 GEX AOE STATU9 IN ELECT. C NAME: C AOORES.S- U I-- o F P HEIAOV-p FROM WJUR:ES SCE. F:=RV. TO A NAME. T AooREGS' S / 41U-s HF.M 'I=DFPO'A SLFNE 3Y TO V/ NMAE. ,. ADDRESS. a nAi° N E pM n - ,5NF BY To F S -F S A C]HESS L 1 = 7 7 E AITU. UR. ^ SLrr - -STS - T O Ill t i'"N C. Sf fHfll Lf.igN I Tq T s q OfF N J iOlrl 4 ? ? ? A F t) O L r I F [G ? ? ?. r . i 0 CICI ?L! D?Ds NCJLU. h.:p1,N . r O.w D [ `I P?.; U.E .:VfI Y SU\Ai UF i R • D O%YI a? E L fAI .F CT ?I 4 .l} n vAC y I ii'1 r VEHICLEDAMAGE 1. EACH GOKCIRCLE THE NUMBEHOFEACHDAMAGEDAPEA EXN.IPIt, '? DEAHEAOFSEVERESTAIPACT. -Q V{' C O INSTRUCTIONS: NAHRO'NISITOSHOWPRINCIPALNNECTIOIIOIIp e - DAMAGED VEHICLE NO. I IUSCTHISSPACEFOH SKETCHING-AGETO (BAILERS. NAOTCRCYCLES.ETC.I PAMAGEO VEHICL- NO.2 1 D. HPa f,A(y + (r? _? la mm /rw?r- a mPt y!?S + / S An 15 Trunk I S.T- --r?V?E! SB ? UM o T??? LL? /.'? . wcum:K+ v,UMelrrraVa ] ° n. orNmm 1r.awlPrR SEVERITY OF pAMACE: VEMICLENO.I IQOISABUNGDAMAGE D? ,V.DAMAGE ,--AGE SEVERITY pF DAMAGE: IODIEq VEH CLEI 1QOISA-GOAMAGE DQOTHERM.V.DAMAGE SEVERITY OF DAM.KGE: VEXICLEN0.2 - 10015ABLINODAMAGE G,'OTHERM.V.DAMAGE H"_, 2 PIJNCPONPL DAMAGE H" _, ] FUNCTORALDAMAG. NOOAM- 2 FUNCTIONAL DAMAGE 4 NODAMAGE TO'NEODY /!j f EU EST.DAMAGE TOWEDOY EST. D+MAGE EST.DAMAGE TOWEDDY+/ TO s O TO TO DIAGRAM OF COLLISION D I !_ C I , DRAW ARROW SHOWING nm _ Oi?PR°OADrIAr3 - NORTHINCIRCLE I_ _I I-? I I 1 ?!? 1 L _I ~~ -? .. 77 e =-C Eave nucccn '- -' PAODAnLEP01+TK- a I I_ f L ?I I F ?w [PCKRTOnvF°ATI?iA'o. co -/- I f I T a PHODADLFYENC3EOR DEErAIA1PATHaDE 1 11 I -- ANDAFTERCOWSION .. - DESCRIPTION OF )INDICATEWHATPROBABLYHAPPENEOBEFOPE DUPINOANO AREA iHECRASH INCLUOEINFORMATION NOTON DIAGRAM E(LOgIVER COLLISION , , IHSABIUTY,REEDUCEDVISIBNTY, PEOESTRIA.VCLOTHINGCOLOR,CCNSTRUCNON OR REPAIR WORK. ETC.) r1 ,d'aFTll_-:./!ciSic/ rt -/.]ate d??-? E'?sr'6orJ.±? u.?_G/a_-_?t°?_?'/_?•__J?s"•?-Tf,A1o. _ a? ,/ __ SLn/`/'•?a/TO/1 dAO//?E/' VN?/GIN_'d?rc°d(:I'-_.T?/fdr rt?d-S .S•i'a/?NC+? d i ?iG6? . _- _ - ,ST+}/°... .S'!=Iil._rralfleAAi i7.siy _j/_'eiyf/c-_ o ?'.d..1S i J'!(/ S Y__?°/ilGd? _/rldc/G_i:>$_f°f"?" ... POSITI VEH NFAOED NO BEFORE GL MILE POSTDIR WCREAS'No CECREA4M1G ON STREETOR HIGHWAY NAME an NO.'S - - - - NO.OF IANES WONEDIRECPON S i PEED S -E E.- LEGALLY pm ED IF PAHRE VIASVEH. OCCUPIED 1 ?N - ?3 7 C] VES 'NO , ,^ YES NO _I r PED. L 1 ? I ? i sRE[rognlclw.Kr , OR ALpa_-._-_ . TRO t0 E Fp IE EOw) ?. _-._.--_... ROY _ -._. _.-___ SO PEDYBICYCU N O: - ,...,•- TEI II I srauwER I ; lerasswAUt NR ?? l_C !I 1 -` - w POAD SURFACE -: WEATHER CONTAIBU TINOCIRCUMSTANCES . - - - .oArreR.KaMnE ACT K lAS . fCKCR6 ICSiCKOnD -ECK, ICHECR p.i) (C HECK ONE OR AAME) 1 C x0 2 -E 'ON EUPVO No ] d °1100 ] 1oq . 7, (-J 1 s ia-AH" r; DRr ? Lwor ? u ERw[wENCEOF I FO ND TDCC LasELr _ C. ? u;R wAP DED 1 , -- + ^? -- : -0 No WET IX E . i] J Du"PU. __wElcca r'7._rJ._.. r[xT[R J lA.c°PCF n xs Av f l [.Kw ] i? yKw I FK< 6tATE0 ? L? 1 J ='O ? ?" 1 .KPa -7 i !] E PEAS - TU. i J 5 a 0 D UGHi /[ 11, -d O 1 I O E (aPf<W1 vAU P RSRE LOP ITSX NOw0 A EOCN") 1 r I THUPEiG UGHTCONDITIONS IC1fCKONE( TRAFFIC CONTROL I x0 I vEwCEL Y[uxEn.;-:TYPEOFROAD NO-2 1-CA-CM-1 VEHICLE CONDITION VEHICIE 11CMR ONE On ] MOnE 0 IPECT9 1 NO _ ,,.SOBRIETY; riKU: ICIECK ONO J V. ?w HwNu - - L_il EaNA3,D _ .. _. ___ _.-... O',EWAY ......_ .._-_._- . F-T-D., !RO.] ( tSiOPPEOw I D( (-? ?1 RDA-1 ?( DATUnHr (:?(?asK`0n ?(.2X -Al -1 w:.e1s"c -.,(_? w MFO? -IIDn srnu?clwve . -- : DAwn .,_L J. SKn .--._ a_. !_°0 _... D KVnt3 _ ]L _ HO! U. A,NCD "- ?-+ srwTlw rroM 1 1111 PAWED Pp91TION WAR .. i ..I+1 Ep .. l WW1?RC aE 1 L.: ?nMn SOB !rY - X 1 .1 K 1 Iltl 1[IFHTEMA- 1 -J ISM IAw?M ,1° S ALLE I 1 ' pl COnI rHAO NOr + D[FMDPoNKNO ?, 1? MCKPq ? RA ^Sf f I.N.K .- ° TWOw.r EErr I 1WwIANF.1 '-'-", noes R.INCwAEO ° i.. ? d1 v DAI?EE>j CHEM. TEST I ?._? . r Lr ° OCTM[ W cm ..._?.-y. IAOUAr ONE( 1 alA- r-.. IEDinr+E1 OMEA I!>FC IM ! 0", E. .. t OMMD x X•r 1a DEr[Ci3 RSIAEFUDCD T JU T ORrCA13P(CV YI ] ca.*Pac X]X -D RIN`lCMr1 __ TEST RESULTS 2 . IxvlSIKATra C+IK[RLwWAR+Nrt T h-? f ° E f IWC(LLar nLH eplCf ANHrvcO Au^ uuvCF q LOw +! w]t/rO[. ?N + IK+ IyOL M M:Fntr C•3' F:FT. lM irEWnl APPIrOr[Q OATS DUPLICATE CQPV, IOCAI U'N EiufONCEUEN i AOENCY'.•.COPY-iNM1CATE CCPY:INVEGNI:AiURY4 COPY E -4 .f i 3 3 Y ° R A ll M, j -Ji m r ` F; 7 ` s i it .l? .L ?` r: r.aMlpM,77 1 11M nmrAt??? 3 S ?N . _ 1 s f I i 1 { h T?j I t 1 ) 3 f` :pu y? Ynl„? A {6 r { J,1 rIIM ?I a !"'%6? ]IF?I cUf YYM]fnlltlt l`Uft••_.-?..:_tu:`.c:,?... ...,.» »--,a% ....„.3N. - ..JUST? • ?.. u?. _.. -.-e..?bi:_ - ':: ..? .: '' ?tJ MOTOR VEHICLE COLLISION REPORT NO. - -? O COL 1'?L/??1II .TME, OF.? I??- C Y un r' yl P Ma,,,r ov t/ t AOIOF L= REII% HY. J 33 aE rIDN w E•, AM O_ EETI?, GN -:•:INTERSECTIND '?- ? O : PHEFI% EO MILEPOaT <_ - -r C err;Iti < N NrER,ECrIC„ L nDN orL sl / I D?!/c,SSGa.E .pI ..rw . _ _ P EEN / REET A c OO t}`_ _,-. x.l.xo.o cxoael„c. „.cw., ox Iocx Nxrlxc u„oxxxx, ax o"? IaF - rER r?FR <L5. , „cc? o a ` a• • F I c CODE USE [ 4 CT T UCN?I??Y_...._._ ... •.? _.... ..E:.ri-#...LaaCLOWNE OF O JFCT .NE AN¢A ESS-Z tti I OWAY. 1? ?? ?.- Ta'nvugPa?Yq r? ORIV F?. T -6W .- yL„?-_)R T? MEN'.:. ?F..,,,?„•,.,?..,f1?1O E o !115 RE, LAST--NAME -" w-I S'?fMM[? „s,?• I•?iM ODIC ?-x., f Al; Q - . rxA„T. a°xxwa,a T .., v ,?a sAy? ANq.9 BO% N - _ _.___ uxso usu STR ET E [.OU NG AN BO I l Rat L ,.xex „ / C • IM ??i?:..l 4 ,.«52T T Cn..se_r?yV L? OOE yOR1VER5-OCC A)O t CIT.Y»?J?•y ST TEy,.s? ,r•LP, CO E I RI ERS; T • w otlMle-v 9 36Y - 0v6e, ' s . NSc'9 A /`, ,,, ,. '?? n ''.O IVERS. LIGHNSE, UMB .EW-?? STATY XEy. O ?OF T RIVERS LICENSE _? Y-.1rI! - T TE SE - - TE'Of?,BIRTX?,A01 ?I TO- AJ F 6• :23 ;.2 J) 1 X 1A J 5! x,LtE. E c„av.l MD eAn O.. Ty le? "oooul E_p M EL 1 Dr sTYLe?IZ e, 1 !973 ctir C'N e. I W94 1/3 ; tEJIO. TATE?.?- T?gN?R?YTC T TEw?a? CE SE P r" T E T. LF PIATE'N ?.axST TFa?y cd /96 Wqsh, U? VEHICLE?IDE, -1!ICATION M.r-- Ira. 8:wegv,,?,wwv DOMLTEPo -., VEHIC -?IDEN?F G _ yNO.:.. ?•?L- bb t•.„tw.,l DOM TlI . 7 -? IS ERFOOWNEA,- I,ar•.VeoACIraI.?y :ORNER3llr..- ie . JOA 'o Tv ?IN-S?Q-A6 ' N ?A 1 YL?° OWNEP9 AOORESg?-?? ICrw[s.<m..we-nm ?? ?,:6r.TE0 61 T OwNERSA00.??`-y?.7-f.L_«__...°.'r1?^„°_!r:!LC,4aniYCiC v4'?TE OFaDIRTX. - PARTS F,VENICL6.OA4iAOE rLLe.?fu:Aw, ?aOi?iylRy.;•nOC:.'.YltiadY b. „?..-. mAq ?,OFVfi I ,M A,.Ai:.•rtxii'?..,n. .::..1. ` man '.J Y LIABILIT`T INSURANCE INFORMATION - VEHICLE N O 1 ovin"AGREM EFFECT FOR THIS ACCIOENTON YOUR CAR YES ? NO AME ANO AOOR[SS ORLIABILI•HSWSANCE.P000Y HOLD[IF?T]..a:w.:?41,A ;:r" ...:NY.?E'OF?LJrBtI,TY.x-IN ?RATeC?E.cOMMIY"'-"?'? ' , P ?- ? c ' • i?nl ?`.?owNSeai `Ire 1 ' ? 6? I NgME ANOAODgCSSOF SU _SA!K['twcnr. .s:i-sx:R^^ -w;.:s::.::r:..J__._._a..-wu??as.-^•YS>u•_`al ..__..?1-_.S"Jt.-_.4.-.., I ;r .. _: N E ? ? J ? ?'/ ?PiI?/ „? E ,.!/. „JO I-/VJO?? ? ? K._._J o m NJQ.w T?- ? yy )? ..q .41 .1 A ;, ?e/ /r a e.}LJ .. »+xar ) 6 TUS OP INJURED I -tN L[ !'?^ KILLED RRP oTe :nvVx n ONF TXATAPPLI , EY ATU I R D: - N.,E ICIF %ILIEO R IRSSOET A o 1 O - ? ISrO I 6m ' o,7Llar L_I ? as IS va?+al IH„ ,^ ?OC. SHOW NORTH Of ARROW IN CIRCLE 4><1 ? ? ' x:?„w.. .„ ©'? \ ? O[SCR [ B LOW WHAT PPEN-1 [R OVtH LIU q IIYv{y7? C.uFl 5.7oPP??_!?t STEP S?fW??? _ Ne.ArJin/? W mi?_ LF ? .. Lu.l. 2. Ne-H?J? ' +x' ? i .uP.,a STvuK on L-; j? C F - W F. .I .v„.., aa„ ..„mLa ,.c,:nn e. ,,.YU ' , f, _ , _ . ,_--- 71 lq?; P E I VEHICLES POSITIONS BEFORE COLLISION INVCSTIGAT ED O E RCIR N HEAO`D ON BTN LLT D [ R J I/ OUR, ?o? en El El D 0 ID R ??? ALON4 - RO -:. '. MD., TO ,TA+.:r'L.L..1E.Hfl? Y f ` tyD " o we I?] ,.... ]n „. ?' ? ? °? I . cow Auq .yew[ r e-? -LC.r cogarlohL rRAE c<o r L 1 ,o.al., n coc ro o I o vE rvc IttcpcTO a, y-?„? r• IIIw, . ra <:: '] I ? ` :, I ?] nxrumlr [? U.ALU El II [j - WAY „n II ? DOING arRAla.T AHEAD pHr v ?1 r] I ? MA IN NG ] ] OAwN ?.I -- SID. R] S TWO WAY r ] ? OVERTAKING AND PASRIN. LSJ1 IIIIII ''''''111111 In SIRLE V Tyy] rN cVSi ](J Sh0 WIh4 1 r] f n ] Lj YIELD DIDN r1 ] (:j n. r7 .r ? MAKIND IlIONi TURN R f O AO ••rr•• T ?r fthOW I00 -.AS SIIIND N- OPi RAMP MAKIND LEFT TURN I ( AA ?J r_I fE °l? b., C,IY S r 1 r I O TT r-1 r 1 F I.D -11- ? S r, A T r, '] M INp N.TIIgN n_ ??[ (((111 1'' ?1 l 1 r l T 1 ° `jy. L1 ° ONAL r I r_l LT 11 Ell U ? NI.OWINp 1: I f • O ]rUMD OA„DER 1 rv "o-ED PoR Tn FIID ?. ? r.? LI'O/l LAa MAI I ( c,w. ,.. •.., e?„, no OA0N 4 T g1 ? (1 E Fv l 1 I J N°;T P 1 - n; I ftl 1 __ . . 7 p --__--.. _. _.__.._ ? KIp I I 1 . TTO I RTOPPrD IN" ROADWAY L L ,- r 1 D I/-'?] lJxl rf NTPt.IV D fI U.IIr ID n ? 1-LAIR vmin nI ?"T^,!''?$'{'ITITr,t..lillF'?Wu°?F°.?:-'AK""""'Ni'I:T^"'Fii'RI2lS?M".":x":LMlfSPLC"S1F""SSP.RY?'IIRRA'MG%Y9.!RPI.{!4 ... ''2'AW/'ObST.uh/:lfa' ?r.LQOEALGla._. .'_._-J d .? 'vs+? g h f G7ki? MOTOR VEHICLE COLLISION REP U' O LT NO. DATE O; COLLIS EL ?+ 7F5?Yr ISION _• :,.TIME,OFCOLLI6101j yw. M ? ?'? 8 P D CITY'r..J 7 w COUNTY CITY. TOW RoJ-rd ILE3 N E ,CITY.-TOWN'. ,-.-E •?:; ao O ADM CL PNEFI% S ,ou,[ ow siA[[i rc [ ECTION LIVE WANE OF 6TREET. ROAOOR HIONWAY '. C. -I CEO//a,J??- :. INTE GT O WIT r' STREET OR ROADS Q PR EFI% EO MILEPOST - a.09- n InrEfls6cno .LacaTloN of c fT; MP AcNAM Dora 1l ...GGG Ii' . BETWEEN Y -6TREET A" OD ,o,P <xP(,r». HrL[ro„ P, .>(»..r,l»? ,»oNA»». .. ",.P<( .jEj XT-A P r 13, M »[, Iwxlr[I 2` o ® I E .CODE USE ??4.rJ Q » ORJECT STRUCK, Iww» cin 1ic;,{A:t-.,.r.;OWNw OpOBJECT9,IlAME'AH° AO°RE63 ..-. LO ..' IN O Qa Pr (n.wr[o cmr. O cT , W FEET 00 E fl VERS LA ?C { 1?1GK`dl? D L B . i E/Vl cY ? e0'CT LCam/ E T AOD E - ', -ROUTE. NO',A O'BO NO: • • xrr p., $$Q i r,?:? _ ROUTE,N A O BOX?N µ lcKf 2 '. .??»,ST TE4 t-y 'Z < OE DRIVER TOCCUPATtO ;,? _ w?„?.;?STATE?yy„•;,n,? 2 CODE P ? ,D VERS OGCUPATIO D A 18 E. 1 N - DRIVERS, LICENSE NUM e?y STATE SEX DATED IRTH? 'AOH VERS GE SE NUM E ?u..??STATE 4E cOATfiyOF_'BIRTH--Aa[3 wa MANQX??^sv.-oooaKl moo! -71 MO°EL?'uA?I, BA y P. Z C LE 1 -.D_ E'1 (v.•ooooM . Ct+ v _ MODEL, -1 C ti?v l BODY STYLEtZx -Z Dig E SE.PU M :. ;9TATE?A - T-RA LEA PLATE N..v ? (_STATE -,,, _ :". = ' CENS6 P TE,NO,, ?.? ,-?TE? _r:T TRIULER PLA 6 y, .JI ,; 6TAT6?y[ - ,-4wo A --, 21.5 347- WA VEHICLEIOENTIFICAIIOf( NO ?r1100B • 0 xcw["1 000 HTERIHr : H CLE;ID T FIGATI° NOrgti„j•ST9fiB„ raw I OOOME?E,NIH?LA ?o T R SYERED.OWNE '-.Iwr•Flwsr.wloo[R.x ?J"- DRNBRS LICEN66 yr ?? - :..M1 ?RE?OryI6T?EcRE0 Ot/W?NLRTIw, nJMIOOL U f??DR VERS: LICL?C. L (I G L'T ? rT ? ? S AOORfi fyjrl ?.---- w.wy wr[y:•ki,jL.• _'p_ATH.OF BR N.' ?O _"E SADORES_:y,{'..r..wl ,,,,. In ?H wi[Lj;yi.;J(.,M$. FOATE °F BIRTM' A 6,OF VEHIC}E pA AOE[Znr`:.tg:2S'A>flAiwl%+ to ?(.Nti 7 P RT9 O. EHICLE: MADHDr yµryi,?.,,inii.^4 '•='=-?yi for .w o,Vrr-. L s V S LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1 - CO-A cEn EFFECT FOR TH SACCIDENT ONYOUR CAR YES ? NO N ND?DDiESwS?,trIAB14TrYttw9URA fiPOL1C•'AvhOLD ?... ;may: iG+.ti:PSSwT??.w/A,. ?rNAMFJO,FLLI?BILI_T'r?tN URAN?EWO.MP?YT•JAi+? vn • S?LL45Ti4T? 5. ME A.VDADORIp90PL A ILITY N.S RANG&ACLEr?Lyd$.?5.......- A! JY 4r:>n w.L.JrS?iTi.?w. - LBIY L049'X&UM^ER Y??t} yR "AjyT,g[j, . - r r- 6 1 JURY ?- ADH 3 1 JU Y 1 .?CL:.dA •r•"f LD•I'b ,? AA.S.•!d .•3.2••LJI .? "' ? •.,• ... .<..iw O +nx+l f ? . f AOE` N E ?o NA fi X1. '..... O E 3 56Js1 O° ES6 .. _ M M8 ^ ? ? [»..r 1»lu ? E , ^o i»JU((, x( .R^ oocroAf-'_??___- oonoAA _?---._- ( 6T TU O JU iD'^' tM r; Rr4FR T NETNATAPPLIE9 STATan OF.INJU [O ur'n' it Yyyw M ARK FIRST NL TNAE APe Wp; H., ® O [NICER -, II -y 7 NILLEO o o 1(rv[n[I r o lo[ 1 r ,»[r<i O E. ICLH K LLE :»• [ rv.l 1 r 1 1 or rCNr r• .. y ^ }L lf TH AR O CIRCLC D CR BC.?O[LOW?WHATH pe RD?IRQFC OT?V?MICL[S BY?(U^BLR ''•'i »I^ w.. N.xn ® ?' ?tk1" Vii t1C C 1 W IRS s-rope n _ r.»lea o pA? R'? _i? . b?l 02.5 t.Ll_ f1?_ V_S t}t G-C£ w?Nr--?Y.- ] s06-T0.forew,, 1-\?vdt? \ ,[n^,»rP»w..?-C?Ot<•.Fp12. M•t)'Rf O)Jcc CT 3 C. t ----- _ l?f Ft? , W ttJ v?ct,?c rr?? -- -:Z;;P _- . VEHICLES POSITIONS OEFORE COLLISION • `• •( `••• INVESTIaareD oY ' [.. LL[ rlCA Ot ° ON 4TIrLCi OR INCHwAY MC OR U I u u YES"• [ Curr ? ? roMC[ , .N ° I. ?9 ? ? ? CAGE ' P_uM_P_ Rs?,1 ? ? ? ? ( 01 x........ . I LLtt r 3 AN ? ? U E w 171 ? • , ` 1 K WRirn[w x°,D,UN/.. O T CONOnION1 TwAr?IC t° wOL [ .r +< (» TrFI O D: I OR IV[RtyRHICLEACTIONI+Nt?,i hw•" R k.rc.'o.R CL .O.ii? • x[ [ ] ?.:?.r•• E ?? DAr4GN1 l [?t ON Lf [? I [] ONE Y ? [ CO.- BTRAIDNT AHEAD [-[ [,] ON t G t [_ nA.YN t [ ?[ S10 ON I l TWO Y u t ? OVLRTA"INa A"D "A^SINO `.C; .v T H O 4 T OD,[ r 1 ? ] [- , I. M r t? T L? nOAU15 PLR ? ] ? MAIND IIINT TURN [ ` I •ir O [.-I I Oa t_I L Onr ON r r ' ( I._I • 1. I NO Ne0 [? A ? Ir•UPRCNANG[ l OP.RAMPI (?1 lJ A ? MA[INO LRR TURN »Llr 1 ? [ ,? 1•?E ,[. ? °lrC r r r 1 t'wN, ,rr"Ir , LJ ? , L r] 11A6HIN0 --1 ALLEY El ? , ? MAwINa U•TURN ? [ ? (^I P .r . R , c,u 1 iv:ww. n nLOwINa ' 9 'P. [ o.»nrll r [J ...r .] ) [_1 or rlCrR tr uOM.V LANI [? T [? ar-CO FOR TM.111C aHAl ° ° ?1 J O F ?JV.S?{ ?? ?q _ ? ? " r ] _ ., [ I [7 6e PA ArlD _ i ^ ? on eio i nr I l l.K.`•,U l?• v/ 1 G LU 5 V `1 / [ 1 nlvl Drn F O ? eTOFPFD IM ROADwA 1 n r•wr Nat rr r'n ? . r n l ? ? ? ?Heva ] r / wk, k t I t t t L r /1 T{ ,.rA ?• t r'Y 2.E .?;'1?. ', ',.. . P,??°'Y""r'?"?R. , I `T.?i< ?; ,?:?? . , .. i1.,?1'•.?i ;its ? ? t1n r ?? L ti?1 N , , I? ? 1, i 401 a '- -or Ems. ?'?;'MOTOR:VEHICLE?COLLISION REPORT -- -' NO- OAfEOFCOLU51OH -...? W .. o COLLI E SION TIME OF COIiLWOM • rVP F HW 4w E9 r COUii A Clt !O 'x_ r C PM _ - M LE9._?? OW OE If 4A.1c4/PY `peWCit9E ©© of AOM.CLS PREF P F(l SLCiII :r cJ 7770 NAME OF BTREE ROADOR :,:A%:;..•:..;..-:, WTERSE T OWR TOO ROAD „?,rr.. wJ.Dp «? axEe -f?,•r"°? /yT?'?O ?-- ? ? , PREFUf ED MIlEP0.9t; : t la:? nFr?Vx?TA? ? l?oGs ?1'?a.,x NOn INfF.PSECT10NdOCAtION OF COL I ON C RAMP OAGRAM DATA i ?ff)(^La •« STREET AND STREET OEfWEEN v HOT ?© SHOw xEAxEai WrEPafCfwiarnECr.pKnWAr.xW5F W4PF N pAAPOAO CxOAEwOMLEFOar Ox lPfrvrrFrwOLAnUNfPK 0.UwWE. Ar NON %RO W??P?yEOC3BiPEEPiO POK? INTE INTFfl CL9.'. ,.. ._, ©® IETI .1 r ?' ^Orv wVOlvfu _ CVErvICLE ?-1E-CLE ?Op EP wwTO ? SPEC CODE USE. / 7aa© EO rJf kLHCO a , '7 ? ttEOMECr ?vFn CLErP.n ._: _AN L` ? ?wr. tOU VOn ?n E E L OF s PUCK) OWNEROFOWECTSNAMEANDAODRESS U]CP STRUCK (1-E OWECf OWECT INflOA n PON OWAY ?N Q MOAO < FEET K eoeE . - DRFYERSLASTNAME. FFINSTNMIE MIDDLE 7 c ORE prat rVA CANS DRIVERS UST NAME F'. FIRBTNAME •` MIDDLE ;? I)= ?. GEl SIPEETADDRES4 HOUTENO.AND80%N0. MulE I—rwO STREET ADDRESS ROUTE NO.ANDBO% ' 12 FIF-II.I. WUP USE A 7 n / 5-5-6- CODE 1 P / ERS OCCUPAi10N.. DRIV %/ aEFARATF EWPiEiOrl °PL' CITY STATE ZIP CODE' c 9 ? / ' / DPIVERSOCCUPATNJN -, ,l pp .V` ? EJ 3> i/+ ,u 'S l- I4 L.f (.r. T CNiVERSUCENSE NUMBER ,, .:._:.:. •, CFA ?5"9 STATE ?i SE% DATED &RTII--.'„ z Zr 5=S E ?' - ORNE 9UCENSENUMBER.. "..'.: STATE 3-, (I 'C wR SEX ' OATEOF&R VEHICLEYR. i MANE,GNEV:D000EI 6ro 4 MOOELINOVADAgi) / BODYSTYLE120R.) VEHICLE YR. ) MAKEICNEV:D000Ej MODELINOV-ART) 8ODYSTVLEI20R1. LEGENSEPUi N0. -...STATE..--. -iPULERPUTE NO.... LK:ENEEPUTEIq. . SigTE. TRMLERPUTEAIO. . ... TATE',' :. r?'19L? A. 2 ' z c? VEHICLEIDFNTIRCATIONNO, .:%,.(19SEMODELS&NEWER) •._. OGOMETERIMILEAGEI - :.. VEHICWIOENTIMATIONNO., ,:... .(1968 MODELS& NEWER) DOMETER.(MM1EAGE) RECSTEREDO ER;'?_ILAV Fl1)STHAODLENAMEI.?:_''...:. ORIVERSUCENSE NO.,;,, ..,_ REGISTEREDOMER (LASTFIRSTJAIDDLENAMEI',.-.::?.. 7 ..?-DWVERSUCENEENO,.,-; '.NEAS A00RE99 ,-• ;(ST L,CITY SATE) DATEOFSIRTH "° OWNERSADRE55 (STREET,CITY ANOSTATE) ,. - X75 DATE OF WflTH.;,: 11 1EAP L D n, Ze X _ D.1 S PM SOFV ICLE DAMAGED - ._ • .., eocosi y ?E. 1 ?I?i A/ .. g.... WASTHERE AUTOM081LE LIA YINSURANCEYO ?'yES ? NO LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- f: oVERAGF9IFFFECr FORT ACCIDENTONURCM _.,. •.;_.-. .. - .:: :.. :.. NAMEOFUABNJTY INSURANCE COMPANY„ ;....:.. _:. NAMEA4GAOOf1ESSOF UABK)iY WSURANCE POUCYHOlOER-_:.:. : tr AODPE`' ,r EfAiE tw , C/ NMIE/N D MP TY IN CE AGEN( -EEBB G UABUTYPOUC UMBER -: f7 4 C ?{ F I `v,.`^ ' •. w,_-y ] I j IT IN, EPOP FOP igx4 I '. AOE '. TNDINJl1RY , i E1 IOrAItAL NAME )?ON{}?T ? 3?V NAME ___ , , _ __ ADDREm 5 ij. __. L ( o hI1?..Ji• t}?-=GLAvit'-?u1R u ' SE%- _? _ ADDRESS E ` ?.? E _..___?__ _ i01u o ? f pOCr •? 1 0 nrP fli o ErAwwt4xPr ATaCipn xA4F OC ® E] x r?MpHXV ACOCfORr AMF f STATVSOF WJURED nj blNEx WyEHK•LE ? rvOEq ,,,.:,. IDLLED MARKiWSi 4WD ISEHPEI CNE THATAPPLIE .y M?xOPI 9 U PLE w i IO . 'STATUSOFIWUREO ? NEP IN VEHICLE ? Yx4[P _ KILlEO MARKFIPS W U., 1 v, T OIE THATAPPLIE W-pSABI N IrNUrNiOPI? S P IE G prcwarwMl ?ntHFA'h RIiEI,y ? 5? 80 FF (E CI 7? NO. ?Feofarwu( ?!:trr?T-14 ? 50 80 of FFNfr I 7? SHOWNORTH RYARROWWCRCLE \ HpcA ea p.aq \ I I , I I. a ?uxw [ e a Y O \ \ i ??? DP KWAY KA4E, Dq ,.o E W4AfKeA<nYeHELE4•ei?Y( OESCgIBE BELOW WHAT HAPPENED (REFEfl iOVENIClE9 BY NVMBER) "1 -rl i -? tu' ??ry,., _ L f?nc5 ??Lra JL rE'.?:SC,'?ll. Ct? 11 FLI'?S_.? ?!/ b? "71`^ ? - _ _______-_____ _____._____ _____ eLPtcrEwDf rwwfFrAPAOw 4.1 _ -- , y _ -= - -- I VEHICLES POSITIONS BEFORE COLLISION [HICIE F W ON STPFET ME I.Cul-NAME OIt NO ' " cE' rr Y(r<u f^.?ucµ?o wVCSTInAreO Dv r0 (mFHS .M?Ct0.1x OU x(I ? inOl ?lOtrlr(w[ eJ 4 S n? ? ? ? 14 Q ? ?'ro;Kr ?a 4111, ? ? ? ? Jtx.? ? ? I?} lo-? Hr ? ? ? ? ? ? ?.K i't(•'''^`^ ? ? ? ? Nan _ DIRECTION uio.AV,D TROM DIRECTION TO ?rf Ci.SireW WA9 u:+N0 1?vm.- 2?W-WAY D? :ProULOFR A?60 a_ OTHER IEJAD 6LWTACE YRADrtR U*-CL'WTX-S :•fa? i ? q( I Il v!iK ? ' IQ nArlr...r CJ 11 ZOir 2 ? RAVUA 7 ? n-N ? 2 ?-1 2 DtAO-I 2 ? nus. TIUFfIC.lCMUNOL --- Or t4Q 4G4Als ? Z ? Slop I,IN J ? YIFLU TVGM TYREwOFROAD .pe onnpa Wn w+Ir C'?I 1 ? CM! r 2 ?rYIO IVAY ? 2 ? T`(-"PR(L WUVEn rvrNC1.E ACtpvS (crKCE nP rn +KKnr F,:R?fIAHO l:rrwnnr _f AD An ? 2 ? UVI.RIAKIN(1 AHD PA':GNO ? 2 ? MAKWOnCHT TURN ? ? ? T2K1W A ? f00 . ? IGN15t?P1F[t ? A ? Il1!A nNG PED ? t ? IrE1FPGIAMF I ? ,1 ? IIAKINn LETT MIIN ? A ?ct S OT" A DANK STIIFFI S ? LY:Hr S.,, ' ? ? 5 ? 1-14 -IN N ILDALLEEY 'Y" M ? S ? 5 ? MAKPgU IUNf ? I:A EGFYI 6 n R ? ?SR CIfY 6 ??IRF[4 T9 ? 6 ? ie16MW Al ? A ?IeKFOf Ai''jAIN ? A ? SLc_NcI N+. AEON gRngT SEFN(1N'K1FR Of IR T?G•r ? F ? M1KFq.f LA('AAAN LMED ? 2 ? Srd FOFON TRAFFIC .F.LwO nMVf MrKKFa%.EEttE ! ? 0lHf M.:FLCHY ? 1 SFPANAfrD Sf0 NO AT gnNAL ? P ? Dn DIOp h(YI VIINh .L1\?F% I.iC TON .{'G? NO1 rC J? 2 ? OVKIFn ? l ? nf%YKIFD ? 0 ? 410w/0 W MOMAVAV ? ID (3 rrAH ? . HY - . ., - , - zr t?nr^?2 r u+e _? -?xn-r IrI sce^ ` lf, ,1 j 4 Andy 1{ LF ( v? 1Y y ? I? .+..,?.vfvl yA+n ,-}+!,v:`VA ,?, ^??nJ•sAxi,1? -'_fr',u .{l ?, 1-•T.4F t "ilf _nICLE COLLISION REPORT ? ?,;? nz'I:c. S QL i?.,6 ' OPFIC AISUBE ONLY y f, , 2 Y ,??. ? ?' F ? ? }F ? . W JFCOL4510N ?J( :DAY OSFCOLIISI?t - ,-TUtE2OF COLlISlO'.^ ru wE m F x '/Q • v R E ; S- . ? ? ? r ? 02n. COUNTYfIOY'+i„? CTY NO ,;y ?1 ?T ? LY I JALA18 ). 'A tf {r ?. , - - [ i .JU PM .., ? Y ' . k 4 ? Y Yn' ? ? TOWN .. rOReaf MILF9 "©© CITY, iOWW NK( •GGW?`ivf fm d l .. ADMCW ?l PREFUL M!/' 9TJrn?f}lr?/O/$SECTK '- . ° -i o e W ©© OF ^S Y Pµe CNOx dVENAMEOF SiflEET, ROAD OflHOHWAY -WTERSECTINGWITN:STREETONROAD PREFIX EO,? MKEINANT .LN NON INIERSECTKKILOCATIONOf COWFION A WTWEEN wnI ? ? 1 h??N OMCRN.I DAT u ANO STREET l!i 10 xOr ®© NA?wO.NC puitErPOw4Sranbfr?iirw6iup°Yie N !R?rII xtFRBFtrgx: FFFr IJ ® Gf IKON M rlrtXt Rf T W [R EnG TER INTER ? ? .IREe M 4 " T GwsRw wvefvE I ?vExCLE VINInL ? KK 9KR ? nlvmrEl o ?Vf E DFVL.uC,FS 1 ?VFw?LEOerECT -?YeMnE P[9fsrR.rl pwx uwx ? x SPECCOOEUSE - fyF-lY J? b ?' 4 '• " '• OBJECT STRUCK ...._ ,' IN+NlpCHrtGre wCRl „ .:......:: :.. tOYMEROFOBJECTSNAMEANDAD0RE59 P:: IOCAT W ROAD • ...w. L? i!.5'ilx:. .r N XIN WAY ..•La m Sr IC a FEET ?[ O EM R? DRVERSLASTNAME :?: RR9T NAME ` I r ' . . ,.,. ., ... .. MIOOLE wvOlvFe DRwER3lASTNAME: ( ?S ?' ? ^ - ....,. .. ...RRST NAME .. .., ... n..,•I: Al00.E, ,x. ura catl Orl wi 9 ? son ? °WD0N 0R STREETApORESS ...:. .. .,..:,.,..:.-.?. ROUTE NO.ANDBOXNO.^:x:- oK "TENO MJOBOXNO. 1 Q SSa "?°" "` W CODE' DRIVERSOCCUPATION - ATE CITY :'3 •IlP•COOE;,_ O MS OCCUPATION t ti; rd ?udl W 4 3 5fccslenf Po n FGM - DNIVERSLICENSEN,WBER;,n .:a...:.ic .STATE SE%` ::d OATEOFBIRTHy.i .AGE 1 ? .:. `IY:: OflNFASLICENSE NUMBER _?,,..?.,..._.,, gTATESIX. „"DATEOFBI1fi AGE. CE 380 / G ?/A K to 'i2 ! , M F L'O MY Y VENIOLE YR. MARE ICHEV.-0OOGEI-, MOOELINOVA-0ARn BOOYSTYtram1 i47a Fa?O P u! VENIQE.YR: MAREICHEV: OODGEI : MOOELINOVA-0ARn. ;. BOGY BTYLE130R)..?: . Lx:ENEE PIATEND.:'. .:. _STATE ,.:..: .. TF,U EF1PIAnW, .. 1t,5?.?1? ? ,F y -; - LKENSEPLATENO.. ---STATE . _: .:ITRN/ERpLATENO.r:_ ..y.STAIE.:;,;y YENXX.E IDENTIFgATX)NNO. „,_ ,.. 179BeMODElSB NEWERI,.'_,. ODOMETER (MRJEAGE) YEHICLEIDENi1RCATgNNO...-.,:?? (1988 MOOEWB NEWERIWILEAG RE/WjSiERE6OWN 'fIERa?.i'r•-ILAST-F1R AME)_?. ORNFJiSL1CENSENO.-,-:_ Q ET b D REGISfEREDOWNEIt ...:Y ILA6T FINST MIpDLE NAME);,: ..: _, .r.,..ORVER8 LICEIISE M. OYMEfl9 ADDRESS y„L'h%;,•.;.2:;.ISTREET.C"ANOSf TEI-, . ?j iJ /?? f?. ;:DATEOF BIRfH' ? d /Jr V7?/Y/QCE(rY1 (,(JF! OWHFASADORE59;. ..:.._.,.. '. ISTREET•CfiY ANOSTATEI-y; .?; OATEOFBeiTN';; •.., .. W DfY rFM +ARi60F VEHICLE DAMAGED.. - .tJ'.[ PARTSOFVEHJC DAMAGED wM1 U04LY Lr1?XV1 _ vNtl[OCC? mfBrM EO DY Y (Y18tl1EEi Olf IAGIIWAY IIAME ON Iq Wn<'OrI [? /04 /IN O ? AI-" ??kl i4r)Th FJve. / 0 ?!Y 0fD Q Q . ?'-, 0"D°. Yxsrl. 1Dur?p d / n ? ? ? ? ? aaN,,,F T S?RV.w CWT !, , '?. WA9THEREAUTOMO&L EL IAB UTY I NSU RCE LIA C F - INFORMATION-VEHICLE NO. 1 - wv fRAG E WEFFECT FDR THIS ACOVENrAN ON YOUR CAR WYES ? NO • , EWOF U MmYM IAME AN MO AOORE590FLU&LRY ;IN W6URANCE POl1CYNOLDER _ x E °°y[ ?g .. .- ".' NAMEOF UAWUTY WSUMNCE Sr75 a, - 41/1 48 y cAeAFr 3 5 ? rm rs /n ur i`IAM EJD AOMESS O FWBARYWSURANC EA '- r ' u ,t `a ?', 4', GENT Orv ,. Q l . 2 RJ L A.0 JI^ ErI d S! S 4l ?u•..[r : .: ..i wBIUrvPDIJCr NUMBER ow s w 83G? 3t/67 7P 7? -:1 p +v P. = 6': ??.?'N?, X FF. -_ . 'ST WJIAiY.'. _,,_ - -'.. . l,. J.?. aaz.1.•!. ME- ENO WJURY, i.. Nlf SfAAR f[A[POn IDR wprgluLw[MA .... -.. ... ... _ ......... AME I .I.u.S...` ?_ /o K.. NANE y?v Y Y1 , XG ADDRESS L rx M F - { Es - --m -t - - A U ? tbY11' F ? ® o S DIIf ° aMRf ®? me ? ?I, rU50FYi,81RE .DMARR MIT ONE-ATMPIJ 9.:; a '. ::.. 6TARlB OFPUVRED :.: ,MAFMf4ISEOFB THATApp[Yg. ? x9! gllED + Y?NtwO IAYI NLAAq ?Oxly[ WVEHXAE ABtfq NDIeYLlflq n a .., .r :. snOSeIE T ' [ a ¢ R Nwo ? ! IsE l Rorn erG lr ?IASif-1 ? gLL.D 1lEVEneI IM?wD10 P[cM } s ,ymT' ( ?m mrEv4 ? 5? B? 7? ?° rM..I re l•J ? 50 SO 7?mel 3? : -W MNTT .B[Y A RO W W LIACLE DESCJIgE BELOW WHATHAPPfNEO (REFER TOL410ClE9 EW NlMBER) •. ?;;f.•:: wI:<D"`„IOw ° ' O ?\ \ r ?Lf?-I?ly 2aS?'_011_SCVVJ7'fl6_._ t?.a? °^ HM.?w I ' R . Iw \\VVII .A. (.ref _ eUhen ?.eh is lei «-2_/?an -?h ram i?.____ l ' I J AvtnlR IFCX IKf =2-*- er««oa -to?li d 9w1??7ni vela. cV-14 I_ clxt-_ q4. Ser?lihA. Y _Wt'7ttcsses !r_r_t/eh;k&,_?3_3ktfed? `I'O,j [oo -, rfer _op lJShlcl? «hevs?. tyj ??oqp? ' ti ! ? telld - rocc?ih_t/{! 5iy? 4 acid R f-_ . - ?Jr 'S n , LooE? ?1 crecYton . o.?. c[(t? Ir `a __ q ? I,•'' ?d'c? :_4?_aay_yr:+ce?._[eli9?esses.. ?¢ftdvthf-?!?... gv iZ-t ov h2.cen{eic./`tic.. 4. lJumv W "- / 7!` was , t rue/?uf4f?on . on4tdkeed •.:t' rfk • I1CLLSP0SJrICNSBEFC L M B E Y 00®0 .F YM x000 0000 . ,iww w.s usPq 9 ? i .e J aw ?'ry. s aM ?"' • • ?"°[? • , , . M..: DIRECTION.-TO, -'DIRECTION; I ? 9DEwMA t ? wfLnw.r 3 ? lfOlrLDfR t ? e ? ux"ix?w °X a Oin¢R 1 f, ' IJCrIrODNarraw TRAFrIecONTRDI ;_, FAKII Oxn.I; meoF110.10 y .xr :.al 'a.'3 arvERYV[HXxe q!a fi b ?y?, ? r '.'"II. •?,f /?rri;b.f•. rF„crr ?rl.c',ep/ ?c?r;f E..c?F ?r is ?on:.Lilri[RL r t?VJ I ??7? I W? ._t I 1. I??`rnF I YV o?1 ?:ur I ®DArlrMr 0 1 ? 9(Wµ3 ? 1 ? ONE WAY ?I 1 OOINO STRNNIr ANEM I 1 1 r. J Q WFT r ? nµ4wR t ? DAw4 ? ] ? STOP. 9 ? TNV Y,A, ? 3 ? OWRYM04,AINDRAe.91NO' 1 l Q,tJw3i: 1r ?..'.00,?. 0.3 0' 1. MAwG.[ A 3 O'.mmm, ,. r J .rl. I F L r' RM ??. I 9 4 9 J _ [f 4 `T? ' ? RII? Y '' Qe 1 , al 71, l wsP"° Y STATE OF WASHI GTOId AO [ Or/ No 2 9 u "' POLICE TRAFFIC COLLISIO PORT , FFF . 2 TRAFFICWAy ? rsx¢ECOMIUI uMn[u out o pu ? PRIVATE WAY ,.{I ' . 'IMF covLLrr / W., g$' "'" I lus x ougl fib J c E,?,`?sv-J cnr w. rmv ? e A AN . J C ?N ?[ II Oq (OwN MIF ? OF [{N Oi $rR[tr Oq IRGHWAV i CIS gW1E 0951 C ql R "' f? 1 S O-H0 NIFge[Cr NG 1 R PoAO NONINI[gStCIgN QN J ./ STD ' / L / x 6 !/ eElwfw ggtllx [ MILE Wet '"Zx _ W srgFH a / ovwaaolRtaloNrWMRF Eqw {wossvgw NEAR[slblf WSl MLL[S N S F W srq[EI 0,19 ACCIOEN[ p OIA RA D ( I([( OF M A A MILEAGE O - - . - - L . ' " r <OIHSgNINVCAVIO of gllr NO jla 1O1µ NO III[O??NO INngFO ? O(IAGf tl V{nIClLS ? pWggrv OAMAGF ONIr OBI[Cr Sl ?nla quN w OE IN wNpnprxs %q0 I M[q Cl3 q N WE ggOAp OR grlgtiq[ CROSSSrgf(t Op WAp ?x ? - T ?,? ? - 1 c '' quCalNNA-d--------RUt[ANOOwNER'S NAMfI [5r-0IMAO! SACW COWNG ILiL f ?/- .^ ;. en _?. UNIT NO.I ognfRzNAMC p usr Ip MI / UNIrNO,,2 VEHICLE oqv{R f: ? PEDESTRIAN ? PEDALCYCUST wr 7 " ?. F ? 1 ergEtlAlgq c -^' - --? sT???J ?_ t ?` rn? ? ?- ??A« rREFI bGRL33 _ a +} P". C.1. 7 ?T oc3 ?? sAIF . 573 /w // s% f. Ll mu NaNL w. "?I? G / D r R ?---r^ k sA? --? x vA ?S HCI se NO ! e N G / g. " s I 9 YBL?? Ga?7a.? L..?.? ?S e• V oA L q n ra ?? ?}? „ fxc oN [ gHONe No [ns qHr rucm E acu 1 aN N 1 hJ.q ? ? ? "c .r ? ? /J [ rgNf No ns T ? r y? r? ° ' ? CHECK (.? vfx cif As:N rMn` r Armd 'v C rN/E ?j - ,.y ? H[q CODES?* ?c""i• %°eu?"' Slnclx%. {•solox•ci IN W ? CHECK (.? v[nn[AS%H FMq;or[fd NOrwiAl CODES ? * 5 "'•• n 5 I S I . L, ' ` ' FF " " H - 1'4 ? ? ? .M•,„A.?I o ? zs:,r. ? .; zlr a ,. n rtAq Mut IOOOGLCH[ q o wr.r?RIVOM I ? [ ? 1b v.l lloAgr.LgvAl SlrsF I)Oq CWV I I Fl MM I V wNOVAI ? r: v oq I NsFp ? 4i ,de s L uF srAl rR ALRRArE NO srArL H nH a ??/ m ? ? ? _ ? ?'? _ y, . I t. vEHgle IoeNrn eArgrq No C D l../%? -? +'E geennREOOwNFR- INr r I / IC ??? I ??? --T-- - r oolEprgNe La ???0 _ 1 crc `.."O.? ca5 i0.? s ? ?-c ? O q n q: 145r Ipgf R , r '. :? - , ? ? . J q 55 a owN[ ? - W A rowge :.5 ° _ , : SI' ?.SfJis1E q N x L Tr 'I NAME aAOOn[ssa wwRANCL CO ogACwl E EfFSS? -'4`? ar - R Gr -tii-?f ? . . " M ? _ ow..iScsE.? - f, r? o", „ C,' ow; cHAR a G tS E- [er R cHAgcl o ;AMACFU Aqu xN AwA, ?RFMAIN{o r oAM. .. w? YYZ. ,'+......-... _ i '1S 71--=77 NAME, ADDRESS 4 INJURIES OF PERSON; OCCUPANTS / WITNESSES I"sf sup^[ a 'Al 10o b0 qNµ Nµ X vul .r cd• IR SN.ME UAN• Aou o• AcINC. 0 e"sl? Tr? _n7?l. / r r )DES._ ?_ - 2 3 A 5 AGI rµut 'N Nx Vµ HI _„- I I- _ if H 1 R N' A , ORO l.YIN' ? ?l M y+? t i Y S 9? ? ?;4a µr? . w MOTOR EH2 ICL OLLI V-SION !' RE OHisJ LP v G .1xfl1„s:8 _-. ?.... 'All 01 COLOS101 DAI 01 GO-1- E ? r Lr M un -. J `. B D .1 ° o u 'o ?f N o? Teffer son o. ?N ?E ?IN of Do 7 A. P °BJDR ADM •%E p WC, wnsnn A I. RS ew M . oN RZZMEE?W?o mT ST. ol D . .9tllSl?? 3 RR DA .............. e SIREZI a 1. 1-7 OO O RALRD.'A""INDMREPDGIDRDEN,FYrNDLANDM,R% ENBNDD P TRAIRAMITA eT 10, O® COUISIO. v,vfD D q o " A B` xT o n ncc N i2 aq O DNC' D: v ENCtfa w ?oi s LEo ? »? E o 0 g,rt N vi ?co R rE oR ROAD L F i C 0534 ? E D3 0 OBJECT STRUCK NAME OF OBJECT STRUCK( OWNEROFOBJECTS NAME AND ADDRESS ?iun oFJtcr c. .... USE S DRIVER'S LAST NAME FIRST NAME MIDDLE F µo,r THAN WEREo NvORivfo DRIVERS LAST NAME (FIRST NAME MIDDLE Nord eon ,darer, ?. STREET ADDRESS TE NO U AND BOX NO COluso„DR MORE ?S W A ° M r Tune ? Y LU . . S ` E JuRED USE "SEPARATE" STREET ADDRESS ROUTE NO. AND BO%NO. TefFe ,- CITY STATE ZIP CODE DRIVERS OCCUPATION N - CITY STATE ZIPCODE R V p A. 987! ORIVE LI ENSE STATE SEX DAT D I ERSOCCU ATION S n a• SJ? O Q ?? EOFSIRTH AGE ?J?? F MD DA r IV LI NSENO. STA,E SE% DATE OF BI A E E byp YV Ad IT7 VEHI -, E(P DR.) VEHICLEY . MREICH .DODGE( MOOEL(NOVA-D RT) BYSTVLE(TD .1 door ANO LICTE TRAILER doo , PLATE NO. STATE LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE VEHICLE IDENTIFICATION NO. VEHICLE IDENTIFICATION NO. 4 REGIS FRED OWNER IIAST•FIRST-MIDDLE NAME) DRIVER'S UCENSE NO. ??? 71 7 REGISTERED OWNER(LAST-FIRST- IDDLE NAME( DRIVER'S LICENSE NO. OWNER'SAODRESS (STREET,CITYANUSTA E) DATE OF BIRTH a!B RS A8o OWNER'S ADDRESS (STREET, CITY AND STATE) GATE OF BIRTH MO DA YR ART OF VEHICLE DAMAGED O DAY YR. M PART F E dr %a' S'%Nao9 50 VEHICLE DAMAOEO R/ h! 6/lnJ4er/, fender S•N? / ee LIABILITY INS N RFA ION- I •T. AS THERE AUTOMOBILE LIABILITY INSURANCE ?jrYES ?NO COVERAGE IN EFFECT FOR THISACCIOENT ON YOUR CAR A NA ANDA E SOFLIABILITY INSURANCE POLICY MOLDER NAME OF LIABILITY INSURANCE COMPANY N,ME Kare.n Alt AODRES _ CI, ST t NAME AND ADDRESS OF LIABILITY INSUR EAGENT -CITY STATE P LIABILITY POLICY NUMBE R L ¢sfe,- D. .200 N• w 5"6*^ SecE le_ RY• V9117: 71 04,24 97 / I, I 1STINJUflY AGE 2NOINJURY (USE SEPARATE REPORT FOR ADDITIONAL INJURIE61 AOE IS, I, NAME NJVR LD NAME ADDRESS ADDRESS NATURE AND M F FFF??? .S NATURE AND M F R EXTENT F INJURIES NT OF I DID I NJURIEB ?? ?? 1 Al I VI U JES REOUEQUIR .1. J IN EXAMINATION RE riLCiTOR'S I E DOCTOR'S OIOJURES REQUIROCTOR BY A DOLTORT D O E E%AMINATION By A ? D( a NAME STATUS OF INJURED MAR. FIRST ONE THAT APPLIES STATUS OF INJURED MAR. FIRST ONE THAT APPLIES OaR IN VCHICLE N•M"n ro"r??!L rofaE IN VEH CLE aMS,Rp NBN o-s.SwN HIM( ?r• PILLED unMr rwox CWo-ryR..?. 0 ? PILLED INrcur N'NO+ii F ca N _. NO .. . _ p f.- r• ?FLn is ? D• 0 0 ' l ?'. •'T 1 5? 6? 7 0 . 7? 5? 60 7? MOTORCYCLE SAFETY. ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SNOW AGAIN BY ARROW IN CIACLf 1 1 NEf, -E! I \\ I ?' .,. EF OESCR BE BELOW WHAT HAPPENED (REFER TO VEHICLES BY NUMBERI Vehic?e__ I W4S_?roa?tLirc?_WeSF on_6 er_? ahA F.util..A.__ea t};on -u no) I; ht(bbhnki \ S H f ND E. W , _ 3 3 - ..f [? 1 °C W.r _ __ 0.6 -1/aJTicle_ 2 _.Was._rauzJJn _ ankh o j? o Rd a _then _confinu _S+r /-_4j=4J..2•4__y.W ? nyHsf9 +o 3oLAth t#i 5 bli kr b a _ ' _ _ _ _ _ _ at7 n n e.- _ 9 - s eay}- ? ..ueyl-_- hEY . Ve ice ._1 pu1-.on brekcs when_ ?/Plffek. z 1I r Wco_aeen Jn ?nlersecNFn'_jAen ia_avad hi?a'rn head on v+ln Vebfdr, ZJ lkJarrlQ 1uJ Whcr MMliw i C nfe ' h? at road. v, i f?aM- ? VEHICLES POSITIONS BEFORE COLLISION .Nn ? my B (GAT 08Y 2 i [ ClE Y?gHIF E W ION (] y[CI O G MAY N M[ O 10 RP }!J!IgS,?. ?lfFr'F rt + f v ;. :15 r? a<uN H O E.W _.,,?1YWi1 .v.r w, ':L@ . . - J e 11 n ^.4+m.i ?1 if h ?N? ?, ur<liE azs,a ` x ' m { r oc; 9 46 rO fa E i 7? yt? rN ,i ! ?Tr T I ?? 1 POLICE TRAFFIC COWION REPORT L-,Q TRAFFIC WAY wll na NUM°te I ? PRIVATE WAY pr<au Ar r c sr N nMf couNn c Tr w. on NO. INwA v v ' DerowN a""" oe r rlc Nwwr OE OrN ", I N .wlfs 1 ?W ?OIC ON e No 0 ra as _ ITR; I rNlf9 aNC wrN. vvFEloe vo•D NoN MFesfaxDN RV[[N 1re[tr a ?? II.EET D111 E q gJNi f9E T vnnx eo. Mel:: M x C9051119tElOR NFAV[STMrI[ ACCIDENT FS 1 t w OIAGVAM D,Iw MILEAGE rteT a CODE c.11-NVOIViD v`R`r t ? OIAINO l[Dy-NO.--D1 YIIAOf ?NrIa RUN 6 vtNtlfl m RTYDN•AGFONLY ?RSUIRD ?v(O'Klf w,M'i'pioi. '" -D IMtR Cl1 CI e,E NfT R90N OR VUfIRNCf CIO]SS-T-00Ap V ]a OexcIllvUCxINAMf Of OBIlCI SreUt DOWNI1S t1- UOND J 11 __ 11 'ITDAMAGE SrtCW COWNG lSE - - a] Q PJ2L C S s UNIT NO I Dvnws NAMlInsr n sr UNIT NO Z ? VEHICLE ? PEDESTRIAN ? PEDALCYC T ogN[es NAM - N k ? e: Insr l r - F :-z srxH ADDVt sr eT woeEss UIY SIAIF ZrYCODF vrrONf NO. D 1 Y 1 ATF . rT 3?8 R OeNIR'1lKlN5t NO SrwrF I 1 L fN ND. A F accugATwN f amoNf w ens wNr fflcNT M E CUVATION M NIMf a nra"e ra. Fns KfTT rex]frT __ N to f3 R O CHECK( nNKif •s AN rM v. ANO T ? CHECK(.) veNKlt ASwN OUO Aqr rte q l ° so r ^L CODES. " J 1 ° 5 CODES P * 7 < . 1 1° ? Ix ° s, y . I lFrts .1.? K ? ..,°A.,KI ? m1l ? n';_ • e ? ml KN rtN IDOM ',eKNFV.I MODfIIDNfWVAI ll l]09.<WVl --A-, am" ? sm. F3 .zll ?r° e r 1 1 ,ugI DN M A OM a? TU r nc?A -A E E - I I m A a L nA Ke T su .MUe rtArc N ppi? 1 TA WA I m nNKIl rIXMVKATbN NO !cF6 rigill'-741-al ' L VN If IDFNIIr I vECnnnoowrxrt rlvsr MlDOIe vNOna rro j a N? - ffit O wrxv: usr rrxr MI a 7 DDVfss or owwf I A 3 IAAu vlaa l 4q w N E NAwI a Aoonss or IN STfi-?C. SwANCI o ov AcfM M also 'A R uil I f u f DAMAWDMIA GNAT gAMAGfp AREA rw?rD?r, CNAfGi A AE a Fs1oAM. . D RNID ry?--I °w' ??wxr" ?nMMNID sS off , N D Der 1? f J(r o fr r : DIAGRAM OF COLL?ISITON N ?iN +ND°KYAll TN DSCRIPTION OF COL SION IIAF 6_ TAl srfer rllpxwYl ,A 1 fP717IT _f IA i? 7Vbawii RQ laa?T Ta RwH'r tY' -- 1 (i.? 4 } -- .__ -- _ F Y I_ Lle_ ReALncO_?r DAsT..Ue__tLw_SK?DO,a? 0,?c- or 2r!Trtx._, _ Ir? H ?Tt? 'CtkP Ww- - (dfe-- ] ,_ 1 F NAME, ADDRESS INJURIES F PERSONS I NVOLVED + CODES 1 - Z 1 S 6 OCCUPANTS/ WITNESSES aH0?^T?o "?Aw ii y? Au i•i _ v,r- - r xr,s N4F ? t N _ wf ..___.__.._ __._.-_.__. .._. _. .. _.. .._ ._. _..._. -. ._ ep ""-------? . FSS - . ma d N O,M a 0"v' O " O? E! N . . . ___ _ : W - p • ._ _.._ . _. DON1s -..__ _._..__.-_..__ N•rL9 ar---. -.-- Movlor.oM? ?r.xAl?rrrr. Or"` O „ r .. ,.. r..NM N AMt . mass A,v?s 1. ?•Ma Or. Oco.N. ^,. ? ,. ? X ?•Mff'`•r.l. s.wMF a.. l.DU OV .cF.,c? Day tisE OrGS1r.Nwc r.z nD o•n nom" •nrovtvf. n l.> d ?]p.]Dri.1 OE]o.D.,r.1 3 !9/? :?? 31 «l' r to Q.g t+r r&49 Mw " r rf " 6 AL'A"9ft6iG!*w`41G" "--.as-::..,?,q?ra;.;.'L.- r::_.,?.:,..?g4r sLL No. G ar, •Ir kE5 fi' ? ?Z? C g? F T p ' i ?1 ?1r1 t. POLICE TRAFFIC COL SION REPORT 181 7RAFFICWAV PaK?coMPINNINUMxR PRIVATE WAY r) T?lr ?OrFI _F F.401r - MD .? sew, x-0!1± 4 Ilene w.ll N. Ir.wr.'rur ISI ul fUSE].DD NOU4I ir COUN .-{'? Cp 1Y CIrv NO. AIWA pUU 2 a -J fLG til gAI MN pt ON LIIYOR 10wN AMF{NO a51v[ETOV NIGHwAr 2 N G FCTCLS RWROR f ? KRv MEES 0S OW OOF M ON l%QnvznplI, - ' NitP5FC11NG WIIM'SivFI'OR VOAD NON NTfgS[CT ON .1-IN S1RE[i{ 5TREEI Pvfir% !O. MILE POS ^ DI7/O I Dr51ANCl6D Vf r F .C.05551vE[IO4 N[ARfSt MIlF PO51 MRS ! Sv! t r[F1 W OF ACCIGENi MILEAGE CODE RAMP DIAGNM'. MIA COU-N N-D. "Rriv: TOIN NO NO KIEEED_NO.NJUREI, pSP MAGI ?N1{RUN mrrSN wNRaDr« IN FR CIS I it REEL RDAPOR teifRtNCE CROSSSTR[[t ORWM /]] CtVII-1S © p PRO11111AMAGF ONLY ?'.UITED ?VFO."U /O 2 o JECT5"4 IINNnLOFOBJECI5TRUC{NIDOWNERSIMMEI f5l O MAGI SPKl4COWNGUSE UNIT NO. I UNIT NO.2 p VEHICLE p PEDESTRIAN p PEDALCYCLIST 8]I """'NAME . -1 FIR51 10111 ORwE4'SNAMf: 151 Iw iIp - >1RE 1 0 55 51vlN ADOgt55 OM c O 0 2. o1v -11 ]IPCOa PHONE NO. D 51wR ]IP P 1 A a A 833 007.. R A t_oc < 33 36'"- -7 _ r2 D4NEq suctNss NO. SuiE E DAR " I I Ir sLluNSf NO SAII DNf aeRTn /' tJ C. I.. 2I c.. V Z.ENR M 2 2 N to 1; B 12z 2B 1 IXCUPAIKIN Rm NAME 6PrxJNE NO fYlS IGnI IfrGni E IXcuPANON MNAME6 PMONf NO EYE WfIGN11frGN1 F ? Z g5 A? Ib0 5 oLl R btYP CHECK IV vlncu AS:Nw° .ImIO1NFVAE ea ?CHECK b'1 vFN nEASaNUnNa:Ra .o A 3 CODES P, D C, . ^,s? 5 I rro•. a's„in " M nc CODES P. 9 cis . i+i?r: S I%elro.I 0 ua1vE'cu s » ro 2 NIMN `? N iN F M ? ? °I° O bAr O ? pM ?YL w7Y' ? p u O ES:rI O HR 13 :° N I Kn. YEAR %F IDOW[.CnfV.l s D MoOil IDA4I.NOVA1 f 1]OR.CONVI s qLJ E 1 -NI -1 ID.117WA v n. rs r. 2D TS.V Tv .I I D4. r 2{x(2 ' v N uaN n No sort mNU4 RAn NO. sort H nn ao4 A ' l G 8 4'1 A W I C m?a 1 ?' v A ]R N NKLEIDEERINCA1roNNO. L vtn NUrl .I zla 1-11 r-l II i CISI I i I i N 3t$ 1 r 13- 1!4 16 1 i Io Z z RfGrSRR(OOw.Itq 1.151 NR31 Mrpp{[ PIgNE NO D Rt RRED wNlR iST E S M? v a. ADDnssa owNE. N A a 4DI E IAmE{ADDREssaINSu ' RA,aco mAGENT EJTArE FARM R IN U N FRRH 6RS ,=Nif. ?• » Rx - t fZ X, r "D Zf inpr EN fbF;L T T O 4 OAM Aqu ' ' J- pR.MAGFD AP[A Fwriior°iu E • » s Idiorio? u1aDAMADE NO $ CHARGE .w'^? ® 511-1. CHARGE _t 11 UYVAVN 0RIMNNID t D s,r,GE $ $ ° 16:onou AWAY BY : ? e d AMA ? DIAGRAM OF COLL ISIO N: IU tu l l evAr.AOw1N DESC RIPTI ON OF COLLISION: IIRI SIAPRM[N1AE 5NE[III NFtISSARrI { _ O ® --? - ?E1S.?_.L_WAS_J?I44g GAZ_:CHEti _sSLGN?N ?.NV!'?ctRl- ? D ptR'ooi?P.-_L??F-V?IEHq'LJr.Si4EP_..SkE,-R 7Sa34f4_BGl?.9+ _ ? - ? . - ? ?_P,N9_SPSLJ?_?r.?i? 5?59!iT_L-'?yJt•N? F<.RWPF:9.__SHE1SLpt5. » ? j ? G??,eo;c!.5?.7]iE_C4YS FCIR'6tPifrC._A61D iSTASa?ED_W[i4JJP_&DE. 1_..{ + I ' ' _.. 1._ D.f3V.NFEDTFIE REAR vr- Iki0. WHEN ST'_RA°9REtit7i SmP' ?E4_..KrAW. _?N:_?5)EN r:Z..Ori? ?.pt.'tKLr.JK, SHE_ HA9 - 1 _ ---.. ? ?- -1 4 i _I?GV .. JEN. k'?, S\PSEA S?IE 4?EW. A PkXk, TT_uE?'.k. YF.!3V.E4`?E, V N P P 3 k S S I__ ._t .`.__ .. I E.. N9 W?I ,LriSNE.O.OFNE.CK.. PL UC.MA •+1 P-ic.SLNG.S . y NAME, ADDRESS 8 INJURIES OF ERSON S INVOLVED 4 CODES I - 2 3 a 5 5 6 OCCUPANTS WITNESSES ioi ioDn?of::i eASMNi i su :a -'- .rus v.I- '", r -N?- R uW --- tsn " .u.. 5 .ME N ° .[wn55 b IN r U'^ Q AM e ? Z7'O E .r J . O ^I ? .N,. :° A ... . ... .. . Ni . . . .. . . . -...-._...___.__._.•_ __.. _._. ._ 1110- 1 NAM " aRRn oP,a ui n ri. uM O.Me p ,,.r p«r.• p... O °, .N r r« •• ..?. ..ml. . X e,x Oq A.n.c. = .A•c.Rt ch°i r5D o?i? wn s RI.O4r Dan r ? ?o .i ? z-zy a Qg , wti SFr u ? S tw???, ?+? ?'rF?'?'`o th 'r? s 1•' t,' ' ' ?fi'1??il? ? wRyyvrAd?„? ?. I, - Vin, BYE P o A.y _ kPoe..7,, R ? ?? L PAR 'PJ POLICE TRAFFIC COLLISION REPORT gTRAFFICWAY '/ rocfca?.ww Nr,,.-ER / , zi If L1 PRIVATE WAY I x' wiFO CIXV ,a IVSf JIW NDUR, COON" ?..' J n.wl - COUNJYNO LIJYNO. iNW ?D ?V,' Iz I l U ' O '? V RA A. pf pIN CIE' OR IOwN [A NO OFSERE(TORHIGHWAr VEFO RROwD F NON NII95tC1 ON ON A? Ro Nn95[Cn[YA1 NG H? SI I'll I ROOEFOR 51 I'S StC110N I , ? _ ?1 I 'i1 LAJ BfrW[[N SrR[fi 6 514![1 NffDt f MltlvMr / &o / ' D51wryCtl ORlMtIS vON VFis R[Nf [.CROSS51vEFEM MwefSIM IF WSE ACCIDENT x RAMP OIAGR .1. MILEAGE r[t1 or /1161 Ibr-I ODE [C <01 ON INVIXVfD.??15?7T vfR E? ?? ?;As AGf ON-RUN FD [ Srq[ry wN? w VIM CIOIS 'R 'u! R4D Fv tING iRf[IOR ROM O4 M[ER(FXt 'S IMfR Cl3 C4p553ivf[IOR ROM' I, n IRJ .1 • OMR DAM,SGE ONIr IJ• pR ?KSUtt[D ?VtNCI I S D l/?N,Y `7 ?- ^ OC/ .EI1","RVC. IN-1 Of-SIR -AND.-IRII-Er 151.0 =AG! SMCNtCODIN.l6f ?- - t S UNIT NO. T De vIR'S NAM[: 1A51 r O t UNITNO. Y VEHICLE ? PEDESTRIAN 0 PEDALCYCLIST J' ? 9 l aEJA6N NITL DR VtR SNAMf. u 1 1/- RHnIA) L - - - //?? e SERIO wODRt55 19 cw,K 1R[fE MDR[55 rc oC c. yrw1E GDOf RnGNf NO. Por<T 11hrJ5eD 1M ?14S3og 3 DRrvtR-SlCl NJt NU D R nr I? loc UN} "R339 R3S5-?Iz3 c DTJ D P 3 2t 5 51Ai1 !. 1/4A4 M fq H lc ID R? 7o e v 2a Iv kL 4a Pa IN „r F I lo I n «DDR. ,m E ND f « wwE v NO WIIGNt IG _ 02 S 6°. i R HE - rJ I o a A DI 17o S A p CHECK (?) HKif ws?N UnRio wryolHEe"l CO ' N' [" ?CHECK (.? FHti[wsANrMRior[[a ANO1HI.wl v ' ?E DES? a ;, 5 lncla a;,°,,; ?- , sS CODES? J is 5lR1a, n iw?eFC.cn • iwN' C Nn- J2 Dt N w?o5 11( l? D b `d. «m ? w.N .,K : ' ? 186. p ?,KT ? " p mN .NI1 sc w1 • D K' ? Eb:1F. ? ?:K I p :'N 4F VtH rlwv 1'DOWF CHF r MODII IDUr.NOVw, slrl! p- ONv.I /n? ICI7y' 1.0 1'J a E I fV.l vi?w -,A mODLL?DeeoNOV"1 r [ (n')r p^^ 'I? luNx RU lN. s1w1t ARIV R.II NO. surf H wH CaoR Il w N wE r 'fi81 1 lt4 - - C, (31K L(olo8 j . I v q - - '3 vfHKl! IIXr+inKwlgN NO. lal I I I I I I 9 I -1 + RlasnRFDOwrnR wl nev mIDIXI R1aN[NO L fn ClE IIXN1 N w FII I ICI IEIs I 151 Igl f rs Do L io NG 5- 2 O N wNlR l.1 s1 ml e U u ?JLt Y? r MDetssa owl.fR wR E FO (15'4-P/1 833 NAml A A l 'l-ANU CO OR MINE Z r INr'e- DAMMID MIw R 0 Z DAMMED ARfw S cro.Dim CHARD! A- CHweGf FCIOII [ l3 aPA.NAG! D ^N 0111-NID J\j °W:Y O4fM/vN[D 1>O1U,iwwGE ,ovrt° A_., • w.r By 6 DIAGRAM Of COLUS_ION I ,mn ylI ti'CAp=i- DESCRIP ON OF COLLISION IVSISw%lMlNlwl sHffErNe Isswerl 1 ..I ._ @>. Cg K2 Sl8 .TPa,?a,?._K ? ,Hal wls 1 ?w E4-r s ls STT?,bf 516,3 -AT Q's "M) Sr ?.._ !-AaN??(c,_ L!eHW- ? J',, V H4ILC AI ?'1N y H p o? VeN 92 2 ?C IE ± .1.- ? i I I _._ - _ .. .._ , S - J, j A55. G•, ?,u¢ VeHFCZ 2gTnie? UeH^I la leo" 1 I I I I.., , { ? _i . ? _ _., ? ? ? I _ _ ComE[w T'? ..Rvm"i" 4.J TLr. Cu+wr?h,w Ye4t^ I I(3 1 . _. -.- ' N ?T+JT Qa T Sk? Dr p S I...I NAME, DDRESS 8 INJURIES OF PERSONS I NVOLVED *CODES Z 3 4 S 6 OCCUPANTS /WITNESSES 'rte ASOwoRI NI HAMHi s il. A., .. . .MT Mh I.A eD i +o .? A DMISS S.4J 0 I.?o,,T , DVKT- b " Me. •we p?1°'p^ ,?C.7 .3'u?1 Mc? N bl .. ._.. N trus , A UE i'R[a NUrt- ;E v1D FROm 0- pRl O o:.1. p C. _ A N 'c" r x s ?"vI ?.M eu,GE O• ?D "o wn?. ,. • KI Or1•A1URD IN ??? ?Z3cJ sP 3 JR»",-. •SL KI wenNU U23S >R„HRJ •Id •1r0R1 II-1-S•? MONO r DAII / 5R, Nry 1 b?`??? a N v Al ?lI Ecu. PRIVATE WAY L6 1 -,MH?Hw,u% DAIlo ocau N LIME O r ,q •7 _ UNTr C nRf. ?r n W?. ups ryI wvS Iri,-Y ?. IUSE }qD HOU91 Z,sc? O/L ?/ J CAIN "IV NO. ?NUUA 9 !u ?ry ?I 11VO910WN O OrSrvFt1 OR HILHWAr r <l5 DM I gDV,IORkR(EC CS PAS QQ .1"S ?,s ?W N loot! QNC;92 2n 2v J' INI(akC,IN. Sx SIR 11 OR ROAD NON IN,(vkC,WN - S EEI IN ST9EFIE vR(PI% f0 Mllf Ppsl Q 'y DIS,nl Olvf II NC! / MIltS M RESRENE E. C.V0555191(1 nFne(SI mII( SA[[Ii9[Ei ENI > DIAGRAM DATA pr MILEAGE NET COIIISIONINVOIV(p fvlRUr ,,pp ??++?? [OR DIAI NO © NO %Itl[D?yG,NO.INNRlDy ?YI,1AGE ?HITAe11N w=xs I F I'. VIMTC? OVfHICI[S -TE9,VDAMAGEON N x?a0 k!I RI[fOaap.vp OqgrFa(NC! - IMF9 Cls C9055 SmFROR 90AD -..Jl L OB1lcr STRUCx INNA(OI OBRCI SIR- ANDOWN(RS NAMtE ?RES., ?_RCIF > O .?) 'Y ESI.DaMAA, YECIMCODINGUS! UNIT NO. 1 UNITN0.2 s DRIV(o- s NAM( . us, NRSI MI t Daneas NAm ? VEHICLE ? PEDESTRIAN ? PEDAICYCLIS IL l Z,,L TLG D.sr --?y DDRtss R(R ADDV(ss - cnr I ZIPCOx PONE NO D /L)oi2D1.4 w L,/r4 J:3.S? SS-SG?3 R r DP ' SATE IVIa S UCFNk NO. STATE BIRn I uEtryk NO. 'fl.L?C..,T/7??Ii.PJ /??A/? x' V D«UPAIIDN F ONE NO .vo o.velR :. WEIGHT MIGHT O< E CUPAIIDN nRm N AM( a P HON E NO N Ens ILHI ' ?%7G.7 G' /?,p?-w.?. ??1_'.. ?? R o EIG H, - IM?'ST AT' .o- ?' L k P. l M J a II. '?aI POLICE TRAFFIC COMON REPORT L& TRAFFICWAY PLA rNwazP .. PRIVATE WAY _ A Dw EOlcau wR up lull. wlp.•N ,M[ V3f IW NOU91 couNrr ,• / couNr I c"' sM'A ?EOyewN t ?N ?r /? enoR lowN Mn[s Os ?w of GHQ ??? .srelETOR w?D`«w"Ar_ ON ND?P,e / sour s9s 9?? d f.,CII?NG VnrN S R II O?V7vOwD INr[95fCr10N IA-GU/d?e .{l JRJN[fN 3ivEEr { 3i9fEl PPtI,% MILEPOST 0. 0 rA Cf I, ROM V(SF .CROSS 519tF fwe[51 M,LEW - /l ^^ [!r5 5 E wAJ/JJ'/LfC ACCIDENT MILEAGE CODE P AM pAIA. DDlll$iON INVIXVFp v[91ir: IOIAL NO NO aILLll1_-)U9fD_ ?SPILLLAGE CJ""'-- LY VI«KL[S m -TY DAMAGEONIV ?O[SULT[D ?VtMiCI[ •, D iNiE9 l33 ReoApoe IIENCE fA0S5SRt[10990AD 5C, )] 051ICl SIPIKaINAM[OE OBnCt 3lelKa NlpowN/r?{S W?M?[IL tST,pANAOF ATTNe? S ? SRCW CODING IAE - .. UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST p' pe v(R'S NAME p 1iv51 Mi L /,??fIKE ?G LA '7L! Ov vf93NAM! NS-?fS i 519{[1 ADDRESS 319EFt ApDel53 v Slwr! Ii OM /NONE NO /JIDfOC.4?/D zv.?. 1? 3 D , r 5 All I F rvtesuuNSN vwre ".• M I u1NYNO Ae ei r Mp a " r¢.ve?? ?,v Zu 3 Zz V e (XCUPAT- aavNCNtb ens -1-IT E occUPAT- FllM P-1 No Ens iG«I EeIGNr Z E CbOK R I'CHECK(? vNttfAS?N o w" 1 ?CHECK(?) A' S VnROrF[ wNOt«tv nN nl ''7 CODES 7 C L e s 1 CODES P ? ] C, .' RT 5 uc a !A .J it Y Z Rrts 3s Sf j;•b p . N . KL ? t.: l ? c8.,. ? p Ma . l 0;1%", ? 86. ? <N ? :°4n. nn r[wR MAatlCn[V I 8 ,Gd MODEIIpARI NOVAI Srrll l]D I ?tiQ E n r 1 N V I rnODt11DA VAI 1 .) ]e 'T « N vnlf t9 Rwr1 t H nNC .09 C v[NKtt lgNrilKArgNb v«,CLt IpFNr I F 5 I L vlG4RetD OMr]69 wl Ne51 MiDal InON[NO O I p WN Wr ]IRSr S?s AoDV[ssa oweu W A w Z N E AMIaApwtss ptNw•ANCf <o o.A/y,??r ? L L a - R u .n ? ?wl E?? d7/? ? 7 { ' awwc?D.A[A AM"A OIN I , c. c= ? g ii ! tC?11 pAMAG[ ! ,vIN ? wWA ?e1nUiNlD AW^Iry ? ?•tAMiNlD 111 ?AM t IOii 3 O?O ... A if OD towloPr rounder f t T DIAGRAM OF COLLISION: r«iill?nl[ce3wrl iv 'eNOVO°i1n DESCRIPTION OF COLLISION: ILnl slmeMENru Yelln NeCll5AVr1 Q[E-?Kl- ?sr.BFouv tiv dr9tr? CDC ?l LLED _. D =- /^Ce^ ?T ??`?? U ® fTD?/E?70 7l/,P.) Z15-y ,. , i4//,ei4"10 erere-/ ?r/D A ? v ? iivev,t , G ate. NAME, ADDRESS S INJURIES OF PERSONS I NVOLVED OD ' 7 6 s OCCUPANTS/ WITNESSES id[E ?DRI^,„N I" ot r.rln u . NMw w ns• r cl A, AMI O iZll id - AON15l O ATS' °' 'j' AM e O EY1c' ? "' . O H O lu O AMI b •aD.n3 1LE.la .9KNID l• 0 AMe pto,cl ?:° .D No AIHNIS3 wlol 1 N s INFir ?AMe ?'t° t' ?i' . ? w ? :° wrnw••A•c o•EUn•rw a.AN. •Apcl o• .p b wlNt• 6y ` a ?wc PIX D polo a v e. DAn 't i ` tE[ "r 4. n 3 c 1 t L? ti'. k c 1 I I!k I] UT3 I t I 5 r ? t 1: 1 I F I ? ' 11: T : . 1 1. STATE OF WASHINGTON RAGE / Dr ! No_ ? ? y r ? z fl ?- POLICE TRAFFIC C SION REPORT !ql TRAFFICWAY r MHNNI WMB[P / PRIVATE WAY ' . q 1 . _D t IXJ, N. Ar IiMF COVNir ? i ? ? R" IHS.. - I-I i1?y1? IUSf x.OD «OURI L ?! O / fEcyO/E? h CrtY W? NWA ?r yW //J?q V/ RURAL f ? pE arv ox lowN NAMES odsJneuov wc«w^r JN JN[IS ps ? ?or um ON // rvrteBECr us 1 _-.771 . eourzdesw < 14115.0 -l. SiRE[t OR ROAD rqN N,tvS[C1gN B[MT[N SIR[[i { SIRlEi IHNK E MM1F aoo % / Di51ANCf {DIRENgN rvdAR e[NCf.CVOSBerR[[1 EAVIBIM t! 51 ACCIDENT N[S 5 [ w -p DIA.-.IA MILEAGE rt[t Dr 7E /?' %?! CO DE CIXI?IOIAI rJp VID ,? vvllFD_ND INJURED? SIM1IAD[ ? « r6RU _ ? N ru« r" Dii MO " " MFR l5 SE 1 SRH 109 ROApd(giFHNCt CROSSSmEET Ix] dvE«Kl[S © prROHR1Y DAMAGE ONLY p pLJlr[D pVlaCIF 0 OBJI<ISroUCK INIMIOr OBJtCI Sr RUCK AND-IIIINAMEI UNIT NO. 1 251. DAMAG[ SiRCW COWNG Uef S UNITNO.2 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ?• L5_ O S ff c 4--y ?? In 4v BIRtFiADDRl55 270 61 z? sraerAwv[ss . , al+ s1A1E 1coD1 orvE NO /?iLViISE•?ro !v,v 0 -0743 D R I srArf _ DRNI 'S uCtrvY NO. IIAr[ " ( I R' lK[NBf NO. AfF DA II 0011.11. ?? ?? ?? D D,r • n V ?o?CS T Gur9 F 5 3a y Z onccu_vA,wN AM s IcNr New«r Cf // E R occu.ArioN AMf { oEloNe No ens Idlr rclc«r ?UOfdu/ /ZL S- / p CHECK (? a[A : aANOrNIC AI p CHEC (,l) [d ANOINIaAI A_. c DES CO >' 3c ." s'aKrwN / D,",°,° . coDES?* ?< s'A a? _ _7 [ rv ?I D B M. 7. ? n ' 0 m... ? " ra ? '8_,, N« EAR Kt IDODCdc«NI I[IDARI,-^ 4rlF RDR CONV n e"Dr w ? --.NCI ? rol.' ? 'br;E. p ? , D1 xrNr er IvA , KN _ l .I I / B/ G?GS10 ??G E E I v.J MODlL IDNr NOVA) J X966 ID / N oR uuNUnAIEN A su,E I[RAA- sIArI H rr N rr 3 / /D/F B3 !fi/! /?EO L,ev 0;6 - nwntlaN, rlulroN NO. W i/v: r- 1 10 411,6 oioi ! L veNKIE ID[NDrI / P:Fi .7 19 31G PIZ 11 Z13i(o 6 v[msrtnoowT.[R ,Nr Hesr MlDme r.nNr NO v? W s eo wN[R. IASr HRSI Mi E /fS flvde. ADDHSS a owrveR R y E si4i?7C I a ADORE. a iNSUVANCE CO ov-1;1 r d R G 5P' wMAD[ NI. Hci?O.D.N CNNDI ?? ' 6S ?h CNARG( rwirp"rOiN DAMAOlD NIA _ IS, DAMAOI A-U 0R[MNNID A'R'AY i]RIMNNtO t3i0, t '" f 7127 lowlo{r, A,wAD f/GOD r ev ? DIAGRAM OF COLLISION" u.rt« NOKAn IN - «lcessARrl Br ow DESCRIPTION OF COLLISION: IUSI SEAHIJHNiN LtI rraassARrl ', ?EA12?? aarcr?/ I !/f //C LC '? I S/o • -L/CO ? ... - -r x r .. . O ..__. l?EiYiCCE r Z SZ.COGK /!EvyyCLE ?!_ -? _ I Fc NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES 1 2 3 4 S 6 OCCUPANTS WITNESSES io: wai o?rva eASM"i ii uK AGE urns '"„`^" U•;- "" r esu rna MI ?.o A Dal.e uRld e AMB ?;W' ?'K . 0. 0". N { DD{.ISS AIWId -- . MOV10 repM ?AMB ?"^KI ? n . p M ?,w u . N«In {r?rd " Ira e. pAMe ?< :KAr ?CaK. p^I: ?:O r 4.r LdlKl.eN M1{r. rr. XT - {N FOR GN . III Olr4'{ w?? L O7ss D xaN«., ?KI?.: D - a DAIId Harr ?-n y p [ DAr NDj ? B . ? , y y xl kz 'n T , MIN w ITT fge"?? D°f>k 1} : E, Pt S ? y 1 ( I ? Y- . { ? ? w1 { I P 7SL B I r it 1 I I .1 ?I POLICE TRAFFIC C ION REPORT L,XJ TRAENLWAY J PIX. IuiwN fR. PRIVATE WAY .. y_.7 ! au N__ f? M/1.J ?,? 41. -Lr I `-'(O ?wl I nne IVSf }pD n0001 ? eouett E r No. F/?_ ] cltt NO.. PNww, ?Ue AN URAI ,.' Oi Siv t OR ?YOII IOwNO C? ?MIIES ffis pE ?w L.'-[T[I1R144GC ON F r Y/ IPT :?v 'L RWI[OA INikR5tt1NGWNN:S=9fflOV VOAp NON e{1{9$[Cl?? (?_-????? BFiwtF y` 19fF1 {?(% SiRFl1 P91r?{ ?(/ F MBFPMt 9/ - 2 D151ANCF{ CRO3 IFILE NEARtSr IF PO EMilfs 5 E P w ? Yv1 r[!t , OF ACCIDENT MILEAGE LDDE aAMP DIAGRAM DATA } <O111'iDNI V[D vtv nit6 RUN OTAI NO t[D?NO INJURED- ?SPIIIAG[ ? bVtnKl[S PROPfaiY DAMAOFONIY ?aFSUl1FD ?VF?'iflf ' Z.,I,s Os INIIR IMf/5, Y D Cl5 IN 11 RIFT R-OR OFIRENC! C903551R[Fi ORROAD lS?¢n0 N OBJECT SIRUC NAf OPOB)[L151RUCa MV OWNEe'51NMF) E11.pMRAGE SMCU.I COWNG TAE UNIT NO. 1 UNIT NO, 2 ? VEHICLE ? PEDESTRIAN ? PEOALCYCUST ! DRrv19'S NNn{. IA51 NR51 MDDIF ELQ,e?DGE f??v(Se (2. D9rvER' NAMf: WI ? I l Sle[[1AOpR[SS pe, EERIE, Z.R. -2 r /??l s;AlE nac oNt NO. ( mi-I&?q -trJ44ch2.n 792-4-0 D cin su 1 I N N E rvF SIKtN O. ?CAR?DR377Z SlAlf ?v 'l!2i I I _ I V EN. NO AlF DATE B e CUPAIIpR fIPMJN[NO FYlS GM MK:HI M E OCCUPAtiON rIRM NAM!{ f EYES IGNI IEtWM 2 U [? CxH RD R ?CHECK(,I VFNK FAS AU ANOrnfaA` ?CHECK(,') IVp,CIF NorwvA` SA I CODES I> 7 cl u• °sr 5 Ir a A S ,AClron a ya°rt"crc CODES 0 3 c? ss - Arts N 5 C? C. IMMD N w ? -j ? 1 ? a ? N KN ? 1 ?tio,.DM ? -.w, ? u ° ? yam. ? „ ? r. M. Ku ^ }, ,I aelw.OGE.e f .1 IDAR ."?} 1 s1YU[ pa.. NV wn .X `( M, ?JISS X YA "c" E n r ( V.) -ID I.-AI l -'° eP I n IRMIERAAI1 NO. StAlf A 1 N Sl l 11 I'I vfn.CIXOR ![FI N , ? / ??A ? ,VA VENKI[Ip MIFICA1gN NO N b;roip o b t(i E-to o qi q r?- 6 F L I l I w 1FnI IpIN i - NO acsrtmpowmr IMT nrsr Mm zA?ACE .Ti,1? O I o wN IvSI ruse MI E Appnss a £ W N 9 ? (? ' AMt{[SSV INSUeANCf CO. OR AGENT E Cir IR1 R I {7r ? >7 gAMAGeDARU oMU I F.NC CNMGE CHARGE ' s ! ! t!1 P•MAG! ? ADWwV ? IAWNID ? WM1 ?.TMANEO l ?OTIOii 10-D 10-D A..'.,"_ NLQ'?- Al BY ? AwAY B1: $ n `lary` p FEY" ROwl" DESCRIPTIONOF COLLISION: (-I SISnEMtNIU B-11 er4C(SSARrI DIAG AM OF COLLISION: _ /O.LE'?``_fl?QA!lUO?F!%iFCC Poe ??? r r Y^^--??^? I P NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES I - 2 3 4 S 6 6 OCCUPANTS / WITNESSES ioi iopn?oM.lyTH M ii u• Au i.u II;,wN y? "':r n5n Een . NAMI AIOUC . _. l M 0 . 0, ND i ?? __._. _.. _.. ._. .. _. -- -. ........ ._.._._..--...-. _.._ _ •lw.fss NAI ;R M ... __ .MOVIp noM N ?AMB ?.D?KI ?".;:. ? HD ? .p wMl N ? _..... .... .. .. _-..._ .. _ .DFNI» ? N{YU M _ .. _ ._._ I,. ?S N r Lnir ?•e ?? <I ?,M,I. ?3. ? GdKIR 1 TMI {a•N. X v1514•I R o P J '? ? p OyKCMD ((?J g? C? (O? 1 /?? ? J I / D rfp . .r ( .dfws , C I U {yamN?? r,?t r t '?V', Iqf?? Ti I '{? . P I. _ e w tat??fuz ??wtVws?a?si_.m ? i 51 MOTOR VEHICLE COLLISION REPORT r AUNTY l Nor :r Na?s? a Je U ?..F G «L?b}}//II aorv? s uorv [s poll Jti?)?-A Aca' QN ?( Qly Orve or o xlomv"rfLS- . ?uie°R (,nEn w« P niMt.:' 1 F ? . Ea ? a ? w ? a. ON e 99i,S-o ism ° OAK xoN Nnu(nwx mEfM. ' .. (rw(Ex A B'o O • nx w( p oxAU o.r' ?7 _Ko. a nfYr w,wLCr NCa.wuT A .EL ©p nM.ne°cn°uxeN•(.°arexlcN " K, ? C? D DES cnT,R E, --al G '' Y 0 EGT 6 RUCK EOloluac?r?slMCXI ??, qWN- OF flfl?IEOTS NAM 0 [ p9 ll ?.???{uu cccc;;((°«uaE 1f1j ? .. ., .._?..- T.? ? ': .. '.'.... ..-.. .1.I.s:J.., ??. $ Y N.i15 R?K(-,.yy veCe OR VFj19, .. T I - - rw0 uRs ....I_._4A5. yA?€__.. ......; E.RSLNAMF.. .-. AGDOLE.; wERE IxY«Vf0 ESflLASIHAUE,a. ---?. cIBfiLNAME...' ..'?[1P.g1-E..:.,.: I cou sloiSi °P ... c 171 lleil r ?? e MOPE THIN Two BOUTENQ.ANgq E:.-.S wFAf "TaROUTE NOIAND BO%ND PE USC A W EPAPATE RP-ly€B?AGQS!?PSlVri.c COLUSIOx CITE ,.u.....1 STATE,+"_?:,,?,('.y ZIP COOS ONIVER,8000UPATION /? PFPwOPT -.. -.+- i Y ?YI ?^?! u a_ RIVERS LICENSE NO. STATE SE% A E OF BIRTH AGE DRIVER'S LICENSE NO. STATE 5E% DATE OF BIgiH AGE 41. I , i./y i u °A a 1, .r.. Y i Yo. oAV rx. VEHICLE Y MANE ICHEV.D DOE) M0/ Ei'L/(NQVA.•?'-- ,. CFy XFdILr4E.TR,MAKE.LgHEY.P-QP..E1J.ElOOELIN, YA•DAR1 :PODY.STYLE (?OflJ. 1? LICENS PLATE NO.STATE TRAILER PLATENO -".STAI€....-.. 6lkEN$EPLAT E.NO $TfT,:.._.. ,TPAIIEP PLATE NO. STATE' . r , VENIC4E REOISTEREDOWNER(LAST-FIRST-MIDDLE. NAMEIORIVEN'8„LICENSE N9y r.:. :-9EPI.LT E.LPYLNF?.I T:LIHNT:MIPOLE NAMEI-;??_ DRIyEN.{UG,ENSE yQ ,?,;;-;, -OWNER'SAOR S ISTREET,CITY AND STATE) ;,,.. :.: .DATE OE BIflT/1:, OWNER'B AOgflESS.:.., .; (BTflEET; GILYe?NPSUTE) .. :.:: .GATE OF. BIRTN.' PAgTS OF VEHICLE DAMAGED M[mL l?? pARTB OF VEHICLE O?iAA0E0 •• • -- ?ITPNn4!?a,y_ If, m.? _ s $ LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1. WAS THERE AUrorAOfluE UweluTV INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ? YES ? NO NAME A?N,YADOHESSVOF/LIA`LITY INSURANCE POLICY MOLDER.:,._.:.. NAME OF LIAOILITY INS gANCE COMPANY I xANE'IeIY' / `flr/? i1 oOPESS .l iE ./?• y W N L' i1 S/lam/ GI1 NAME AND ADDRESS OF LIABILITY INSUR NCE AOENT,?-v,u:i C.:.,..:._?•-GT1-.: A f;; .,,', TIP ;LIABIL{jll-eOLICY NUMBEA,. rlL.lO ?c..f 1r it a.-nt •d t? ! 6 18T INJURY AGE 2ND INJURY I aEPA"I E pEPOPT IOp b E AOE •? __ ujE NAM A' INN11E0 NAME yv?:.- a ADDRESS' 6EA NATURE AND M F ADDRESS NATURE AND ? ? ^ EXTENT OF INJURIES E] 1 r ??I 1 ? EXTENT OF INJURIES 0 D NJUR O REOU PE u ? O N O DNJURES REOU RE Q Q DOCTOfl 5 E NAT 0 BY A DOC OR DOCTORAME 5 EXAMINATION D OOCTORT AME ` _ a9.TATff4 gf.INJUREO --___.r:,.MMILPI&17` DN6 ,? TAnOP1NJVREq,t, . Y... FIRST ONE.THAT M -. RAIE3 O ow uLV ? °x fy 1,1 ..F ? RASA[ D NIL lEO Is[ve+[ „u xrn? iA ? fwss N0 - KILLED ISIVEx [ xonl YA 70 EI 7 El T MOTORCYCLE SAFETY: ? HELMET USED E3 HELMET NOT USED MOTORCYCLE SAFETY: El HELMET USED ? HELMET NOT USED IIHOW NORTH BY ARROW CIRCLE DESDRIB4 BELOW yWHATHHA(-ED: woKA , IPEFFA TO VEHICLES BY NUMBER _'AVbL[NANKNlO.- O ?? \?, Q?Y - --CFJ![_ ? .rt1.G ., ??rCY'?rCG??•l _ M ) aA • x ?-e---b r tTe.Y_ a•,°rb a rxrLL..w ?w -5/1. e7?1?e.4c. _ • . I- ? a •, , ?, arnLLTenx°.,Y...?' rCS4-11.t 1 - 2 VEHICLES POSITIONS BEFORE COLLISION Yawcla INVEBTIOATED OY VEHICLE N S E W DNSIREET ORHIGHWAYNAMEORNO. "0 YMH '"(' oc°M0(P Q'AA ?ia x L$ k I ? fi I rw"? ? ? ? ? .. r_. .:.?._:?.«- .Q..i?°. v`Y?(... ? ?Race ?wr Dw T 1 L' l ° ? ? ? ? ? ? ? aurr k 1 1 ;t tl nwHNUr ? ? ? u ALONG °X FROM TOn. Y I 1 PEDESTRIAWPEDAL CYCLIST WAS USING Q(,a"N, r?wN ! 5 ?Y..,,°LA .?r':"" .,. L?"::;un .?5r"EA E?:;".,? r.?ne.PwA. f? r HY PEOESTRIAWPEDAL CYCLIST CLOTHING COLOR, ? Q i KL"r A n.xH T' MIJ vl _, ROAD SURFACE LIGNi, CONDITIONS TRAP/IC,GONTNOL - fYPR O(•NQAD pRIYER/VEIIICLE.AG IONS P A - ? L ,• (Ej , ? ? } S 1 I?W??U{TNCq ? ? 1 TTi(••?F ',?li (11 f, '"'al No I , GG='La t Q D Mxa,i QI I pQ S ONAIIU axN O.I I pT ON[ WAY aI r-, LO( OOIN0 81RAIOIIl AHEAD TQT? ? 1 Q PMNIK. I 0.11 ? ( Q STOP SON Two WAY p 2 Q OVERTAKING AND PA831N0 I '4'Y1 ilI ? .? Gil ? WLI 6t I[T ? NOAD C L ( V[R SI OLL Q ] Q MAKING RIGHT fUPN f L-!` Y f?? ? 2 QSNOW 1 Q SNOA,wO ( ON IIGPV15fN((T Q 1 n YI[1061GN ? Loop'K P, W ( ?1? a 0UDHr501I ? 1 ? it ASHWO P[D ? ( ? INTERCHANGE [j ( ? MAKING LEFT TURN IT ??? •I !I? ypl'J ( Q K( P (?IM'(C.I LEI ? f TI ( C1 S1Plll?KJNiB ? L Q 1-11NO AMR(N Q ( p Al ? ?O1NI ? 1 Q WAKING U-TURN H! IYq*? CL n f J , SMCHY i? a?[L iY ?( Q RR 11GhAL E p Q LANE Q f Q SLOWING 1', (• l i 1[ J 1 'D 1 S L +Y?M}" A CHAR-Cm ROAD WAY SUNYACIE TYPE... Q 1 Q Olllt[0. F LAGMAN C 1 l "I 1 fl ? 1 Q DRIVEWAY ? ? I_ 1 n, .81 HH ?Lnd1 1 510PPED FDA SG AL C 1 17 J kl E I ! `• ?aY ;(] ??;, p?'a` ? [ •Q oCr.ra SPCC rr ? 2 ?`o W'o[DIW,1....,. ? ' ?'To"ico NAOADWAY IJ w Flr VD1 4 r.Ti x? r F 1Kn,YIi- l '?T+' n^NP-r _7 7 A >rt r ix IT , hr L . v J+?•I, J, ?d ?:.ib;e..r1S f v? 1 r I- ?[ LANE ,.?? J ?k a t L ? r i i. ll I ? , : Y ,I . a3' ?f . z N ; •? I i EV. " I ?K 1 a' I d A k ? ?` ?J g POLICE TRAFFIC COLLISION REPORT ?'TRAFFICWAV 1 ouE UFCau PRIVATE WAV N-. .. DAr r couNrr - [ FDLJQCOMRAINTN BER. , ( 1 +? w. un.wl w:s+?.,, i sn lusfiao nougl - r muNrv.-NO. QEMVA u - QN Q E QIN crvo9lowN ano orsrRFDOR nlcnwgr N•'• u Fa ns Ru gWiE S Rf c Klr+ "IIES QS ?W OF efJ xc ON eA, r IlNGVnln srvEFloR ROap 93/So . Non wrlusFCRO" R9EFI l0. Mllf W)i ?? S BEMLEFN liRf[16 ? Si9fF, '/ /??/ p13,ANCfep,vECA'IION O rFRfN E.CROSS Stuff OR NFg9[SI MIIf YOS ACCIDENT Ill q` / RAM9 5 E W MILEAGE ET DF rLoo?o?? Com qAM p•1A CO TOTAL NO IXVlD Fvt9Nr. ,,..// ,( ? qUN NO RgIFD •n -NO.INIU9[D-V/ ?SPI[IAGf NI1a ,u"DwD," O'r -lc- N 9RORR rDAMAGf ON r T- f l O' %.qp I RFIO LCAD..".- IMER Cll CgOIl S,RLR09 gDAD. _I F ?g5 lilD ? [ ClF OBRCiS,RUtA INAMfOr 5F, CI Sr9UC` L,„DOWNt9'S NAMFI t3, DNAgGF 7?Q SR<Y4 CODINGIAF " - E UNIT NO. 1 DRrvERS NgmD usr rlgsr M1DDl1 U NITNO. Z Q VEHIQE DMILT ,s Name: si Q PEDESTRIAN Q PEDALCVCl15T E p. LU c4c 1 * S,Rtfl ADpvEl a SL.) L `? clrv 'Ll°'''7D l,q D REFI D9F35 $ 1 ~ (/S39COD -NF NO, 88 R WAIT l !NO LA.1-11CENL EN Smel / e ,H - l t n MDI °"+' I Ir ICLNSE NO. „{ M EM BIRin LL cL-1 occu9AT- I LM NAMFavnoNF NO. W ?(?2 fr! 1cn, r.lcni V E 9,VBSLL4-IIo occuvAlloN "IM.-E. -NE NO WA F y `i ?20 3 °Z - vhd I0 2 1 EF R Fns IcN1nEICN 1 UA3 Om L i- - I ° ?CHECK(?) 'l,{N,cIt AS:„Fm?arfFOEAN01„F?ql :V° . Rs.. CODES?* ] ? i w"' + ?CHECK(y? vFnlci[AS AN UAVitir[Fa ANOT I [ ? , S Nen B ;${„ no ;? w s u a CODES ? * ] 5 Nl - p v ?oxya s r Ir HoI M jumi q 1 0. nnvE?R MOOesQiD`AnL.novAl W-LT uDVQ eow . .o.. Q, Q u c, ?'bh! Q ' vi i , s. E? " I . v l OR 11 e q r II v.l Mooel lDAVr. vAI rI ?,I t.'4' -7 {A ?? aC r,.,?+I 7xe NlNS{91A fN SrAlt Nlf9RA,f Np S,Arf H . Vln CIX09 I vf-11lolNrlNCAT -NO. W!t - I C l - A- [nIG! ?e,EArI Na ? l?A l Nr? i I 1 1 f E l I 3 91GISRgtp OWNf 931 NqS, MI if hgNF L M I I I 1 171 91 "1 1 1 ISRR{D O P, J O WN{4lA51 r1R11 MIDpIF F R I] ApD9[ssao I, w b ?e ?'T?11 ?S' 2 l N 1-IFELLISS FR.suRAN oonAGw, C N E q Srj+l'? 1JC2 DAMAOID MIA 67 a eon R ER tA 1 N 0 `I _ I .0 " cng9u - DMSACt ARt -711 A nor 1 cnA9u v'er'y"` oo c"' fsE wm. ?? y L c< Q oat^iN l] Ow ORI f, - - AW RIMNNfD 21 N OF-NID Flt. DAM AwAv! S yo ro no. 7 AW1.1 ? iw rD DIAGRAM OF COLLISIO [ lu F1y Nl "RO IH DESCRIPTION OF COLISION W4 ose SU9ne MENiusrKU MeessAgrl Cea+e¢ ? a1 Nf6 Vnlle -- _. __ y 1 S1b ' .. Q0 . AT ..:U.1Ti _ RSetTlo[J p r .G? -?VG QA + i . !? ! . I u ?/ fl Ce ai l I i -' . c S h ln OF .. flH? tt d - La F? IFS4o : f?FTx YcP? I ? /` : I }-?I I '11@ R 1 W f ; _ . _ M NLL.Iti_..WIF»? I ;? . I . ;CL> ?.?--...IZ? I f i i ?^vellaU la ..L'?ittss. of _ (??TtD SQaeD _.--- }N?6 .V VAN ?D °p STOP (:> 1 I n L T _ „ - jo NAME, DRESS It INJURIESO F PERSONS INVOLVED ' CODES 1 Z 3 4 5 6 . OCCUPANTS / WITNESSES .n wo??aE:ii`uu'i •M! Ip NN! fiLL15 m x M F ii _ 9 "'1 uA Act ums 'v°?" "' Mrcr Riv+ u¢I n i 1 G1 • hM E V R(:re5 u 1a I,q, -xz Q• MB 0,Ml, N e. ' Q" N- N ,,, if."",re.rR'wQAMe ??:110",:N.QC+' AM Rcx TL]rT?e ND -3cLe3 - 41 1 nsLl, snn e: Q•wA .,,c[. )•a«I E.E.r? .v 9 " ? y .F O .E .:. ?( ?p ?a ? :, pFIDOr•,VHG Rncl ,AO D•npgllwl .rovln B. p•n L??Z R1?$t IT?y?) 1I 3 86 A wt 1 , 'I I k ,1; I ;F I I rk n, s1? Yf9 ? M i ) ` r Y k R ryz xT t flL...WS a I ?J POLICE TRAFFIC COMION REPORT TRAFFICWAY ,N•u 9,A1M NUm ' PRIVATE WAY (o D • D" JA1 COUNrr _' ^ 9: b ?!Imfa?lc.? l: 1,.1. lu, oU9 ` rY/10. CpY NO p`Ve" 01 0, C1111OWN AMF6rv0 0 09 rxG N . NWAr prG mEts 3s ?W ON IN11-CINGwt1N. 51RfFr Oe vOnp NON NrleHC11ON A gWS 1 it // FN%-t 4/ O L/ ? Z BETVFFN si9F[i 6 SrRf[t OIS ANCESD9 r rle1N CROSSSiRFFi OR NFAVFSr MI,[ m11fs R FS I ' W MIIFAGE ACCIDENT «!i Or CODE Mnf rosr D•D v pu AM W1A CO 1'DNN D? rv0 [Rll[D??N0.1N1U9f0? 0 IIAGF pN159UN rClMnogoiw R(RORRR 09 R[rf9FNCF 1 IM[R CS CROSSSr .17 EN CI[5 vROHR1Y OAMAGF ONIY ? vl UIEFD ps101[`! OBIFCISIRUCR INAMf Of OBI Ci SrvUCS Af,pO y /?/?j IJ f WN(RSrvAM[I [SI.DnmAGF SRfC4LL CODING l6F - E - UNIT NO. I UNIT NO.7 D,5 MID VEHICLE p PEDESTRIAN p PEDALCYCLIST -a' 9 ,F ? 1v 95 N mE Sr 1 1 ? ?- ? icy/.a,1Z. C a ' 2..a ei? SrvFfIADDet rY . . 5 v([1 ApD9(SS I slAll .NON[NO. R P R Dvn IClNH NG $IA1L !x I - qJA S CFN ' ArF All lilliTT «cuvAn m 9NONE NO ns 1GNi 1<1G"r E R HIM « RAr oN NoN[NO !s wl cNi "r '. p CHECK(,) veN C1lA : ANOrN(e AE p CHECK (.? 'vrN C,f AS AN w Ri o O a ' CODES P- 3 . A/I S n ua r ro, t .sn n ' . orfl f AN iN[ CODES (s 3 A j. ' L 5 In a 'sxO xrcL v 1in+." uwN i -n ?? Nfw os RIN,:."° p • p M, p CM11. ? , YFN All MA•t EDGDGEDN[V t,IDARr?rvOVAI s-I5D9 CONV ? NN,.N 1 ? 1 pHV1f O N Y S.'z S? N. a s19u! . 1 GG a?2 vuF 9A [9 E H tA9 I CNtv.l MOptI r.NOVAl [] ,1 n a"1e NO. srA1t vw eaoR 11 _- n"InuaNn1u11 o-i NO. vl" waNrl t II c31h13 1 IB12210i?S3 RlasnelDOwY+u us1 rRSr mlpgl MgNE NO ?121311I GO61D161%117 f s(9 ww . ? '?. ?c c sA?E O 9: 1AS1 N9s1 m1DD1e 5 • q W i T v ? E 1 iw A s ??? NAmr a.DORlssa lNSURA o oR ACADEN • T '8G7LFRT?- DAMAGlO . " R - /-,-- ?/) „ 0 cNA9u cNAeG[ ._--_ V °,„ J-AGE1' [A . w C - DAAS ldiorii: 5 Est ° rp• U Aw':r ? 9lmuNI. 'Ll•Yww ?-AlN(D t5'D ' 1 1D ro 6 iortow 5 /"'° = w(D 1 Rr .Sites U AIAI _ N A, NI, DIAGRAM OF COLLISION I u Waal DESCRIPTIO OF COLLISION IUSl S,MRItM[MAl 5-111 N[CFSSARI'I 1 -; ?7--? 1- ?lY SSA}YI. FY Yp w ----, - _--- - 1 ?siei?3•? '' „. { I l l J 1 ?'?dTr?Y.?ceTie.?_.. - - - - - - I 1 I I I I. L Oi 4?u? rsN -I I ?Tr.P: .?r6 . Jr E sTo? _ .S 1 V / NAME, I DRE55 8 INJURIES OF PERSONS INVOLVED ' CODES 1 2 9 4 6 N OCCUPANTS/ WITNESSES Icy -119o'Al Avi .Mf ii i '- .1 wsi S u¢v- • /c/cv a DMH W r • y 3 9( - - S ae. 0AN. pES'6' p" . pN a Z- • a YD . ? X u.,.. ec. >. A;vrA• p : 0,",-',. o u: p _ '?,??1 ? ?. .G G•..AonD /GSA nAAI 170 ? D•11 e1RG // D I T f p >r ?;aYfi3 ?q , d . s I s? ? u ' ( A Ir f _ A, I r .9 C t r J 44kk ? l i -M ? e ,o t7 d „ n T FL i r ri L ? •GV6• clP. IG .V ? . CI..p.IG D.NpaIIVa p['n ?I, ? q} Z Gcrl 7; EP I " V I G-JS 4_ />R°°5 /]G3 8/dfBG x r f ]I rya .P UD' A5, ? F+Wa4Gk'1 .li' ^' e n ,. ' :?.. vdht. ?i,lrM+ ' z ?. I ? ii a l ; t f . y , I k i. f I r` t ? 1 4 ?rvrf 95[CriNG wi :SiR(E, 0990AD Cp'? NoN lrvreasfnloN nna a MRe pos, etrwF[N sraF116 slaF[t Q/?? / D?S? NC[nOaFMiI N Mv(,FREN f CROSS Sivffr 09 NtAVtSI MRFPoI N ACCIDENT RAMP DiA 4AM DAtA M1[s [R S F W MILEAGE ![Fr O, CODE COn;Orv INVUlvtO FR rr l unix IN %y0 9 CI 1[t ROM OR gDERfNCF O[AI NO NO vill[O?NO N,UV[D_ ?SV LIAGF ?Nrn R'UN ruxowD?« NtIP cm CRO655iPEflOaIlOAD (i V[NICIfS pvOM9rY DAU.AG[ONIV ? MSUIi[D ?S,IXt 57.'.V 09,[C1514LKVINAMt Or OB, C, SrvU«ANDOwNlRSrvA]Afl fS,. DAMAGE SRCa4 COOING IRE RC s UNIT NO. 1 UNITNO.2 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST pRrvtR'S NAME U5r F . IRST MI -E Da vF4'S NAM[: 9 DRFss ratty ADDaess -- srArF zipcou NE D STAR ------------ - 833 t R S«77LC 444 /o Sfi's>J rvlPSDCENYN SrArf f, I , Arf • O f B R N p c o <u nnoN npNOrve NO. is GHr ent E occupArloN MAfe v[NJNf NO IIRMN R v G.II NfIGNI Z 5%r .)E ZYv.C `'6 2 ,,2 .Za.'E-sss? ice- , E?. o? of a c 5 L ? . wl ? CHECK(?) rN Uf AS Arv v'rt a"NOr9ta CHECK(?) vtN ttf As AN &N- Dnnovtf A , NEa O CODES w - D ODES ?+ 2 <i 5 rA a y° p + ° U l[5 . l M ? 2°' ? M. 0 -A.Cl <ii o o a E zs:r,. o K° K E [IDDDGl CNfv 'F .l IDAat NOVAI 1]D<ONV a 1 t Ntvl ( ., v pu vA,e r A u9 nAte No suu H w aoa TRAILER RATE wi?T7er V[NiCI[IDEMrCA, NO v[ C E n IF IDWt[ N I? ? I I I I s .2 G p0 FSO l 7 171J I N 13 YL1 I? K .?L?i / 171/ Rfe srtRfoovmta r sr DDIf L ADDaasa OWNfe vwNt NO S mG W ReD lASr rresr me A95 .? o R1.J t 82 / N w to N .32?/ oLy?sJl?iG /?G E p, q /O l NAMtn ADDRtss Ia INwRANCt co wACw, A? ENT N ur / ^LGt.=!_ wMACi°.sf. ?.?"?o Y O ?• ° 4wwACeouru ?u.,C,bx.? CNAR CNARGI „", ? N a » D Y 5 [5. OASAA ?.DSW?V AwNID ?^wArN ?RE-NI f3?'D Gv t p A r A ? {. 1 =D. Y ? . DIAG T_.. OLUSION' IU rvAl - R rv-11NOOwarN DESCRIPT NOFC lLl$ION IlR[$Up[SF rA(SNfirMClSSAavI r swi[1u,?Rr11 r -- _ 1-- - 1 O I . ' I NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - Z 3 4 5 6 OCCUPANTS WITNESSES ICRR ADD-, 1 1 sfR Ac, raus owR Lncr "%y A76uS / 3aT G ' R y?/ ycno - - - - - .D[?±n[ o / Si4 F.,? ?L' .Q7 T.? val o, v :tt"N" ,wM ?AMe p ;,AI O o ? :` . .gin •wnu i I r, ,.14 /, ?s N; ,v "M MOTOR VEHICLE COLLISION REPORT cunrr I` CITY u „u. „x ' ?v No ` ° w!> w o rx Igr6A.. 3„w ^AYCe'A ?W x 111K ,• „ " enN,r /I'[SoN Na. ? x ? l j'? I / pay t? ,? ,Q '. 4 ^' N • ?• ?W ?ol ON/J C'?j (?/C?o /7?F- Lc •07.. uxrk o"atquT CenE`'? IN. ?' S ?lfJE: ApHQ a ".xT(R,EpTp1 - i "/stis? 1r1nr O ,E n!r 7. ?'7 ti O gw.Hp.p n,9xn w.lPp)T nt, .R,ppE. .,. ? - °.. ? ® LrwtEx !„pwNE.gLer,HNq ).NpLA„pw,Nq w• pgN.pATA ? ooV9GI6r Ee `r?; F, ? .11 1 SO, MAp°wpKWSK . RWaorE! Rp1 SA- s ,A xrD1 ?_° ,xrLglEer,nDbrgEE,DEEr°op oq T„ ? HEPTN x En . . OBJECT STRUCK x.wC arowCCr )rxuul OWNEfl OF % OBJECTS NAME AND ADDRESS ?T$?1}gsiH y ;?k,y , L7ln Y p i.iAf ! D Siit%I?,s7 IeA.. ?patR eppEp,E , DRIVERS LAST NAME FIRST NAME TWO C MIDDLE. Eq 1 v 1111EI OgIVEgS LAST NAME •FIRST NAME ; IN T.. S/ `? t•q1 /\ MIDDLE C h6 7,J CINUSIC TIAN` STET GONE SS gpur NO. AND BOX NO. °u J? ?sO -SONS WEIE gso sEI° STREET ADDRE59„ r?IT S / ROUTE NO. AND BOX NO. ,? 'L A ?TO.Y S.W. -11 TE A zip coo DRIVERS OCCUPN COL 15101 wNsovo (NA[ O? ' CITY STATE ZIP CODE OgIVERS OCCUPATION Ofll EflS LIC NSE NO E.Y ' -TATS C SE% DATE OF pIgiM (GE ,.' I /)`e ?.-R? / AAw x f p DRIVEq'S LICENSE NO, STATE 9E% DATE OF BIRTN aGE T.ei ?J r?r 6 ?v €" VEHIC E Y MA CHEV D r¢DGEI AND%EfJ OVq OA'ITM BODY STYLE 12 Dq.) N r "' p%r rn y S o? GC ' ?EpINBG.B 2? /? /p VEHICLE Yq. MANE (CHEV, OOOGE) MODEL TA-DA. OVT)0 DODY STYLE 12 DR.) ?P hill, O. STATE C TRAILER PGTE NO. STATE LICENSE PLATE NO. STATE TRAILER PLAT VEyIC),E IOENTIF ILK - Fo R,)_'A Sa 7 JTTT 1/O VEHICLE IDENTIFICATION NO Y .FIp M?pE?L 2 + 1 ISV? ,EP (Iy,?AI' Il'r-FY(/E NA DglC q'S UCEN3^^ w ?gEGISTERED OWNEq ILA9T-FIP9T-MIOOIP weuc• ? LIABILITY ra IN Ja[Ih.$F{/Q ./7 IAMAGEO 77 - --' -1' j n'S ADDRESS wo yr, 19TREET, CITY ANO STATE) GATE OF BIRTH MO oav ' h 'y.Et J T'k"g rw,rro c o r ro PART90f.V. _.EHICLE DAMAGED. ..._.-. .... a?uaV? ?e?r ro Wv v, ri - al TA CE INFORMATIO q N-VEHICLE NO. 1- Of LlApllliv INSURANCE POLICY M OLDEq - WAS THERE AUTOMop GE UgeurtrlNSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR F? f?Yes ? NO 7 l P7r / \ ` xl•y ? ? ^S J?v FLI BILITYI SUflANCE AGENT 'Y c??,r - .L NAME OF LI OI?LI-Tj-Y INSU C[??]O ANY ?5?? /7/E ? ???????r 1 - 0 , ?s S'?'#? k LIABILITY PO C NU _?LD RA,S 9- y ?&kw I73r " ? ? 5 130 C r R S. m . w? s?? ? ADE ? " D INJURY 'USE SCPANATE HEPOPT rOq AOp,i O1A, INJUq EtI AGE Ix Jug Ep NAME .. - ?: ..SEX. ADDRESS SEX yyyy f DOCTOR' CIO, •?' O IgA1E - ? ? NATURE AND EXTENT OF INJUR ES O OID IN ,,,, ` JURIES REpuHt OHT DOCTORS QED MARX FIRST OHE THAT APPLIES E%AM NATION-RY A DOCT ?? NAME ICL STATUS OE INJURED f,IRST QN ox o MILLED I 1MwNH I ,w Np,l. nl-.r ??.... ..... ?e I ,. A?u^unLl1S ...... _.. . _ ., FETY: ? HELMETUSED IN CIHai --- s? 7 10- p Y! O .174 rAb ,x ° a NA,prlnr, a r•,„L...„gpw - 2s -- ,l1pq -- ----------- ;v s? 1 7 Svo 0-_ I 'R7 Y VEHICLES POSITIONS BEFORE COLLISION VEHICLE N S [ OH STPT.[t Oll InC11WAY NAME ON NO W te. Awn rt [ r ru w.. rNgVES ,IOAICO OY P '1 q?. ' '?/ ?T ?n?", ? ? ? ? a?'r„v, lOlr"Lr?"o r,l Mrr r1{l cx°rir WII.i„ul ? o,ti [ ? ff ? ? ? ? ? ? ? ? ? ?e ?PNKI ?MrnNbl, y l l ?. C PEDESTRIAN/Pk DAL CYCLIST WAS USING'?„u?•y t?.Mr• nc+u? [ROM TO PEOFSTRIAN/PEOAL CYCLIST CLUTHIIIO COLOR. vC?4.lu r?f?O `=-l?LO"vrw• •?ur„Ix ,?a 1 7? (rI? ?,„ r ?wrrxet- :;r r;1° ,nrrax.r k I sl V1•A ILO C018UR/ C[ WGT RR Cl ac.M• ? {.IOHT CONOITIONg ••1rge AlH,ct rt r a X1Y N'N1.r vl .l r.xH ,R t? r I r IRA/{ID CONTnOL„ TYPE OF ROA 1, D wNe r.H..1•lrr, .,i. Yt A L [7 y TT G 7 r. [ • I r DAll1Gn1 "? --- rw l IFH v ORIVCR/VEIIICLE ACTIONS 1 ) { N 1 / '•4 [ v y"!+lt t ? ) ?..N ?I ? b1GN.l9 cA H " r lcxlcru.l wn- 11-- , ?" VTS: 1,. tF Iy1 ??{$. 1 ?Oar }}y'.4? ?) ?w[I )? INrNf1 ] ?py'., ? > ?910P 51(11 ppp?11Ir)'?tOWOWAY • 1 ?rl?? 0011691N•IONI AHEAD i 1 I[? tl 1. ? ) ? Yrdt NO O.H. SiFIC I Y11 ? 0 ) ? OWRIAN NQ AND PASSING -@ I ) y 14 1 I Mi 1)?"B•l L P, ? J ?.NOW r?II , ?'9 ? ! ? Y/ID l1GN ? HOi 601[ M 'rL-•J1 ) 0 ) NO IH011t TURN •YI I-* Q 0 1!011 • E4° I1r Y,' ? , ? IC[ ! ON IN ! ? ? u DAI,nM 11A1[t ? . ? rulnlNQ PTO r[AO1ANn[ [3 ! ? ? MAKING ^?r,y, n,11S.NG ? , ? u OIHIA ?15Pf C1r4 O 1 ???`oor,NAMPI [3 u•N bo urt TURN 1 1I ? 1? . )lA,n,Nn AUnln Y AJ " ?fJ ? 61YC1rY ' !rH!)T UOnrL f In ? e] uA%Nnu Imw i '?,d' .1 a ) ? soi•iL[,iY ? [ ? NN 61nNq L"u"UR. r v y r.: WK, Q Ar u[MAC[RR ROADWAY WH/ACC TYPE 4r El ) ? ? ! ? u:.ie?"IH • ? Nlpw ND ?• r, I I t } t I 1 onlc[Nrur.M.N r aunwA. STnrr•[nTOnuwnc ?' d "C El El 0 I+4'4i ?? . ? nW ? ' ? Dtn[N 1, [D,r. ? , ? 44 J / f?'i?$ 0 40; i0r PlD Ar 610NA1 Y? ? NCAUWAr r2 1 f ..71!" ??u I D D [?7 .,_..!Nn N[. ?,,uL ?" Y I,IT f:/ L fi. A !„, 31`AVkN't'.rTl°1„ VV 'l?'^-` ?- n t J I `I I ? ?? v r •M?. NI KILLED .! vLn 7TORCYCLE SAFETY: 1:1 HELMET USED -DEECR pf OWWMATHM PENED: (REPENT i Ca yyrr C? ? ra- r' , iE A ?1E rl , ?` .4??srd,T,3vR ' POLICE TRAFFIC COLLISION REPORT TRAFFICWAY rIXICE COEAPVUNINIYA R ' PRIVATE WAY cau. n s counrr H .+?.., lust i. o ! couNrr r+? .`_ cm NO. rfrWA UZAL C RIOWN O ffi09„G„WAY pN 0, p iCTCL gOUif04 IRf N T .1M ?s pw oi ON 221- ACC-N, nE5 5 E MIEEAGE If[i w COOS P Of R R P 01 RN.I MIA COII SIONNVOIVtO E r113A"V« 'OFAI NO NO tIFD?NO. ,N)UPEO? osRlL LE p„re RUN rN. D I N x?RD 9 CIIN fEIORRC4A 04 RFEFRFNCE IIAfR Cl5 CRC65 51Rf { r ORRR O OA 1 , , v(„ ClFS PPO DAMAGE ON Y ? gE5VlH0 ? ifaClf rR OD L , / g / ' L / 5"?j D JO . _/U C I ,f r S ULx INANFOP OB, Cr 5t4Ua N.OOwHE45 NAMEI fSi. DAMAGE SRCW COOING Ib{ '' E UNIT NO.1 UNIT NO.4 ' DRWtR'Si F' ERCEEEHICILE CI PEDESTRIAN 0PEOALCYCLIST -3' . -1 NR5r MI OIt [ !? ? D 'S NAMf, N51 ???N4 V - -`-- srReerA fss srR-fxs Loi l?ot3/7 /a5 `, sT ??tt 1 OLEi9N S>4P vA1? :, co? , 3 S.S- ' R srA1f , { ° w 330 / 2 NtR uCENSfNO. SIAIE Fx „ Sf NO. E Ex DAFE tK eI auJSSB,?! I % l it V ?oL/+??JyoGtlo c?? e ac vAnoEi?1 MNAMFaRgNF NO. G„t NO„1 //CL r '?- u 3p ' E R a<wArlaN?J iIRm N•ASea v„oNE NO. s r r ?0.?9.?i J Lj¢/3o? f?/ u ? ?• Co] CHECK(, ) „cIE AS nNMNr rEEa AworNFRAI ' ? CHECK (?) FAS ANU NOrFEA Arwr„FRAI CODES ? T aii n o • ss CODES ? * S A s; s N e ^s'•° - n ?i I Es o M a .w„ ° 1 ;; p .„M r ? w ? es:?. ? : , K u? ? N N . I a U ? zs.n. p c , ° „DI 978 LrJo or ,¢RA? StYItI D/2 E V "3G MDDL?vrA, If I ?? 2 „. IX O<NSf PIA c%C- srMt RwµlR RAI[NO. surf GJ? H G. ? X 903 a.Jrl ?N c ? ¢ p Vf ICIt IDfNrIIrCArx)N NO i ;SL+ LZoi/iSTSG-i- vFC15RREDOw«f R IASI rlRSl mlOgt vtpNF NO ` . vE„<l D ?LgTi3LS?oV 3? t R Is Ev D w„e O W R? 1A51 NR51 mIDDI E s?,rJ(S ,rlU'? ly.s ADDRtuaow«ev N E A wnfR Sa'.JL! AMfaADDVnsa wsuv.NCeco ca •ct„r N ! ,N LL STi9iG R o - .... DAmAC1 ARU ' O CNAR L --? D•MACtDARU 11 / h y?',DOwtD ?etAwNtD G„ARO{ w vN pRFmAINfo Ss1?oiAM. 1 •ilav loiona?• s ?s _H y U •wA C3:w:?er _ la DIAGRAM Of DLLISION wf r4ss.la I pcAHNO41 N .. , I Row DESCRIPTION Of COLLISION; lusE 3uv t t astafti tt l .. .._ ?Ef/?a=wasE3 ie?:D.Z I -- ?••• NAME, ADDRESS & INJURIESOF PERSONS I NVOLVED 'CODES 1 2 - 3 4 5 6 OCCUPANTS / WITNESSES lust su.Nrvrnul sw n.DDrtICHAI n•ME A"' n S, _ sill •c( At s '9 ; ;" .°, t ,_.,_, .tsn , _.. • c Nra s UG 41 $E Z w S/ 3a?iOG - z =", 71 .. khUWA 0LI-sn wiG. •?I : ?` r ' -? ? nee. ?•M 0£41!10 "'8. >a ? ? ?? tE/z. .sue 3?? _. « wans - G.1t ?Sol , ,nr ?,C A ... , -„ +-,..oMp•Me p"."..•'Mpr, .per" o, ) ?6y3 RI vfi9 3BS7 1. - + •u«. " ? one vu t f IroP o ee r X 4? 8 S P ., . '? Ar??? ? ? a id .,?y. ?. •a •..:ka.l r ? t ? ,.i r,: .,,,. ,x ?y"„.AL I.?• r Fr?? ,t 5 t adv. '? rA ?E? rr l Y f L! Is ,ply?i I :riP {r 1 l t 1 1 f IraA. ? I 'vl _ 'J POLICE TRAFFIC COLLISION REPORT Fp TRArFICrnFY l ••? rollcECOMPIUN uM PRIVATE WAV pA OAIE CIXV l TIN[ COUNTY is 1 ' ! If.lnE! ,fir 'H IVSf ].00 HOU91 R w 1 I t CI 1 3C" JEI?? l C5 CIXl C1tt PE0. PNWA ? CUR- ? i o 1 CJn J CITY OR FOWI IN FervO GN Gf „ qAl G ETOe MG"WAV MRES 3 GW DP CRS 40U p9 1 e i t4Ar- _,Eni ON Qfl1VC-e au NT(e5EC1iNG VnTN: S1RFE109 A NON 11-IT ECTIOrv 9Sr/SO ] p 5 U ViLLL E -N IT III d SteEFT iSTArvCf 6D?4E l uET 4tN E. C40555rRFt 09 NfA4[SrmIlE P05 I% t Mil[POST /? ¢n 7! /VJ? M f5 5 f «Fr p` ACCIDENT MILEAGE CODE - DIA RAm G[A COll15roryINVIXVFD FRITr rp1Al NO NO fnlFO?NO.INlUREO? ?EPI(UGf ?"Ir6gUN ?yrvo°eon, CO 11 ST E g40AD 094fHRENft IN IMF9 GL3 CA055S1eELTOR RDAD E: CP V""I'S QPRpnRIr DAMAGE ONIr G eFSUETFD W,[ CEF OBJ[GTST9UC%INAME OP OBlfc, I"- AND Owrvtq'S 1IAMEE EST. DAMAGE S .S?sCOD SPEGIM00044GU5t ! UNIT NO. I Oervf4 'S NynE. U151 "IT', UNIT NQ 2 G VEHICLE G PEDESTRIAN G PEDALCYCIIST -- MIDDY RNERS NAM E : 51 -I.- E Z STREET ADO9F55 C1tt STATE PCOOf P101T NO D STgflr ADDRESS r STAY L v1v[43 UCErv5fN STATE F A R Nf W .1 N D ' I vFR' U fNSf NO. ATE E DAIf IBRM OCCUPATION MNAwEd1-1ENO. EYES WF GMT rf GNT E i OCCUPAION MNAME6I-ENO Z 4 . EVES YR1GN1 iGNI GCHECK(el ' _C. S:M."olr[[A ANm"E9Al 0CHECK (E? fN CIf ASAN f v Pt 1 O 9A( Z .,,. CODES?* C,pry ro s NI n to x.e l " M rE[OPAN O TN[ rv° CO- ? * 7 A `s:ii:"' s l%e " e is ew.ae ? SI ro _ t ,5 G Aticf G Mr. ? :. r.11 G aL VEn. rfARPoV fIDODGE CN[v.) OD(l IDA4T-AT ST1e'lEl]DR GoNvl m °r, D G wfm. %f G f ? zb. ° G . K;l ? ?l. rA4 r l QEalc. /? I E I NEVI MODEIIDARr.NOVAI Y 1 D .( 9. m S F ARE. RATE NO. SEAIE H vEN.Ca 9 u FSETRT , ? [NICIE CEN11rlGtrorE PEO 41 141.1 1 121111 '814lISI I! RIG SRRfDOWNtR Sl L TEN R IDFN IN A I N I I I I I I I l I I 1 1D (/ S, mIDDIE hgNF NO fill \ .IJ:J ?/?I ' ADD9tuaowryw O W ISEERD w fR: Sr IIRSI .1 ° l/. N - Z V 'l?rly 9PA7v N E wNFe •• --. es Am1 doD4luar msunANCtco wA wr -K. ._AO A%FA O R w u AN J I r !] "[rdr DAM AGED AAU ` CNA9GE ,M OIA9G( o crw 0 l for n,.rre.,rA r"ffD+ "NE 3] ........ .-N 10ROTTOrr f tar. DAMAG[ .TOT gFmwlmD ?ew ?9[mA N[D [sL pAm ? `r io s A m s Aw n.l?LLtiZf ?l? PTO ED er f Io iorioM d DIAGRAM OF COLAS ON lu nAl ND,ewre Np9r OESCRIPTIONOFCOILISION lust surn[mFNru s"etT rNtG[lSAerl - - _ _ -SI S-) - nr ARVpw - ` ZGN _. t ? I I I I ? I 1 I I •E 1 V • 1 HCt. !G ?`µ U? FG'Bt ' i i i I !J?? ?!.. Vrr[ r __ ?R1vE ?1 [ /-/1uy_t Scfa`? ] ? _. '- I ._? C-IBC I V •lI ,. + TT ??F S •- -•• ... i. rL_•... - .S __„ t A rti?,, ,., _1 ft`I j ?--r -? VE ? NJCLE._/Ut?R'IN..-r.P N-_. f3EA Uf1C ..V/J L. ?'b ? ' _ . '-i I I i c;?F F?_ .1y.. Tl?r--. 1f31[rNJT `!.. STJQ? X 1. ' i I I ? f ,IIF.uAl1AA??. S i - ! I CAR Oe_ BS I J Stu`- R r _ As r n NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED P CODES 1 2 J 4 OCCUPANTS /WITNESSES 'ioa:pDUOau+':ai .... -'- '" 5 6 6 ?s MF Ir s[% AG[ rnrus „ asrr gTGr . ND . :i EL ro nP GAMe G,'!1".r G: e v t _ Av( 33 N R u r TY 0 NOrID,vW G G rq Er G n? • G N ? ii? .vd q P • .• rar.. T ?r . wiv u u r 1 k N 4 ?J fl fs %AN f e 5 . ? .M .. y y ? .. , E t ,,- r p ' 3 JC ??1??lr?t? - h.. ?'+y? 4'? ET* ?t w q'?I • ( E ? `:? ? . t_,r {} h, 1d Nld: '4r'Y 5f iar ??S'IYJ'' } t!4?$i'SN'^ P.TS S51{ 1 r rr. ? ?+IL !h I >?q 1 1,i t,? r,, x s h TAI l ' TIY 1E. f4? % eta - _. ? X - tri I _ ... ?..._ _ . .... _ .. _-- t -.I iION REPORT ®TRAFFICWAY POLICE TRAFFIC COL No w PaKE .,.wewI NUMBER ... PRIVATE WAY _ ? ' u(G.cas; N oz\yY ?Q oAY c (Toy.-,-. +JeS.! eI.vr .'.. 61 INI R C nmE IU$f }.OOH URI t 059 <oulvrr -c- JrGFf E?SOgI couNrrw. arcrvG. t(wA OfUReAN qA 23 I N O f 617, CV OR IOwN ;7 O O OR niGnw0.v MILES Os Ow ?-, MF?C,frN ON ,D?RJEf I Z6z CLS gWIE -TED, 76 J IN TERSfCUNG Vn I., SIR 111--AO C0rLACU A0 NON INIEVSECrION T N 519FETA 5 PRFfI% 'O. mILI I 51RHI IArvC DiRfCTIUN iPOM VfiEV N<[. C9055319fft09 NFAVESt MIlf v051 Mllfs s F REr W Or DE ACCIDENT MILEAGE CODE DIAGRAM MIA COLLISION INVCNVED 11-III: NO. INJUPFD? ? SPRIAGE ?'?? TOTPLNO. NO. %1llfD_ IN9U N wvovlRr. INTEq Cl3 DOSS Sigf[T09ROAD9 ROAD09 REVERENCE LY 7 OVFHIClf3 P90PF9TVDAMAGEONIY ?i'vFLiFD ?5'FIXCIf ,3ZSo ?. F Oe1ECi51vUC%IN0.MEOf 001[Ct SIRUCV ANpOWNER'S WV.+FI EST. D-11 SPECIAL COOING USE ?- V 5 UNIT NO.1 UNIT NO.2 0 VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST L5 pvlvfR'S NAME: ve51 rIR51 MIDIXf 1?05? Iv; DIL-IF s N-1 I? Eck ?R=QJL0. Ary Siqffr ApORfss C,, U 191 GE??C/I ? EEr D SS A zyo SE K??UI/1 GIY TAtf Zi CODE ONF NO /Z6Eil5 orT a/' 9 Y67-/OSl Z7/393o D R ITV SIAIf ZIP CODE MNE PAL Id (? ?Z22 ?y Std/ \' -' 2 1 DPrvE9'S l1CtN5f 0. Jy76 TAIf ov fA ry o !oi Y? I v Iv 'S UCFNEf NO. c7 Ib2 y9 A or i AIF Of 019tH oSio7 !!9 ?? l a Z OCCUVATION nvM NAME I-NE NO. EYES wFlGni .,.;T La6b, TnfEe44Tre.el oAe6 CD, l? Sm7 E R FIRM PHONE NO. EVES VhIGHT MFIGni RrcTI? f zw 60 ? CHECK (?) v[nKl[AS:N UArior"Ea AwotH[rt'Al OCHECK (?) vfnlcl[AS AN [MPiov[[ofANOrntaAl _ CODES 1? * ] E i 5 1 6 CODES 0- ' 9 ?i If ' / 5 u J 0 i rcl` ?I. 1t 2 uRlfS LNIB o J lwRro, DM O..N A t 0 aVtl ? Es n. ? Z2" 0 M ;agr DM 0 M,RA - 0 M", 0 c,&- 0 ZM 0 C.? v(n vfA9 IWS IDGDGE.CHFV.1 82 MEr? F'IDAV1.NWw1 STrlf IZ09..CONV.1 sP? N yD` H r(A MAXI F Hfvl MODfI DARt?N-AI YUI v.l 01DS C??c ? 2 DM 'Pf N 5t%tE AF9 AlF STATE GR R rv ? I A A BAR Ern o27 of u p24 Sir or vMIClE 1Df tD1ut RJN ND v[wClf lOfnON A ` 131P17 l131SIUK61213191\12 R14171AIyIBItt yl8lti1613!7 eFG15TEetDOWT,IV UA51 E1v5T MIDIX[ PIgN[NO. Sf1NE 0 ISrR OwrvfR. LA11 nRSI MIDIX NO. 5Af-t N 2 ADDRFSSp OWN(R N E FR I— A ADDRESS 0i 115URANCF CO OR AGENT STf}I ?i4RP1 /2?Ea orr R IN u AFEGO A Sf?7/? yI N oAMAeeo Alu ?, Aem1ARU E n we:o ? enA U eHARCt g ""'i:'o°."c[ r s (s Ace I T? D IvIN ORtMMN[D CJ iw o O IXAZIN OR(MAINfD ts?o I?s o? s?p? (Z 1 e er B'\Is ff AWAY 010-Der A.Al SZLbD Is . -DIAGRAM FCOILISION 1 mN l NDUrF NOVin •.... .. luw ss+vet ._ er AR9Dw . i1 r s r } µl-I. , R;c>s Q? _.i... C T T - MN1 -' F DESCRIPTIONOF COLLISION IW15URI f T L"(TIFNFCES5A Y1 _ ??e SIB - SiA e. U., i.:.UL? p-its , - > . i ? I I C j I.?j9 L•?.'k6Et Jlw . Au{?E1'p? _C-I T.JI? . _._ . 1 ? 11 'i"1 I' 14 41 S-.M D F4,_ S.4-111J (YIc 5`?;p 54 8 v' - l ?? I _ ?LA.T4_ # la?lc PA,Iw u r a. S P .. _) W. ,. .I p? i I \ . ld? (vas boo C? ?:nE+E:.?1 S y.ls _ i I t , I.oS S Z Vxl....la f j ffEl 7 E NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED DES 1 - Z J 4 6 5 OCCUPANTS WITNESSES a::oo"ItoMti:1-11 1 ,i.. :Gi IAius _j * ADptF (???s ?? ?1L _ - .Blot " [1 0 Or ? : O ANI •• . AMRIl: NA ?vl Or olWYV101RyA ?+A ?n .e ?to a ?? ??i ! b Ml NA r? v I 4 I '? N 7 C O U 7 N o u r? N o c o o Cm O 1 00 o: ?y 00 O, t amo H O J i Cat,°h :l?? x? R„y ?r L ? YJ a x.?1`f?n STATE OF WASHINGTON r N`rI lJ u" DNTY `I ° MOTOR VEHICLE COLLISION REPORT_ go u o o « Ibis , NDx w M3N _1 3m a` ,' 11" ? N p" 7 0 NG. 2 4 7 F3 / 1 1 :0 Ea - I F SD D 93 J m°"^ ? A? w? v c. O 3 crwo«,rx •wur on xo- x xrwLECT- L 00/LLG _ W O O XAxx? o p ne.NA[XG:,oAlpwrpwxxL NoN xX. '"°°E A .. o' 0 El ?nu r`vMOwi u`Tlpuu Fi•a x ` [j ?..: ,:D '. x io lpEETORROA pEFE F C ? ? 8 P Drx,n+cL crbEN , .?aE..r[x ?.E° 8<oro;.'E?°,.., B.Nso„a ? o 9g€?T$TPUGp?T? 1AIIW .i Aupl QWNEROFQEJEG7 rAM€nNGgO ss, fB AFAYTcr wscCODEUSE • .. IF NOME-1 Ea.?`?".:n'•;' xB81YE8AkIi677lA11E_?.:. • - -E19'iiIMNl..:,:.,..+_".. :.y1Rf..: wEnEI?IVawivED 4nY`fl?:.°r o ? I" T`111 C' /-/ NolOie*ww wo 4GL s ^ BTRE ?A?CIRESS,.. „_„;:.FOU,7 Np.,I1Np BQjtNp., SO b - USE STREET ApgIIESi "':?,,,, RQUTE NQ. ANO BOX NO. CIT STATE •. ZIP CODE L I [hl Ofl!YERS OCCUPATION E?? 00/. CITY:_ "„•gTATE„?,;;?y?+jIP COQE N1 4W I gNIVER50FCUPATION OflIVER LIG SE NO. STATE SE% pATE OF BIRTH All R'S LO. - STATE SE% DATE OF GIRTH AGE D IVE N O kpmllt EHILLEYfl: WKEI NEY.000 E) 14 yT _ BODY STYL+E(2 DR.) -pAR J ,yEryIGI.E,yjl, rAAXE.1?IfxY.llllpQt) X1100 LINO J : . u o GI_ v ? LICENSE PLATE NO. //S``TATE/ TRAILERPLATENO,,. STATE RAILER PLATENO. STATE .YENIGL.F..!p€NTIHG11T10N ND, ..?:_ .. ._::a._....._ .. ,, ... NP.. r, v+rxuTIELGA,TION MD....- }t.E QIBTEFFSD.oIYNERIU¢Li1fl fiT.NlR9LE.NAMEL.i / T OWNEHS.ADDRE98 . ".(STREET.GITY,2MIp-aTA7EL;Sx'r,..::'..:. :. .OATE,AE IRTAIa .OIYNERS.AO?BSE.:It:".:l „GUY AtlO,S.TgiEl ....'.... oATE OF_B!RTPH. PMT90F.YEHIC Ep:. ;;. '. ... ....:.:.. KM 'v% ??..: LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- WAS THERE AUTOMOBILE LIABILITY INSURANCE El YES ?.NO COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR NAME AND ADDRESS OF LIABILITY INSURANCE POLICYryOLpER ,...?:;?„Xy,?;',.,.}I„?•j„L:"'' 3-.'Go-.".e)CIAME LI ILI _INS S O •_ ,O; F AMEANOAOORESS OF UABIUT%.IH Ff,AR ?+'"-".. AT ...+., 'nr.:r.,, SII??T,.@OU('tY:!)L?MB:.eJ_::_ ..: ... ...J OE' IWGRV lUe 9iP.wAiE AEVOAif ADDTp PIE91 AGE ? NAME /`? WAIAID NA N d •MOF, , & ADDRESS M F ADD NATURE AND NATURE AND EXTENT OF INJURIES EXTENT OF INJURIES ? ? JUR IT ENAMINATION BYOA IDOCTOR'+ D ?'^ NOAMEORS E%OMNNATION BYOA IOOCTOP1 NOAMEOR'S 9L?In&LQtlR.TJIAT AP.P.N S.._.-. .... _._.. `• I O [w °w""x,a: ° nONw°+IYx° F°INnv ? Oxlvw ?, I F? M w?:°r` `OIN'?+a`r wE u,xox oAUttA ULLEO L[vwT u oA counu o ci v F WO ?vLUSww NO. _.____ 1?o.[D. NO........ + ' « c 7 ? 6 ? wprtuu ? 6 •')po ? S ? 6 ? D OTIEP 7 ? MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED OW NORTH BY AAACW IN LALIf` Y tIMM' n0N WGML ? iYME1f4 O '?\ ''\ ? xew 'Vill on ,• ' wuciciOiuMEIAxPMnW ?? W YRI W EFfATOY EB BY NUMBEflI.. .?. '.. -:.: L.----_---.. 4LrKtct?_ F ? ?? --6 ,d'• ?_. dGLS._ ? Cl?ti .S 7? .-! ??6 tg ?j?- /`'C???'?l-L?_ ? _ . •rxfcr oxn ? •I-• Iw«rA. ?? ?? /? _ ?# ,/ - - 1", 2 eaAe - VE,HLCLE,%3OSITIONS BE VE 1 N b C W FORE COLLISION ON STREET OR HIGHWAYNAMF RNO. xO w,Ax1 u ?cr `E"e?` vMxcL `va M xA ... xis xoED INVESTIGATED BY ?p? °ornC? [a E] 0 0 1 l l C] El ? 'o ? ? 01 zx -- FROM TO ? PEOESTRIANYPEOAL CYCLIST WAS USING. 1?lxA I?«u s?NAX, .?u ,?a I?O,x r?u [?xo A « •" PEOESTRIAN:PEOAL CYCLIST CLOTHING COLOR. L?„r nr lO rxox,N[cn.l «, r,rnne nc 40P.. r?[n ,?N,. ,?a[ . JQM7 OWACC.x _..WEA wA..._. ._LIOF}TXAINQITIQNQ_. ....... .LY1IFSE.9QAD .......Ory,IyERIYEHIGFE ACTIONS tir.t,E cA dHI ` 1 ?YLrONf WwnllE l I Itn[u OnF. DA NOM r ?O• 1 ff? n 7 ? pAWN ? I ? 610NK8 1 ONE WAY 1 I? GOING STRAIGHT AHCAO ? / ' 6?[11 rry?II a 7.1 L•)?Y E ?pMMP10 7 ?(%!bA ? 1 ? ITpPbIGH ) WO WAY OVEATAXINO AND PMS$NG ? 2 ? ? 2 ? w . % ? IIIpW 7 ? -INS E ? DANX ITI El gHib ON DAAK ? 1 ? YIELO SIGN ' ? 7 ? R0 EO IO i i b ? MA%INO I11011T TOP. . ? 100 1 ? L ? E ? FLASHING ? E ? ILOOP N Yil E ? MAKING LEFT TURN ? • ? Iti L ? ISI'I c.". I ? S P[EIIN\•'ib C] ! ? FLASHING AM.. ? I C] -0 ? b C] MAXINO U TURN ° I ? w- 1 ? 4NCIIY ? I ? pM ".AL ? I ? LVF1wT ;I LANES ? b ? SLOWING TM rY +- , , MI /A" TEN[ .... , ? r ?OFIIGI IIAG.AN ° 1 ?ONIVEWAY ? 7 ? STOPPIO FOR TPAFFIC u r, ?]+?w.. 0 ? I ?OIN".bvt L1IY .?QAP I 6R-v6OAT SIGNAL ? ? OR b1P 8101, I v a + , J 2 9 ? 7?DIVIO[0 ? I ? STOPPED IN ROADWAY r .0 0 . rVY ` 1 374c 1 NOI C 1 ND VID[0 Ib bfARTINO N y 2 o P, ? I n 4 1 1 1P" St ) Ana I r st pmt . 4 ,I ^ilNa'u' 1 Ii .. Ii ! ''nnrr?? . M& 41 {M1y . C+ tE8z4; y 1 FS r I !?A fs Ilk s !r`, ? YekF'? g 1I T m 5 OF WASHINGTON OFFICIAL USE OUty -,rl R VEHICLE COLLISIO °PORT NO - L, iTa' [s oUn [ LL •°H ? COUNTY NO CITY Nq, p[ " Rp MON„°?L[p N C rDR,DwNM o w dIA ITN- ON wDN,r. L9 ?e pwp°, Rqu? Le IAIG ON 3 g933SD" aN' ?[r:T° „°.r .uMT[NS[°,Nlx FqE[ ., to . •"• MuuooT- _ ZS Jv p p I,Yx ? ' oo RAL„°,D?°„INDM[[rD9,DND[NT[.,N°[A„?M.,I. [^?^°•. TA. ,. ? I? ? REIEEP[NCI CA0939THAA OR pD „ 8 Ba OFUEGT BTNUCN M SDf _ cy OWNER OF OBJE 8 Y?ANG.SE?+ ^WTirP4 a ,i r ati _ $ r IF MORE 11?1 TWO C' Fi: DL 891V .8 =. -.-_ °,au""'..•.aliBR3I.NA DE .ry :..,,,._..-k161a:E;.._ FI d?j r Yp N ,? ,¢•T?EETADpRESg MORE THAN Two NF/.?N p/1I iS d; PERSONS WERE BTREF, ' NJUROUS' r.'.: ROQT.-NO. AND BOXNO d A E D O 8 b+ TT ,.._',, STATE _COFE. OgIYEflB SEPARATE OCCUPATION °REPORT" GITT /yq,LATS „A !ZIP S'AOS EDNIVEflS OCCUPATION t r - LI eAr/oY FORM d C cK GeJlt 33 ITF. ORWERBL O. 9TATE SU DATE OP BIRTH AG DRIVER'S LICENSE NO. BTATE SEX DATE OF BIRTH AGE r . MD DAY YR' , " M E1N° 1' y d . B l Q EI _M kl. -pAq, 1 BODY STYLE .It OH ?Kt/ Pr. LICENSE PLATE „ STATE..".. : LRAILEg PLATF?NO.,.: LICENSE PL,\Tj (?w• STATE _7 ,.11AILER PLATE NOa STAT ,? Z2?2 C?lCc 6AGV ` VEHICLEJOENTIFICATION NO. Wa' >Ji ' 8 ' : - .: : '.i: VFMICIE IOENi1FlCATION NO .. ,,.. _ : , PEGISTEflEq OWNFA(I.AST-FIRST•MIp rye A DLENAMEI. DRIVER'S LICENSE NO - 9 .._•;, r... bE015TFYREQ OKINILF}ST.F, T;It r IQQLE NAME).,`.,,;, ORIVEHS LICENSE NOr.,..,, ;,- `•' n beo orSuS:eK/? de P ESK /?Z or - 18TREET, CITY ANp BTATEI C OWNER'S ADOPESS PATE.OP, 11 TR;_ 6WNER9AODRES3 __„-(STREET CITY AND BTATEI .: -DATE OF;gINTH ??. 68 K 1 + e ... _ MO DAY t: VA?R.TS QF.V _EIL?kE DAMA,. ?pEQ„_.•?,A?a.-,. aj;u+ P TS OF CLE DAMAGED O? ^R._._. X - _ f iNn S°R€°e ?. E P(Zo NT $ $ LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE LIABILITY INSURANCE ppII COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR I[]L YES ? NO NAME ANDAODRESS OF LIA8ILITY INSURANCE POLICY HOLDER v' NAME OF LMgIL1TY p1 8URANCECOMPANY y? U[ AO°nESC ,.i Or TT, '?. COG •FS !E K. P TER S icK D y a.Lc$ WMD(dZ': GIQI-}yU Y INAMN V QAgpREBB OF LU8ILITT.I+SWRA J o Ff A/ tea 2 GC N { K L S yE,A6?ENT ... .0? •¢ P?IH/. ?Sa UX Y•PNM EI ?P09T FOPND????ESSC ?Q U b ?v _. y NAM N "SEAlgEO NAME N C) JV ?? nIZ Y ADDRESS ADDRESS SEK. Tri- N!AiunE AND M F EXTENT OF..UUFNEE NATURE AND M F ? ? EXTENT OF INJURIES s } plO INJURIES REQUIRE DOCTORS Ir III E% MINAT ON RY w OOCTOR+ iO? NAME L_l DID INJURIES REDUIRE Q O NAOME ns ? 7 E%AM NATION BY A DOCTOR ({ 3 DEJNlIIREP:;.' ... CIDdF NAPNIIPAI. ro seI uL ' ' w3tNTAPPII I. y:. ' yips, T.+j O rASMI,o[R ,J? MILLED A;xr w ,Nlurv ? PASUN°[„ NO - .'. KILLED II -. N 21 O ngM,A N wrl NDR,,N° DO P A u 6 ? T ?cN. ? - R ?orNLgwR,LNI 5? a ?.°°,R N El O1H[P wnHE R' ? 5 ? 6 ? 7 ?c r id`d ';7 MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USER ? • ( SNOW NORTH By ARROW IN CIRCLE HELMET NOT USED r' U, AR- _ _ •a z A / Y ? 4Y u', - ?'.: .1.11, L.,.,.., I E --- ---------•-'--• --' s ????yy ', i VEHICLES POSITIONS BEFORE COLLISION + M INVEBTIpATED gY g?' ',i VEHICLE N 5 E W ON STREET On HIGHWAY NAME OR NO. FELL ° °ulr NO ru1% NNA unlD ' Y 0 [IF ?1 ,' N, ? L aR :°'-"L.?L?,.y/y:;Q.?.D.Ll: HD ::C„a rH1? D1 Nrl ? ? ? ? ? ? ? t ? r ? ? ..?(,.?, . ? Kos .- ,.. - ??Ly1 -,? . pgwA3 •.. FROM - i h, 1 1JL • PEDESTRIAWPEDAL CYCL TO AA 10. IST WAS USING , ? , p r ?D,NIR ?r0 (4 c Y"M1 '!r PEDESTRIAWPEDAL CYCLIST CLOTHING COLOR. p,b L? I :. I ? .? re 11 l r -ROAD EUryACCWEAIi1LR LIOHTCONDITIONS cnrr 1;, ,'t p? yr LRAS1IFSONTROL, ;[OI ROAD DAIYIFEI HILL ACTIOVA., - 1 r1..ae I ?LIGHT WI "'Gp IDMfA n,11 'IeS Q?{jLL?t?L1 ° on S •, YVTp( ICMWOw OR NO I - MDFLII• . Il i', I fMr 1 '-' 1^.'F-rrl?" ] ? MIMI ? I p SIGNAL( ?I 9 p( ONE WAY ?[ 1 p GOING STRAIGHT MIEAO 4 ; :}YP 1 k ? f per t ?RAINIAq ] ? WIS. ? ] ? STO ! P A.G. E TWO WAY t ? OV[n TANIND AND PASSING „ ! TI r .,-f ] ?SNOWINO 1 p q„TO?ET p ] YIILOIION R(V[gSIpLE 1t? 1 { f.,,?? gOAp ? ] MANINO NIGHT TURN A . ? ] ? AND`* A ?1HfR • ?1IUMATMQ11Ei ? ILA],gNOA- ? ] ?IIWPrNAYVIE ? Y F ? L O 'cc ? • ? I 1 ? MAKING LEFT TURNL M1 A `H wcAIl (. ?IOEIlCI1Y1 • ?a1P t(1l GNT3 ? L p IIASNIMO -.In ? 1 p elL[Y p 1 ? MANINGU•TURN I Y ? 1 ?.,. "/ 1? SI[LIfY ? I p RA 61pNAl p S p LEFT TURN 1 1 !?P LANES p A p SLOWING '•"' j rr.M1 i1'h„, L11+. t' I _ ??,.II,?AL¢¢lJJit%'1. p 1 ? OIIIC(WTLAOMAM ? ( t ? e1DrPED tpn InA(FIC { Ir 1 M1I ji I ,I j ti ?'?Y°'T^I'1 L.11L??^'•1, p 1 0OTHER. Sr(GIY ?? ?DNIV(WIY ... e:. ? ( ? OSTq OPPESTO GN P nATeIONAL 4 , p,O -, y w ?1p SI I p.p ? t ?DW O[G ? / ?S TOPPED IN ADAOWY qllp, 77 5 kr ?l Y Li 1 ..I if1 Y t I {M V 1 I I II NAME, _._._ .. _ ,., .. _._ a .._. .. . ___, t. ,.. .. L _ ., ,... ._ ., ?:, - STATE OF WASHINGTON t, c^' OFFICI?J-}KE ONLY t, MOtOp VEHICLE COLLISION pEP NqO..,/ (? - f L vIX` 7?5 su NDU es w O1i ns n" s V,[s" °ue ?N ?E ? N a "K •'f TYI?. CITYOO ?RWAI N fd.N 9 .; a 5B5?W?D. Az (A m G,"°wrxs,EtrDRR°An Nx,[RS[GTDN ON. J 9/%/SOn° - I x[,w[tN „Rttl. [Ix,AT ?f?AiA'S . N U swwntAx[si lurwsEGrlun s,xF[r •?DUwN rwus[NVUx Mur DAwAy DN^ r RNLROADGxOS]NGNt[PD]rORD[NNrr,ROtND°.", [RnROE M. °? RE o'F OF E 'FE - [ O ?. ' 2l ? [ ADa . q? . q q FRq [D ". q D Ds55r N5 G GOD[ si?oo r v ? ? OBJEPItETJiIJGL Lt...: IqN, [ uGM OWNER OF OBJECTS NAME ANO AppgE55 s F µoo -- - DRIVE R'S LAST NAME FIRST NAME- ° ,xI " . .; r eo- ... R0. E:.:.. NQ. AND BOX MIDDLE. WERE' DPRIYERS LAST IIRRTNAME A-We E EoLL L ".N OR MogE,HAN TWO ' dt '7 STREET ODRE69 PERSONS WERE REETADDRESS,. yT+ E NU... ET ROUTE NO ,AND BOX NO w1C h J\ :?'< S " - ' `-l PA L CITY STATE Z!P E pNIVERSOC UPATION IN ,uRe E A CIAITI, / 3 F _; .6TATE IIP /DRIVERS OCCUPATION F { QflIYEpB.LIpEN6E NO : BTATE .S ,-DAT QE IfliH:. ADE o [ - " Yc ND ! M ,? -l?{ VEHICL"E Yp. MA E 1 EV. DODOEI MODEL (NOVq•OAR B DY IYLE I] D J VEINCLE YR. MAKE ICHEV. DOE) OD l IN VA-DART)° BOGY T 12 q.) o h p 2 F P LICENSE PLATE NO. STATE TRA RpLATE NO; STATE aaI?C}'?? IF b LICENSE PLATE NO. ATE TMILER PLATE NO. STATE I[y 'icw /F"P b o < VEHICLE IDENTIFICATION VEHIG No I r CAT N NQ rA?Fv a . IAI rLG /? (y f ? 2S REGISTERED OWNE ILAST-FIRST-MIDpLE NAME) OHIVER'S, LICENSE NO. REOISTEfl;D OWNFA L T- `' IIflST MIDDLE NAME) DRIVER 5 LICENSE No. dam f (0 F W &+ UWNER'S ADDRESS (STREET. ITT AND 9TATEI GATE OF BIRTH OWN R'S ADDRE - STREET, CITY ANp STATEI DATE OF BIRTH IS U7 " N OAr Cf PARTS OF VEHICLE DAMAGED [[\ Si F}i?? yEnTto}r ,D s o , ?? G}Tun"v}nlfi}r ro , . •t PARTS FV HICLE DAMAGED „? - LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- As THERE AUTO MOBILE LIABILITY INSURANCE f?- COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR 10 YES ? NO NAME AND ADDRESS OF LIAOILITY INSURANCE POLICY NOLOEfl NANO . ?nE `- .',NAME OF LIABILITY INSURANCE COMPANY c ET Ra ? F[ : ?? Rwf?e cJ?39#37o r NAMEANDADD SSOF LIABILITYI191RANCEAGENT C,rY T TE hers - • '' ?? f{ 11 Z!.1 S . tlf •., ..:. (? .;LIA_BILITY POLICY NUMBER - 5 cff:: ISTINJURY /'Y?? ?f:}?I _ ' X53' SLRTUS OF INJURED MARX FIgST ONE THAT APPLIES NA YL _ ? INVENICLF ..,.,$Tf)TIyS OF INJURED _, .MARK FIgST ONE THAT APPLIES aTr?, ' ' ? DrsAU, u° N°Nm+uni""c ? DR nq IN.. 1 4d [R NO... ... KILLED •+unr y ? RAR s[vex[ u NORI PA ? PASS[uDrR NO.. KILLED Is[v[xf N'u y°q °ucr ?. - ?om[N W"IrL N ? 5 11 6 El ?7 ?GI ?? nTRLnw ,L D. _.._ ? 5 ? 5+? 7'0`" M1 ., q MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: El HELMET USED E3 , 9 OW gRTHB q0 ERC E H LM N U D OY NUMBEROT S[ - I X ME;:: ICEp NfLD.REFERTOVEHICLFd DuOlln.[t .:. ? .. Nt gg ;e 4.1 J ?.i.SrAALMAffAVpl y tc,i- ? :` i _._,?_ «.?? ©}?1 L1lLY1L?(' lh ?lrBL1...Q?:.-e f1:T .77 _ i ?r .. ... AA' D ORE59 -. ._ , . .... . ............... AGE ...._. JUN SEX N y IV,,, sLPAq FOR RIESI ADDITIONA, IND INJUR._ _.. ._...._., _. _. .... ..._.. .. ... NAM [D .. AGE S 'iI , N A EXTENT OF INJURIES M F ? ? AD RE NAT E ANO SEX . M F ' ?_• OID INJURIES REQUIRE ENAM NATION pY A DOCTOR'! NAOMEOR S EXTENT OF INJURIEB E%AMNNgTION GYOA I OOCTORT D Q CTOR S 79 ??d 2 El 11 V N 9 f W ON STREET OR { 17 M, m ? ?? aNy n ? M ? ? ?,tec Ehll I. n ? ? ? ? Along PEDES7IRAWPEOAL CYCLIST WAS USING: ,?Hw t PEOESTRIANrPEDAL CYCLIST CLOTHING COLOR' ROAD ELNIfAC[ KC WEATHER LIGHT CON01T10 a A ONII I [ ?I wOAYUGHr Q I QORv . a ,?? ?: gWa [ ?A ININ ] ? Du]A ] ?SAgWINO A ? lb,?,3 ON [r ? . ? a[ + ['T roD s ? tD16niO131 oilE r ? E ?i: i i s ? wiinq [ ? imai°arn[ n rH[ I qq . L N ? ? n AT QTUI ROADWAY BIlI/AEl TW I? r A Be 1.1 Ha??d...-kuc INVESTIGATED BY OR NO. IxttrwN LH[L r rAMDUq r ,[L rWl a HwA Cun10 ? iiinw ? p1NC[ RE. El [ [3 A SIGNAL [3 [ [3 El ? OII4L0.TlOn [3 ? N[! ER-90 uDAUUD FROM TO - A ?w.[.w.r ]?MOUIP[A . ??inuwN. •?'cl'"ioeiwuA • ?DNKA ,?e;+i n"nu'li° .?[ID.D,vAr [?u;[ ? .n f C L ?LRAI Cpycq?H I R? L OVERNWIQi ACTION6 H b Yk I ?SN]NALS ? I L N0 [OMf WAY[I OI F?DOINOITPAIOHi NI[AD?IN I ? ] ? fiTOP 41fIN ? 1 ? YIClO SIGN ] rWO WAY ]IpLE ? I ? OV[R1A%INO ANO PAESINO ? , ,..,-?,,r ? ] ? RO?O ? ] ? YA%INO RIGHT TURN y ty - ? . ? nunlNn R[D ? . ? iNr? nr ? i[ ? L ? MAKING LEFT .All ? ] ? IIAM[WO AYfl[0 ? 1 ? AllfY ? [ ? MAKING UFfURN R TWO WAY. U'q [3 6 C] [WINU I I l OnIY[WAr E3 I ? SiOPP[O FOR inAIIIC ? [ c] OrH1.R. En rer ?? ARA71pNa., .. ? [ ? a,Dpv[ng6lnnAL . n f7 NO lgAlla . ? :, U [p . [ on aroP ON ? ? .1-p- N POADWAY ?6T WE " Y'v4,;?1 ? I? 'R ?A'1 ; ?'x3 '? ' ""E`•° V.f '-0???'3'-"l}('?& CI'{ 'u.?? w^?_-,,}?yL??: ?? II Y + { ", 17' ? T n r o r, ? 'ter ? ? M1l? T .. I: I r ? ? I NMI r , - sns aR • ?` /E rlc r t '. -Mob M .. INOTON a FFKIN COLLISION REPORT DAY OFCOL TIME OFCCppLL HE" ?? EI°N Iufs wfD m su • Ty,,, AY V?- NO CO j' CITY(yp N,q a IM MEEK /3 c[rr. Tovm F Dur ' 1 - . V fEaI,L k Q© .; ..., CIIY.1 OWTI,.; .. : Ap , PfiEfot ROUfFRae rP[Frc- EECTK. ?, E ®® OF f//A`•T Y I, v !ET,ROADORIRO- ` 94?? Q 3rpr , _ P - .. .... NTEHSECTr4 N1TH: G REST Oq ROAD.... PHEFI% EO •F JSION Ma£Pp?i RE P' Y SEREST Nip STREET M I?pIM1MAl.l 4AiA ?? -- .il tio, F.+.Y. ' R, W?w[rgsvriOpMUEN"iOSl OnluEiilVYwaYw+OIXilr?rnxruueER UwusE. OF ?vEwcLE E,crrAE ?DrNfP wwr HON .q crr WTE OR CLS u+oaEp a°Hi[?i own rnFO ???a0 "Idi',Y?YY 1 ? "' •y, ?Y'1 , L D l wCFES /• I__?LI VFwCYOWECr OYCxCLErP,W SPED COLE LKIE ? • 1 A ?VFNKIE PEOEa1wEx ?xDVCIXUSWN ? ' - . ! wl al.W . ' CT 9TflUCK... ,. IPNEOf O•RCT•TRUCKI ' q T ? . ._ OWNER OFOBJECTSNAMEANDADOgESJ .. LOCATKM - ? . ? - O© WROADWAY FEET OF tOPEP.'iq OS?jECi. E00[ ' • • ENS LAST NAME F MwE TIAY E?w?.w•/??s?. FF1P mom I .. S • E?W?,.. ..... ..:..•.. FN9T NAPE f//3 J /(?GIfA7ZO S WERE v0.vF0 DRIVEflSLASTNAN .t MICO,. - -., ET ADMESS coE ROUTE w. DBO%w L' , TiWV STREET MDfiE59 n Y?? J//Y? LvA ?%S TCVY©.P PERSwswFRE - ?..-u.?;_. UIEIW,ANOSOXIfD. / N`_ ? - STATE IW CODE DTEYER$000UPA SC R E .A J 7 a Y /-Ic c- 9?3ad CDYSD„ GTY STATE, CVDE [ELVER9000UPATKW. / oIQT T w r7L+/7 A?t7/2L-O ` i Ow! /` D n ERSLMENSE NUMBER u E. o --f rP?IO ? J /? STATE SE% OATEOFSIflTN AOE Y > 77 J 9o A. ul M F DEOVEfl9l1CENSENUNpEq STATE "`f" ?? G SEX CATE OF BigpE AG M F M LE YR. YAKEICHEV-0ODGEI ?(p/(? an M DOELtNOVA.pMT) BODYSTYLEI2IXL1 'E p a vful 3 /0 2 . y Yiz G G VEH CLE YR MAKEICHEV. DO 1 MOOELINOVA DMTI BODYs YLE1YDR.1 „ ENSE PLATE w.. STATE TRAFEER PLATE NO, t y 1 G STATE LK;ENSEPLA sf.SIAFA Fr7P 6z U? a J W i TEw. STATE TRAILER PEA7EN0. STATE ? IE IDENTIFICATION w. IIPBS NOpEL56 NEWER[ [ ??j-• p1,4 O e.-^ ODOMETER WAEAOEI M1 D d'O f{ Z G s 3 2,?7i- 9iEAEDOLNIEA (LAST;Ei9f.- 6 G7 11?u DE{HTFp TON2NO. t'?J[t°SBMODELyS 6fNEWERI Z1 ? _I ??" /? '?` OO METEfl (M0.EAGE1 TOME NAMEI ??? (./ ' I OWVEflS LICENSE W. REG19TEPED OWNEf! ILASTF4I:ITMIOgE NAME[ n! RtcHRYf/J I NA ... 't0 DRIVER S LICENSE w t - t A 77 Efl9ADOgE59 [STREET, CITY AND STATE[ 2? HO QO ?GA'L tY192dT-/' y,8G SATE OFBW TN OWNERS ISTREET.CITYANDSTATEI / ...: AiE O - .I IF s OF VEHICLE DAAIAG ? 'Z j ? F BIflTN w v . FD GH'r' N T EsnuprlOCOS, PM190Fy-ICLECANAOED JfrooE?FYIX` , ? O ' fNl I. AR, o EnvD E ¢ l i C ILITY INSURANCEINFORMATIONVEHICLE N0.1• WASTHEREADTDMoaLE U J ASIUiYUR.Wce WS . A pADpRESSOF LNBIYTY COVERAGE EFFECT FOR THSACC IDEHT ON YOURCM ? YES AFL Ipq1 I1ISLIILAIICEY wLnEq ...•.. .. NO iE- .:. FF I NMIE OFLIASElTy E19VRANCE COMPANY . :+ . NIDADORE9SOFYAOUryryypIANCE AOFIET .. U ;- " ; .:: •TA,E ....• -.z•. rLUTEUTrP000Ywue@q,..:.,.. /u!v xRF .. AGE ENOMYURY: IuEESfPNYTE RFPM FOgAmrxxuL VMUIEESI -, , AGE F `, ' n NAME _-..- R M p ACORESS ._. __. __ } O O 1 - _.-._.. ___ sFx w AWIL,aDC,w, ® I• Pnownoaa _.. r1 l O % ; . STATUSOF EAKInED I burl N VEHICLE ILLED ? EY,YN„ 4^NPr,pLY,rCPI ®? A KFWOSiDYTTN'PLIE9 _ 8rA7U90F ENURED _Kg AT_ UES R9T QVww ?uwvER IN FICLE AELF IYHR[ N? M °O ?PfOE Poµ NO. ? m I S OR PIrfO Cou gµ, vosyulE II•xOIY ?P,SSEAOEP KILLED VUU _ w ISEWPEI N aai 1 R n 0 O? 8? ' 'o DV wzPUN, CI _ MNORTN pY AAflOW WCRCLE • O \ ?" '? FJ? B? ?? 0E8 N \ "N E O I ?Y _ +w. CRE3E BElOWYA1ATHAPPNE04 EY?q`TO VE ICIEB SYNUMOER) : ' Wa .w a"m"iro,a,"r"E N,Ere°w \r \ . t _?i. - fa.V.TT?_/Se Y1!d-aN .$.::V{_Pf}•LLt<j' csi[b .?? t Lif.O Ile, lke4 I bAlJ a? --REU r ?4?2 f?oeF ICLES POSITIONS BEFORE COLLISION lE N S E W ON STREET OR HIGHWAY NAYS 011 w MK11ulE 14 •1u,Ow Y ML"ogAq„ ED YES ! O[—O INVEBTXIAikO SY uDw f>d ? ? ? Ea E ?::?doL ? R- ,DNAAr ?EEL ?? Ve7n- V O O 0 o D ?^oMD! ?o,r,'o an ? ? ? ? Now ? ? ? ? ? ? ? arKwF .rwANWA9usIAa aIO•e•n r ? SIDEWNK FROM DIRECTION To . r ,1 1 1. I, AD SURF/tE 1?WNKWAY O?YrOUI.pER A K IXWTC01prT10w ? [w .."g- DIRECTION Wl AINER 6 [I c?iIPPSw?Ix A KwwO,Rr tI1NfI000NTPOI IcrEC%D,[I TYPE Of ROAD ?OTHER T 4'F, ?L ! H-1 wqL Cxo,E DMYEfl/VEItICLE ACTIONS I'.. gCIEoi, "rcu Iq DA 1E' ?s l h!?+n54'? '. , um, 1 LO Ai 1 1L) YLNII ? 1 ? 910NN8 W ' > onwYl i!? FrwCAwIOR wNCI ? ? KNN HCI ? ? W WN ° ? 1 ? ONE WAY 6", b?I GOING STRAIGHT AHEAD )!!yV, L?A?S1I{'Et, } ?YAW O ?aIoNPw D ? MSK ? C3 D 9i0P 51011 ® ° ? TWO WAY ? 7 ? OVERTAKINOANDPM&A, HF. t?A••'' ? ? YRID s,aN ? 0 ? m? Y14E ? ] ? MAKWORIGHTTURN q 'r l'/a I 4??,F VY4? .1 ?cc • ?Too • ?ife FACET ? A ? 1LA-AIL RED C, 9AFC, OTHER , ? ? a ? • ?M1rOOP/RAMPIE ? • ®MAKMIOLEFT TURN r ° IlOrri pFFEr ? J flALWOAYpER Lr OSPEGKYI ? DN fD ? S ? ALLEY ? J ? YAFRAA U TURN ?. i f l 4 lW{I ' y E ?. M{I wiJEEEq DAN01R ° ?JTHE[i LILTS ? a ? PNEIONAL ? S 11AN ? L 1i 5i?^ tr AFFF-FAR-1-1I1I I ?'*A ? 1E ? l ? OfFE:[IUIIAG!!AN LANES ? J XOWw GFY y a ? OTHER 9PECEY ? I ? JIdpEO FOR TRA({IC ? 4 4 i,.' ?,, ? 1 ? sEPAn.110 ? a ? STOnSTRFIROE"AT SIGNAL £ l L L' !T£ ` +-,7 I N°?-1 NOi rnC ? ] ?OVIDED ? ° ? STOPPED IN ROADWAY aTNti•IOW } u 'NAPE ? ° ® TrA ? J ?UNnMnLn ? ID ? r 1,; { SB1actt" rnufCLNE t A T IF, OY 1 ti , tY d + KIr?=« y f?i r.d I; ) + n. T'? .a" did t F .?? { ++: 4 dl ;?dr? .. P Lwk IC [ r.. a"+'Y''?('h{nNp1 I G A ,z y I? Ir:'' - ', r r 11 1 7 / I ?T?1 w, t 1?t T SSI?? Y n ,, i r. , r u, Y yY C -. r POLICE TRAFFIC COWTIION REPORT LLN TRAFFICWAY poDCEC m,RMM NUMBFe 2„ ? PRIVATE WAY 'RI CA,t or COIII r:O,IB v J° I !O.:ntr COVrvir INO CIIYrq. r I1 Qr- 2 8 n, .,c ,. . v.. 'tf :,? -•-^.?•[' rr / /(L G URBAN I?auRAl r"T G• ?f G ;,,.O+r.-.a. :. ':•'tir?c.wr.w N+• m,I•' ?5 ?,: ?.? ?Zl.?r•?C..?n,, oN ?•r.,; r? (?: rCt Clt . ROUtt Oe treE 3 3iSD 5[CYION /?) •,ttPtl ,: J B[ :'[Ff' r. ylPllt ,N. f? Mnf P051 I? S.? ' L} 'SIAI.C - 1 ACC OEN AI .E AGl +MP V A u ?] D - c o ot , coo so vi I .? ..n(.t ?' ^ " '- Mf9 CIS m R Ea Nc tR¢toP ROAD OR nrwENCt CPIritSrR(Fi OP POaU r w nvE"uu ® GP`<=t['. DAV+.n. ,. G Is ?:i;:'7l ? ?5?6'BG - '` 2 nno s+[c•NAMIa oD.rtnPr. n"an°Nlct•.nmT lst DAV.a ' 5 srtaAS CUDWGUSt UNIT NO. 1 UNIT NO. 2 G VEHICLE G PEDESTRIAN ? PEDALCYCLIST 1 )• s_ U s.mI us• ,us' r.gUlt vtP tN T nMt u.t rrv '+? I tN 1 f. 'Tiug R?E-D FJ/ 11PRD ELF[>R.iD _ 2 tteEEtADDP,tt t oo LOP-l-je-p-, n•n ", ' D t,fIADDPft.?// ErAR z C 'R O:-cc*:) RDB 2 . ,P<ODI P.."r lo RTVJ; ?N• c?i>!a'? Oi- Sl R ! L_CFJv 99.3'74, - - avEPSnuNU NO >,°n a,t ?rx e,w I ,v PSt aNS(rvD nn I - i 3 ?AAR -7 ;?3 B 2 pcuPatloN r t a PwoNI N . AF wt cwt DIZ uluR L 4r !J C E R N oNI ND Er wf cwt .x . puR? 'wl FI D 8l C . - _ G CHECK (?r oM t;°' -'111 -N G CHECK I,, rv M v',Plorfe nr A.mr ?%?" 14 CODES II CODES 11 14 a ;' r J) I D ` ^ t Io vtw rl+v st, Wt4f Cwfv r N? Df[IDAeI rvO,n Str,! I)DP CONV ? mo y DP, E .«,: nfv DG i-IEi/ DL A vOVA. I )D+ u v l ..n I I? C/ v r l 7;irTr frvtf Plarl NO trAll to 0.atF NO $IAI( FI N v w CPOe I SF' A I A. ,D A t oRs?z w ZY17 LEA. 4tw<If rDENr,NOAr ONN Z C t 4 L w IfD t,<A? NN IS r 4 H l SS (07 RtcsnPfoowNtR "st r,ev m?DlxE Pwo"t NC EAT E rJP 7- ADDeE to owrv,P w uas¢RloowNEP "st NRSt miDOIE mNo A A/ EE As BovE wNIR ,I Z O + JE2 w, A N E Aml { ADDPisS d mtUP+NCI CO W Aol Nt R _ ? u AN a N /J 77 DAmwro APIA :ciD?°aEA ? ' n :' s i o+« c CNAPGI r? ? 7Lt 1] A'%V: ?Plmuvfo cNAecr ;,U ®:wnvN ?vtmA?NfD of rb?m.o? _d `?0" ?s i'` rbi o o { towmBr wwto°r S y _Y1oiei DIAGRAM OF COLLISION' -1 i iClt.Avr, °u N° DESCRIPTION OF COLLISION: m(N"I twtU rr w<tst+Pr ! ® UEH• #i WNS to. &4ND ON [),gBOR q& l?NO S FA o F u S C pes, I E :.L:Fj AT .LC.EO To 7br op oA THE EN-R c RD, • I/EFd #' 2 GLJAS $cun r. oN CA nr-ER RD. AIJO WAS '5'7R ct< ON f- LEFT' REAP. v 7 Gq UStNC> ZT 7Z' CO Sl.r.O THE - : v 7 -? H' * I ?1cxoDEO AMfZCIA. 100 PT. -,o =.C.:. APPWY• f4o Fr• rel PetS, Alpo a F•r• RROM llif PO BRN TM = RF?o; HEP. F . TO WHERE, S.- u'4ME. Tq LxTS.BevAAP ti . ^^ rrr. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES 1 - Z 3 4 5 6 OCCUPANTS/ WITNESSES ,°I''i""I,""`s" .c ecr.al •.+.w In s so Am +rvs '' Rf,•c Inn .° ' 1LE ?; N ?Rs39 '" ass-7414 _ Q(cs pmm v ^ • +n4 E t c.?j$ C(lj??lROi1+.'if J9 G ° ? L.. ' _ - G ?_ G • '0 . .. _"-, Q .. _77 Y 17/- Y /.\ ?1-?J?%? ...li i - I.-. _ _ .I 17?•r? 1?',?17r I n 5 ro} Cie+?g y.- ? s 1 , 4 u. ? Y 01,4_ x ` PAS 6 -' s STATE OF WASHINGTON -MOTOR VEHICLE COLLISION REPORT IOFFIOUL l ONLY O. ly" 1 is 1 -r Ar• w «ra[s,en .or co[[. , on ?,r, -7 iP s5 r.en [,w Hr , ia i"?" r,r 1 p SJ 5 J ff Fro M? YNQE r `J PITY FAO 8 O ?unn µ ,k n p .,, ? e G ? [ ,E GN MNELTm p W L IV , ?: w ?« 1LYf" IOWfiS?ndON.LrondalE? lzcl Co 3 33.5"D e + A S :,, ' ! urw Gl ? E I,.. ne,P G,ess nc uA[xO ,xew,rvx Al " 001 u mAU pArw I R r S - _ V=oF5:e?[n`Z / ?°NE 0 8<e ,e;rtwo`o^,[wH. ee ,° H;,.,;1:;° [.? r[w OBJECT STRUCK IxAML Orow[ rs(nuTxl OWNER OF OBJECTS NAME AND ADDRESS v¢$rne o f ..??..G 511116 NI", OR ROA 1.5--f ..... ?of 'yz?ro" o t ;#Rq? ur I . DRIVER'S ST NAME IRST NAME MIDDLE 1Z.LLI. e s w Ep DRIVER'S-.TNAME FIRST NAME MIDDLE •. ' I'1C ?c "' S. J ' J J J[7 CIC? A? v STREET ADO 63 NO TE NO. AND B R % NO STREET ADORES 'ROUTE NO. AND BON NO. PEISIIS Cl IN,pn[De9E, l? '- CITY STATE ZIP CODE DRIVERS OCCUPATION CITY STATE ^ ZIP CODE DRIVERS OCCUPATION W llud Tck WA k36I ea i rl I,,lii ?b8c ORIVFH5 LICENSE NO. 'TOTE SEX DATE OF SIR H AGE pRIVER'5 LICENSE NO. STATE SEX DATE OF BIRTH AGE W4 is . M AF YR GoN2??s5 3% uk wA ° k g r" s as ++rE;3W 16 VEHICLE YR. MAKE ICHEV. DODGER MDOEL INOVA-DARTI BODY STYLE 13 J - VEHICLE Yfl. MANE CMEV. DOD EI MZC(NOVA•DAKTI BODY STYLED OR.) -1 udl r=ub 4,1 r 7+ C?ivy 1? 2c?v LICENSE PLATE NO. STATE TRAILER PLATE N0. STATE LICENSE PLATE NO. STATE TBIRULERPLATENO, STATE ra31 vvA r_?rsb? ; WA. VEHICLE IDENTIFICATION NO VEHICLE IDENTIFICATION NO. REGISTERED OWNER ILAST•FIRST-MIDDLE NAME) 1 111111'5 LICENSE NO. REGISTERED OWNER (LAST-FIRST-MIDDLE NAME) DRIVER'S LICENSE NO. P ' t?c+lelo S. C`lenzalcS C-IuNZA Sc)sD OWNEfl'S AI? E55 ISTREET.CITY1NO STATEI DATE OF BIRTH OWNER '5 ADDRESS (STREET, CITY AND STATE) 1ATE OF BIRTH bL C 3? r?Tr11J,C lc. ?A 7 ?°? ND G,Y ,n PARTS OF VErIICIE DAMAGED n,i•?ri?i?uii[r IO PARTS OF VEHICLE DAMAGED AxFV?nv'knrfoxL„o V f `?'{i - LI`., T CL{ ? XXXnnn'DDD E S alJ g-, -fyuvlk $ - IeFI 1 1 £ ILA n IF) LIABILITY INSURAN E INFORMATION-VEHIC NO. I- WAS THERE AUTOMOBILE LIABILITY INSURANCE / ?, COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ? NO NAME AND ADD1E$S OFLIAITYIySUFIANCE POLICY 1 LO E]x ( "AMECO^F?LIABILIT: INSURANCE COMPANY (?? L MANE LIL'l1rle>,r,Dpn95 doe- -0x{hv d NAME AND ADDRESS OFL 1 ENT - .«lSTATE LIABILITY POLICY NUMBER ar _ Sci {rc y _.....-._.. _ -- W hb 3 v7., V E7 c%.5 1STIWURY AGE 3ND INJURY (USE SLPARATE F-AT FOR AODTONA. NJVINLSI AGE NAM AME ADOIIESS _SEX IxNnEO AID ES.RY 5E% NATURE AND M F N/j AtIYiE ANO M F EXTENT Of NJURIfS ?? i E%iENI OF NJUR CS ?? } EXAM NATO HYOA DOCIOA+ O' ? NOM10R5 E%OAMINAT UN IIPA I OC TOR, "?" O CT .RS NAME ry STATUS OF INJUAEO MARK FIRST ONE THAT APPLIES STATUS OF INJURED MARK FIRST ONE THATIXAPPLIES _ i []NV ICLEPUx vsx[ Clu INV HILu axul iI f ? N NO " KILLED w ' wNrxrl oo n r I5 ,x N FILLED acviirt ;w non couv`^ O Ar9,x.,x ? 5 El 6 El .70 An, orN. ? 5 ? 60 ?or7 Ou' 1 MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SHOW HOR111 BY ARROW N CIRCLE • DESCRIBE BELOW WHAT HAPPENED. (REfEA TO VEHICLES BY NUMBERI I J nAnNEO GU45 Sfp??yx?.c( QI WIt 2y i„rr,,rl hr?,l? `7cTn, 5 icJil2I OiI z Gx .. ?' w. wuf fi, y "r _1rZ(17e1L fu Ucae Aw• yl<?n:'.LQ._ vgE,REL,nIH« A. rv, cc /FFf ?uvi] i?JL Veiliclc a )o' pke, rear cisd- L LLy /l Uc? ?'+ ? c m 0.0r. 5-/u olf/7 i,7,12aat.ryllnlu e el ?Ge?fs ?eere c?oni iil VehiC/e f/? - ?hty clidn'l even s7hev. l rA? VEHICLES POSITIONS BEFORE COLLISION INVESTIGATED BY ' xy8 , Y ?, ICI x VEISCLE N 5 E W ON 5111 E70R HION AY NAME OR NO ,x . r.O rIL no ITS R. ?p?KT ? ??? v A $Ir L::`?? [E?::'?B r;Yo<?e ?°AOKT°;? z r H,x, _ ? ? O ?1 1 ? ? ? ? ? ? xr ^ r NpAr ?:. ( ` } ? ? ? ? ALONG FROM TO Y} I r 141' ` PEDESTRIAN EDAL CYCLIST WAS USING: ,?„T,rxNx E?.H.wA AlldNdM 10 +?u .?G, ,?ne` 11 rL?. MpP \ ,? J ( PEDESTRIANPEDAL CYCLIST CLOTHING COLOR ?e, S?L ?nx,ws ,?u R• .?,u ,.n.L??I r.,xl .? uT.^I'.: ::?W,`.1': is n^n'L I qP' `'? ?'L6y { ?A ROAD SURFACE WfA1NFq LIGHT CONDITIONS x 1RAf11C CONTROL ro TYPE Of ROAD ORIVERIVEHICLE ACTIONS _I E,?,+ ?-S Llhl } 1 r rtlxr.rtir ' .HxGT Gnrx lwU , rHxr.Iy ,crx v Irxrcx oxT ON UOnE zz1 \, }., Yr .a `Y/1 (?wrIIGN, .,x u(xN ' ?+HW 43, L. ?T V J {f { I Ml ?1 r 1 E]I r rrn,Uw T ? -N ? I C] SKINALS ?' I ? ONE WAY [^ O1'I xcL ?' GOING STRAIGHT AHEAD ^{ _ R I J ?HAr- J ? ows. 3 S'9' 5 ON / `E,+T' Lc,Rl 3 IWO WAY ? 3 ? OVERTAKING AND PASSING T'yf ?1 C I ? 3 ?FHv ? _-n ? DA 1-11 ?T 1 / 1 . L,O 1 ON r?,J J ? • LLD S GN ) ?? %f r........ E y? T AMA^w0 RIGHT T.F. 1 S J•E IX',-r-,- L. ?3 ?ArWW .?IOG 1 ?HG 90rIET ? 1 ?rlA'.HNRTIED ? ^ ?IIOOnN YPE ryI ^ ?MAKINp LET 11URH(Myllllhlj• f 1 ? • ?rf,E 913 4AN NG U-TURN J 3 MO?r 11 B ?SIRff OLKINIS ? S ?--NOAMNR 1:1 S ?AIIE? °:irn ? S E) 1 Vr 5 I T`1 U }• t ? ?Y ? [3 [3 °vrcir ? rma ' ? `IIVET SAY ? d {f Mrs[ 1 B IONAL EII JUN B [] BLOWING S qG { 1-VVV"'I+II"{J'Y A AY LTL ROADWAY "FACE TYPE ? 1 ?OIK(A 1[A[IMAN C) E ?URVIwAV E ?S,OPP[D fOq lllAfflC f t - Ik S I, [7 ? f ?U, E S lC ROAD SEPARATION L BfOIPfID AT90 M.I, LJ J [ r l 4 r iN k !ryr?] A?^ ?? ? rr• ? i ' ? E ? DR,wo ? 1 ? S OPPIG M RID GWYI L+E I /`f I ! C 1T `SJ?T?•.lI..L J , rrn 1 I NR IH l 1 fy a 1 i fa ?IIf??1,t,, <, gg a A ?' d {t .AI rl I Y ? ???r ?tl w#r 4 V,A L . s ? ((?? ? 1 I I:{ I r. ?I n to ' POLICE TRAFFIC COLLISIJ'Fl REPORT It9 TRAFFI PRIVATE A_ fIXKE Nrry 2t' I wiE O{taus ? 8 .5 A I VIx Vox Ivlf n14 wft IE ? IIMF IUSf ].W HOURI ? COUNtY T JL??Sf?l ODLW CITY N0. FIAVA QURNW RAl Y ? Y N QE QIN CIr--N O. O{SIRfFIOR WGNWAY I AVlE1 ?1 ?W ?DF Ngdlof 1? ON=CwdA CIS RWt 1 fRStCi NG WI1N Sle(EI04 WAD M ERSfCI ON ?eY SEEWfFN StRFfI A STRFFt O121ANCElORf f f[4ENCF C401111RfE104 NEARfllmllf PO11 ACCIDENT 4E MYFRAi O DO D DATA M ES MN 1 E W MILEAGE ? Q DF CIXUSION VOl ND r.RlIlO?M.INEUR[D?SDIIAGE ?H18 RUN H s IOtPI O ; -j w'D IWY OR RfifRENCf. ' IMEN RS QOb111R[It OR ROAD iii . -. OFVMC 1 ?y.. PNOPENtrDPW.AGEONIr Q NSUtr[D ?SFaCIF OBI[Ci SIR C[ ' r- S 00 Z U IN-OF OO 011- ANDOw NE4SNNneI ESI.DA 1 3 SPECW ODDVfG IISE UNIT NO. I UNIT N0.4 R ' VEHICLE Q PEDESTRIAN Q PEDALCVCLIST ? 2 D wF4 S NAMf U.51 FIRST " lE E n E4'SNAMF. IASI ?I DR?AQQI Co oS I L SI D 1 IR[fIwDDRf52 W 6? . ?? LrLC r I b21 Ste, I'{ SzY'J 2 Clrr SIA11 -Oo' PMNE NO 61Z'86Rx A cimn .??- D R -1 SATE P IALOK A 48y0s 7 D4wER SUCFNSF rvO. S1AIE FA A D DI H ( I N -11 A D 50 A M o? Z4' v8 V 1.1C)Qq WA M J 6g OCCUPANON E E 2 G,%s-t 6eA ISO so R QCHECK (?) mwovE{oFAHO1NtRA` QCHECK EHtt{ASArvwviorE{aAMIriR R CODES ?' 5 I A ;•° la+ ItN CODES 9 axis 5 u 6 t'"OA N rin rot s. L - _ ATC-0 o..on" 0.-- o CAI Q ran14 Q c ? ? w<N e IOODGF.CH[V.I mODfl DA41 MVwl vIE IRO4CONV I 1 Eos Q wr Kr Q u Kt ? W."'. Q ? Q,Np KIi R ?Hf _ Io s . FOi? ii u E I vl 1 V) MO?O1[I IDPF ?MVwI 1" I6tAA I"f ?? ??r tB. l H. DR UCENw PlwItN AVER Rw1EM SIAIE H VEN.CDtOR Af A I DL Tt1 Ib o v[NIftF IDlrvi { C 1 A C ?IfJC r 1 WA >o I l AIIONM ?I u8 7 0-1 L VfHIClf I0 N11fIGl N I r PtWS1FeEDOwM4 111 /IRSI MIDDLE PEpNFM ADD4fssa owwR O 4f RfF4fDOwNfR: -1 {1411 MIDDY NE M. Si? ? l ? N ( w y. E ?? 'Jj alrvweArvcfm wAGFNI f'?a/I.6r.,L.wl BeEliawS?or r,-AuroL.AN m R STATE t-I!2 1ALOHA cJA - 41} iDM1AGl A4IA ; 1 AM/L[D A?[A _ ro1.n_•??3 ED 1 1J 1:?DaM:l,l a f7.00 , r.,4? ?lrl ?, er ? vl M..I.I? iEiweo EH•oE:l - Aw WA? tD nvlvYN wIF1AINm ?A en °' ":'"?' al DAMA? IF f - ' •_ loi ??lt .? 6 • NoRm DIAGRAM OF COLLISION: ID n Nu INy Alv 1r4[I II W CISSA RV I F DESCRIPTION OF COLLISION: Ilh[SUPP:(MINtM Utn lF rxa5lARrI . /J Q r S-; . %: v w''& Sm =A 4A. Q t f NN' I L t-lt L-ii?a4 `hFA.n;^L tt-T t IA Aa p.+1l5y oic.? A N/tt u,.J.. yr•/Pfd 4;4, 3 U p t E I nn 1 LW EIS ? ?G (A.W? -'jp .1 -Aft U s_L. TL•-. s.4 rA? k 4Z Fkao &4 -Zd z pos,• 5?? 13DE . Uv+Ki? / ,?rt:sfR( /cjS G.FS1 StEn I?IZ,S•?e i ? RS.TF?.nk-4°re sfc.. s,?•-f ?O? 5??.?L (? f ?.?OC- A•fcT (.JtC+lc_1+: lJ ?. r. trec C/49•t leeu.(„ cdl i-c -b P bl? NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES 1 - Z 9 4 6 OCCUPANTS/WITNESSES 1o?4uw1lNA M AGf w „„ I YEN ,cv I RE11R Exa N Aw rcW[MLI, V\ Nq ?2lS-!S`>? F N 4 A Db111 S ?LaI U41p K A M4. [I- i ? v= -1. . N D i • ww f%W YS q W OF v AgvID {EqM QAM4 Q q[r Q r4rw . Q N ? n. •D N •mi i E _? DE11t - Wtitl FKt.2 vw fYArlE p ;v • in?f °' NArKr I wln KI OISIAICN Sr(MR? fU A K I IINU 0AN4 Q UArIa MI b n'n.r OF"..E QN Qn' Nfr ? l?M C.?O IJ' Z I mZO $ ? (J L SSd .?1 { l 3 3 • OA1E 2 55 i I m xvM?• >?v:M e?d ' l 4• ?r M ? F rta ?a t , s ? t N IzFI' I POLICE TRAFFIC COLLII REPORT ?g}3RAFFIQWART '- Ic[c mN BFR+ I PRIVATE WPY ?' ?Q YI OAIl Oi « •C. lI UN w, ",, Nn. C...... I s IUSF x.oo NOURI COUNrr COUNTY NO. CITY NO. IMY ow AY Cir pN pF N OV rOwN ?nF 11f''n rvO 0i5 fE v A (? iCl Cls / RWIF 0451R 3Z-+?d 9 . mots ps pw []OF ON l_!L . ?Tx ,rvNR51Flc?f, ?NG?wFf,?n pSIN`Ff I?GI?If ReO+O rvON NI[NSf ON el3"f •R"? LA?:Y`?y BETN[[N s[e(F[ 6 SIRfEI PeIEIX f MNE POS[ ??/O - IOrvi M"""" F CROSS SfRFtr OV NEAREST MIIF 5 DISIANCf.EURf ACCIDENT RAMP DA RAM DATA 1 'T F/V i[fr [].QE OF ` IME(FVE / / r EIOR OR RFRRFNCE xx COIn,gN ? elr• ry( OIAINVIXVff NU ORLI[o_NO INIUC}ED Iq SPI[lAG( pSrOIFNN '°ri IN/ / I % INIf^ CIS C NrR ROSSSTlR[FTO AD R POT ad 7 OF VFHCIFS. pPNORRrr DAMAGFONLYI ?YfSUIrfD ?vfn,tlf ? SZ ( J " OBIfC1..YlX:v INM+[O[OD,[CI SrRUCX ANDOWNfRS NAMEI FST DAMAGE SRCW CODING IAF i? S is UNIT NO. 1 UNITNO.2 ' p VEHICLE p PEDESTRIAN p PEDALCYCLIST MI l x' s IvtRS - NSr I.- Wow ?? ' ?o N 'vJ RNER SN , NSI e 51PFET AGGRESS 1 4 REEI DDPf55 Z n. I zlPCODE orvFNO D I r "AR III CODE R ?. O4-111 FNS( 51AIE X B H ( V I R II ENSf IAIf SFX ?DAI oOiB Rryv B (KCUPAr pl frfs wf cHr H[ICflr AME 6 Plgrvt 1+9 l E accuPAr oN NhMF 6 PIKNIF NO Frls wF GNT n cflr L ? 1 Stu R Q' CHECK (-I v(ra ANOrNFe"E vfH c [ :N Ra ?CHECK I?) N[_A'vv" l v[nr A e ?n ; 5 NICI a, Is ""O1o c.cu CODES ? * ] ??: y. 11- a ..... CODES ?' ] i .is `N R ' o E? P U o b t. ° ° N.. l p 11 ? Pb.,l. ? : ? r U N a[ „ O A. M, LJ p r: D IoODGf CHEVl vUe 13DRCO MWNIDAR[NOVA) I'o rA MAXI F H¢I ,lARINOVAI 1111 IA fN lC SIAI MIFR RA[F NO? rAlf VI-OOR IL A NO. A ., C. ?? C N v1 HICIF D[Nr I,CAIXXl PX) v [nlClf rXNll{ A NN 3 0? L I - RIG4 Rf DWNFP USr NRSI MIDW[ Pigvf NO O I [FRtDOWN[e lASI fIR51 MIO [ NF . ?[J< W LL' ID ADDm owN(R RC .As11C<veS N A F iow[ReY , r ` E swANC[co OR ACINr a N u AN Dx AMfBADwtss N A '" - R G E • DAMAGID AYEA mcI'I'arDi, D t:5 z r. K. . CHANC " H 7AMA ! A 9 1>I DAMA[Ie, w ;N pYtMAINlD F-I -O pAwwvN ?RtMMNIU I w"r m. wnr er. IqRAM OF COLLISION u wK oR IH QT DESCRIPT10NOF COLLISION: III 5-EMFNIAI-ITIF WCi55AR1l ._ 3sauErzN.YRD. , ? I \ 1voc:?? v z E MAhC ?1 C ?' H lmacuM• O L ? . ? . _'L? ?6N? ??iFN oN ? v ?tl(dG; R1a -ALJG v I n APPx_SPeED WA5 LO rAPN_ 1t ADDR NAME ESS 81NJURIES OF PERSONS INVOLVED ' CODES 1 - Z 3 4 5 6 _ , OCCUPANTS WITNESSES ?a o :i rM+AS.: ii? so AGE IA- '",,;;" Nsf Encr Ylss Rt OI unX n. pAMe ?)Y1' ??` wI ,q^ ApW15•. UR101 ??IMJ I[YOM pAMB p .°A'pr ?i°r° YD l lt. .rl. -WO, lIW'B: pAMA pn°Ip ,,r°p x ?Ii 1 ?•ronl<rvs+„ X J?JIet?,l?_ e,ccl O• 4 7 ..N NC. .. I lunPAIOR4 I'll G??.r?d?e I A. no l5 n aalvYl 3-t3.85 .Y?z,.xl?lES /?_L/!/7? DAn .3 14 &5 T .k k ka f i? f? CCC Ky .1.,....._. L!R _ ._ r STATE OF WASHINGTON - - _-? - u c rr - f MOTOR VEHICLE COLLISION REPORt - Q "^ - - _- A DAT(cf/ COlMB1oN rE? - Slw I.? Iii Y WJ.! _ ?1 uw 1 v?... X C F G 7 6 J r ? r MI Ma? 4 .fin 7 WAGE COU/TY GTY, TONN amsOE kEB. ® I .:OT:IIDMY/.,-. ?"Yy M n?Olnwt( 35gr n y :. N Ze?eM so•r OI?aA q ® OF f•7vcurf sEU. c) 3iso r n n0A00N DWENAME OFSTNEET,IgAOOn HM,iNWAY w`.. i:•M E'q'MRE OTPEEf OR f()AD _ 61 L ac e 6_4e, Rc? &..>QN RJ a R(lac? A U " ?? ®? o Q f« NON I'nTEflSECT10NAOCATIDNOFCOWWN li ?AMF IAATA BETVIEErv STREET AND BTPEET "?"••°' Ilk ... 'L•n_yl+•' ? r.,. ,rNDr r ©® ° ^^.?Na.oc`PoS.'W""MnFPoSroa«?i??°r".Nwa";.".mO11I,M...,uan. ar.t ?Fe N?,cIFI?L"o I ?rx? INIERSrmlw FFE ' coulsDN wvuv .. 1112EVFncLE ?vEN ?m?EAlwnrn 4?.,i ... ,? a ?uF? ,r,. r , _ arvElIM.clE .. O-YEHclEKLFll. FEaEarNNr p cLE-rRAw OBJECT StIWCK INNS arONE<r a1POON L OWNFA OFOB,IEDrBNAMEAND ©©?a ROOT r .. ?,v.w,p .. r /97 3 MG- /nE 14E>7 Ol...ratunl1j0"OnAx... FEET xw .. TITAN e -I 01YVEPSLA4T NAME F'YFDT rNYE ... ,.: MIDDLE -0 ONVEnSU18TFW ... _ WI!'•- AyDp}!._ y? av ?) 1 n}; ) P bon LrJ: ° r,7Y•Dr ,I ,..•. .. Ire vin e-P4 G n SrPEET ADDRESS RQVtE NO.ANO?_ N0? ?7 ?Yq? r I( /Rao E 2 Rr7. 4'? --A 6 833 w z o ?. , ( GEY BTATE 2W co" C zip DiNVErLBOOCLpA71Mr .. ,? awsnxF C1h' •..? } AITAT!-:...w(L«.:'.? DOOE OIYYEW OCCUPATIDN. I"`•???` ? ?u?, ?F n7 AL UM )f °B'?.i 1DSYdY C/Q+''i rr .ToFVASI'{'I? GJ -gyp ?E>8 6 DRWEASLe:ENE1Amn STATE X DATE OFB°RN AOE pyy(gS WIDI :NL.Alla .. ?': 8TA1E' 8E% MTEOFBMIN AGE 0tA_=v AI LiA N F 23 rE f a Y F" t; 1 1--i I ( '1 VENIGEYR MANEFCIrtV.-0OODEI Ar00ELBIOVA-0APTE BODYeTYLE170R1: :..: VEm.=m. MAMEIGI(V.-0ODOq MODEL11gYA-0Mr). BODY BTYLEt7ORl „, 1973 lbG I3 2D? R.ukle T?cfak- LICErvSEPUTENO STATE TRAlENMTEHO. STATE .UDENBEPUTENO, "FATE .TM(ERFLATEND. BTA?.., YS X 2W 18Z tj)4 / VENICLEIDFNTIICATIONNO. IIaeBMODILSa NEWEnI ODDMEFERIWLEAOEI YENICLEIDFNTIFICATgNNO. '..'. IIBea MODELS{ NEWER) CrMNSUD 3oo6S > 308 - nEGSTERE00WNEP nASr'fFiS1.MIDOIEMAYEI. CWVEPBUCfllaENO flEOLSTFAED ONNER .'M4rfiLiari/pDEENdMF1 :;:.:::...' .nM'ERB M ENO LI .S?.YVA SQN? t 4r OWNEPSADGIE6S IBrrEET, CITYANDBTATq -: ?::OATEOFBNTN OWNERBAOCnESS ISTHEET.CRYANDBTATEI EATEOPB vn w wv . 50. k g.?Y :[ 5 wYL Ea wr rEAP . ?»`? . Cyr I' PAPi? _r r, eaMMTFOCOBT PARTSOFVENE:LEDAMAlEO 'J WAS AUTOME LIABILITY W S'TT Y. `w COVEnMEP LIABILITY INSURANCE INFORMATIONVEHICLE NO. 1 • r ?F TAOEEW EFFECTOFBILOR TNU^ACGDENtS IIH.W ONCE mm cm VES ? NO „ NAMEENIDADOPf880PUABRAY NBLNIA/1CE POLILYHOLOEq NMIEOFIMBW ,NUT, W1CECONFANY v.F"! ADOA[ .. SIAIE - KU z lor7 /.,, P f ao ??rY. , um 3?tS SE, ?e c o {Y Rc) _? NAME NIDADDItES90FMA®LITY (SURNICE OT' NAre', Ir mL,,ABER _ rSY W871TYPOF r _rHr JN n v. 99.?i9 N92 Si9/ a ?) {AOE WJL M `. 7NNO_INY: ABATF_PEPORIfa? 51 .pE +a . .... COWL ...,.. , ?? K a? P ___ ___ :SEX ADDr1E 15, m LL IL I?JA r O m[ OR• AEw OOCr Q NAT! OF WAIRED MAR( FMST am THAT AFPlIEB ®®.? • ? NVENIDIE rossAU HAnTV80F N.n1M0 .. MNMFM ONE INATAPI!L?0 k ^ ? W HIEDry ?I COMPE. p?vA95E NVEIYCIE TWO r+nrr OYYNNO eg4eMlE Ry n KILLED r IAUl.aril eo Ou ?lAwl ` p? N? e? s? a70 r1?1 ?rFa,,,a" ND D 5o' s? S?: S.IOW NOnTNDY AIIROWNGRCLE ? J' r 'k ' N°CA?e O.rw D..- w ,.• 7' root BELOW N/NTIWPENEp: D1EFEfl TO AENIDIEB BYNUM8EP1 .I"? ni /r' • ..I?I. 1..1-Te (?%^?u,•l ce no.-f?L an '?I.e GLA?ir- roA?. !.j 1 J: , is?iaan" rA.wwla o: ' (1 7 IErwulL in ersp T .,. NAM, ® a. .4 44, d At- s foJp ??on? s'a?p/Nec1 0,?• ,:? ,'?? N"o° Nw cL rcsD pr tA? n \ I .sfw?Fa rjyA? Dn d& pr•.o?ara S}DP. RrFrmlcN.. rellaa jyr4aoe) djw"!• jo'jz, uken x no•FFCra y,. L1?? ••••?Y_., '?'(W-?O_ MO"FO•J'c ?tS CO*7Aning &11 4F•n (QQA.J(?r- .r I Rho3?{ Drrlle O y ay~. ra•w.al..+n ICeF) y'fe brA.bts `/e B?t.Ae.S ilaah;e?? "'. 1$ .rte ?"'? E? E?Qoco EfG¢n+ b f whQA eF Xy eavNo . aS. rr l1?.1,Y raD-IlwAler . 2L,- Js l bL?• r '. .Jk brown pY. hiv -fr&cilbs• (NoZ5 _ /A" T ViKLL?Aj. ?JaB6e?./Y)r. B[!D?.art O'% ?!.f `/?'lDA•' ., ?y„{or c ''P"d an 'I a ..EerTinr_I 9. ,Aau/r3?Y. 's n Ra z.a$e Zeo'orso_.6.r7ovC `''. s4p 51, y 'fv &-A QED &-t on-to ? /h ta.l rf .. ; VEHICLES POSITIONS BEFORE COLLISION ND nLAAea "'Nrf '/?`?M1!I MC 1 Nir.cuvaa A9rq rED BYi was uDNA sruNna unnue:NrsD na o^rc ICIE N 8 E W GI IREEi OP NONWAYIWI(Ofl NO DreaiOY f _I p9 D ? ? oc°cND ? iiinao° ?,, '..,D.:. ? , :IQ:tO`,A':? ? ?aclD°AraO l Ite j ^.f k ? A9 ? ? O r ? ? D O ? ? 0-, A - woEa1GAN? ? O D D ALdo L EApWe o. aI rrroM D/1ECTION To D111[CTION F EL r - % Mus.YD ID LDEWAIn 20-WAY ] . _Q SUn., E WEArN[A UnorccNcal" 1rW .cOAl Q9rKKADEn ADS e? b y°. a OTHER M1J; 1 _ ? OedUel TrPE Or ROAD DMTAI/VEreLIl IOYpI? «cu L .nI .or "c' owwoilnr W KrAa v.EDBIw'I fdUal r I 1 W +O l fr.e.YE u P?l•[w I o LAYLONt ? 1 D ynyALB f?f tr ?1 ?plr 1•CY.c.tuul ..Y .. .J' 1 ?nGrvO BTnNOh} WEIR ?(? r r 7 D NAweA 1 DAWYI 56 7 lj wop qN 7 • WAY ? 7 OVERTAIFYJO AND PA8MN0 I I ? 7 ?LNET l ?srvOWArro ] C, DUSK D J DYNLD DION J roADE ? 7 ? MANwD P4- TURN f I I?' F ? a De^'DW A Dry A ??OrIIe OHET 1 rawarnq P[0 . ?M[nGINgE ? 1 ? 4ANWO LEFT TUnN1 Yyn t 1 ?? •\' 11 A D OTNTR a D I("c" a ? IEiNIl d1 T n rlAHY1D ZDnEA ? ! D Iµ00PTnAM% ? 0 D MAAMO V TURN .q D s ?OF— 1e Nn T" ILEAaON fOIINOT YEMDA.M a ?SIIN[r IIDNTa [3 e D In . D n ? Mr wLtL ? n D sLo-4 %A ' An wDWw mAeroeLrcl NDwiiir ? ) DdrCfP./lAOUAN LANE{0 1 D91GTEnroa TRAFFIC ? e D O1Mn, n%Cer D ? Il ?1rlAlln !DL a D w ra?O,,v,ON?u LIB NnP !+ 1; ? 7rONOE1) D ( -1 HTd'MDNnOADWAY f 11, ?? ? ? a D w rflArrlt D AS (, INDm°co ? rD ? in'"iilo10LAW«E ` ' ?'!i T'•ro..:.''""rC'I• "'"'*'.pAMhy 1eA'":A77a" " Fn( I IrArIIWD rnDM :1 t ;tl? I Vt I xA T' Y C'# f a ?}?yy A d ?:' ?y qU '???`FfT ? & N . l ?k v4 ?T IE- ? rv -0- 151 MU P Ip RI PO.1 • TUAIE ,p; ? rw c ) v - .. ._ __"_.............. ?.. - •• > ' ? "'r"E C.eu,wNiNUMeEy 3 - J PRIVATE WHEY ? F Of COII N IMF CpU ?? / ?I p.r r? 1 L I w upx Sul .5 i. f IUSExND uR) G; T V\ if0. S//_ CITY NO. ?ffeyq URp W URAI ,.? ?N CIE DUN gIIr OR TOWN E6N0 IRtF109 NrGnwgv fCT gt%Itf wits ?s ?W ?oE "MINCAAtA ON _ 9 SD 1NR93FCIlNG WIM: SIRF[r0¢PogD NON INIFRSFCTION P¢Fil% MHF POyt . //.. FIWFFN SiRFFr { SIRFfl (/?pD FtDI t eF 1 EE .C9 5531eEf1 NFggFSI MHF WS 'vt R S ACCIDENT 9AM MIA MHflES if F W OE MUEXf \ .. CIXUSION NVOIVfD'? v( %RO 1014 NO. O "ll LIFD?NO NIUYfD ? l1AG1 ?ni6 RUNMFq CS OOSSSRfl OR NAD Ci VEn Clf3 ? PPo 9rY DAMAGE GN Y III A l 2 I ? 11(D ? V ICIE OahC1 SIRUCHENAMEOf OB1[C131¢«H-0W.1 SN4AE) IS' D-1 SPFCW COOING lSF _ 5 UNIT NO.1 UNISNO.Y ?sVEHICLE ?PEDESTRIAN wNErs NAME: lAtil lv I MIDDI 4Af: ? PEDALCYClIST --? " ' I ?Tqu1 gDDeEss srvtn q°Deess 10 A1Y SIAIf ZI'PCODE PnONENO (o(4 D `c R 'Z WNIR l S N All E. DA ED D trn V ICENSIN ' D f?,.. w% EOfB RiH D,r r PA M uvAloN .En PnoNF NO 4re-1. M •Z f, r E «cuvAlloN T Lf.) . d rc lS '+ ? rJp R _ s fYAl ccNr ? CHECK (Al EMnoriE A .PMioiNla Al vfNclP` CHECK (?) Al FMP OV "nE As Al O :ODES ?' 3n: 'r i S 1 e,",° % ,l %CT?Ew ioxr¢1 I IF E ANOrHlv CODES 13 vu9. ioa.c.t s E%clwn I sv ?mNT - N° Sxx Nif3 ?.?? .¢D ?.NN..Na ? ro6cl ? 2b.Tr. ? S9?EIS ? ? / a 1 4f ° uD 1 1 ,v MA.IIUODGE.CnfV l EIDnR1.NWAl STYEE 2UVCO NcT ? ? .»' ? ?6.R¢ ? '? ? ::?,. . A CK M M . GR NII I E Vl 9 1E .I VI OIXIIDAR1NOVA) Ux v.l •- 3 JL? nCt NSf PtATF O ?l suu ST q? ¢ e NO STwif I Cg09 t N A I ? tI N 11 R ' 1 WA 6 3 R Cf IXM NU1ION NO. 2 S 8 8 8 Z 8 iGlSR9EDOWNFR: EAST Kl MIpDEf P c L IXr f -ClEll All 6 8N6 L 5 T 2 5 7 . Z M HONE NO. (aT, Q W AEG SR¢tDOWN[4. 1 IX ?T? f ssZ ?5 so°xss or ow>+Ee "? A of ao«Ntv '"-?`+?4' III c Ave 14AFaAOwnssalNwR EcooRAeeNr ` N E uMw 3? trot ?V o . f• z G. 1C TatMla.?? R All 4CeLDCjLA41I% B °.s,'c"'vo".°?N guAACEO w9u O1 n" Ell o? cnAwcl te. / _. A CJs E31 OAMww;v ?p[M4NlD N ?9lMA N[D F S (ti ^omDar ! QeWV:r°er. 09 Vf 5 1 IOL'oi1 P )IAGRAMOf COLLISION $ fwJlrt NElc ssnRVll D?cAilo In DESCRIPTION OF COLLISION. IDNSAP-MAl5ME1 f NtCESSAgrI r a Ww l $eoPPED PT 'Z;Co? 5?6w1 AND I) C 7"111 PPQCE6DEC ro msIkv p. L.EFT^C4RN \A"Ica •Rt1o" A0. . VE41.fiZ SrRU YC'k1 1.. bk%.-_A of V s k !R 1 S?RtEe' T4lAT 41E W agAV .. - N. pr ?CLIE ?ASECZLAN wqS N rov.R \uAat .ST"OP ?- ( 68f«? NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES 1 Z 9 4 5 6 GCCUPANTS / WITNESSES I" 11-INIAI -11' OR ADD l?p14 NA- ?SIH AL AW AP,`2 E. Wp`ts?td ». 1 `? 2$(o N I ND L t REirv lAC1 j 1 AIDREO NuEmcp ?.IU INl llr AM A ? 1W1 ? 'H • ? N ? {iii. H ARVV L Wpp•,v` ,J ^ " 9a,R - 799 DtWss,?(_C•E, 3 •D l L1L Ei E.e. f 9 ¢l+vevmr9C a .o,n ?..? ? ?NO ED No NAt . t1 1 w.Trga?cln.¢w ? OI U Nrw s ,,..Y ?x ? rz K Ii I ?? r t?.t1 JY: ?r r I t t r 1 ,,gi?pp}} f I A ? P ? yn ,L Y ` ~? I / Y.i. %. ?,i? ?, s ? W •,? fir. r f r i ?j tn 'I G i O U C: O Q O . i?? ', "A" 1 ?I . d I i. 1 M' !?N ? I. hrw 1 ' ?A (x ... ?{.,.....{ ...?.:, .......,.. ..,, l z I?? M NO. 1Il TRAFFIC WAY N REPORT POLICE TRAFFIC COLU PRIVATE WAY muclf Nr NUMera w 08-03-4-0219 121 wrt ol.ulll•?wN D w r,.uu?swr+ rr ter. I..PE sr>n., now, wnNl. cournr Ra 6 cllrra. 0A nN - 10 1 8Lt R 1635 Jefferson 1 wL 1 L1N 1 Qrry Ou IOwN {NO 4llat1l Oa niGnwwr 6.6 Mtts EA]s w Ego. Port Townsend ON irondaleRoad Ct5 Ou ECNSU'tl C 3 /.?S•?G rN Y INII.-ON4 mrn PI ,wU o a rgrurrrlR5l U;Oq tH lU v.nl Poll j Pla le . d DaweN Rttt a s1an1 - °- ?' 1 r-esl DaLNU {walewl: N,auM trwu.caos;slaluoa euc(su, ' t w S• 71,' V 7: /[rt 1 O I.! neuo[Nr MILEAGE CODE r neen.-A J , 1P N n aU r Il+5(<IiN4::ICIIr4v 50.DOa rrtrlatrKf lti (OIIISIOrRINVOIViD I?,I,?N iD? Cl 911AG! ?nrre RUN Iorwl NO NAR:Il Uv n !t,;? INIIV Cl5 C ROSSSrR/i(IOR WnD - ry © vveN VTrp Pet ONP ? ol6UI IIU ?CrvClS ? - 2 OSrfCi sIRJCR INAwt Or ODIICr StaOC, M.GOWNtai NnM[. 151 pNAPGf Pacific Northwest Bell Power 13ox _ s $00.00 SRC?wl COU1NG USl - UNIT NO. I UNIT NO. 2 7 O VEHICIE PEDESTRIAN Cl PEDALCYCLIST 9 Dawla'S NPMr wl nasl A?DDLt Williams, Clifford D. D.-IN-1 Ande Si iRi Mi DR on, She #a 1.1 _ e 51atl1 AODRlSS POB 654 rattr ADORISS 6810 0 B IT 1 2 Olr Stwi( IiPCOIX ' ' ' P D _ P <IZiPCO NF A11 2 l 1059 - Quilcene, We. 99376 73 R 5 Port 1 37-2574 - 2 Dn tas uuNV NO lTAT' e'a1 I alvfa uw! D xn own?iD aln 1 1 ILLICD322i.34 SJa P! 68 11 111 V E ANDEBs 61P;0' PA1 ON 1-N {PnONE OC F 7? 20 124 "" NflGnr K - 2 OCCUPAIrW MNPME{PnOrr[NO. fR[s MiGnr raiGnr Student rChvnictm Hirh Sc1:ob]. Dlu 16 0 R 0", r CO -- -^- 1f.U QO ;C4 - CHECKI?) ww0i j>°' 0 CHECK I?} Nrr OiP oiiiu'Pl - n• R CODES ? ' ] J- 1, ? ' ] CODES e n An e i v''•'I T :• 2 vaa5 bone TIN 3au!a;.n,jrrir s Bumps and bruises 0 .,..n:r o 0,-&,,,, a vR + R DODGt Cnfvl t ID.ar.ravwl 1rU 1, oa .corvvl s rt CR w Lntl 0 ED' ' 0 es;rla 0 ~. 0 rlwa nuR ( [Cnlv.l w'OIXI EDAa1-Al rLLI]DR. CONv) R n v . I 3 door 1991 llonda -- E 3973 1,od re Dart 2 door r?'r 1 oa uuN Putty von as own NO wn H vw Mo. N w A.! wn NO ATE iiaroon ]O;S101 'la. -- -- C . • /? r '.r -- vtnKtt rowan uiONH 26 "j vlnKl 1-1111CAl-No J H !•; I Sl Ii l 5! 3 1 215 1 B;C 11 1 414 9 71 4 L C Ili 12 1 31 C •3 101 215 111h 191 41 1 1 1 3 IS YlGi5na10pNNta Wr M1R51 -11 -1 No I•iOr, er T,an -- ADDalS50OwN19 W a(4r5natp OwNt R: 1A51 oast MNIXI PNOnf A Same -- 1 pOwnla , 11 2 FOB 65L E, '.,Is 911.376 E Same 1 NAr{wODat55p w5UawNCI CO ORPOINI t T d F 1 R 4]. 2 ol.msrn arm,1 or State 1D.. , tial Se aim rnA 'r' -- DPMwRIw (?o-l?nr ?V r ' NUc• Iw DAM?G'DO -- ..,: r •• • C. CIl lnr r ' CY1 .,One •,. a;( - te, El lwuwGl ?alvx•.lD iowm rickson TOTTI,r' ^ -1 A- _a1MAIN(D oAlD {? AwA. nr hills Towin. III DAMnGI 3000. ID.D 5 r•D+ r { r ' - _ COLLISION: DIAGRAM Of I i 1-r 1_- W?Wa Q?W -{ 1 I c l j ?mGr? fi i I' I DESCRIPTION OF COLLISION. t 515u t I sill [ct !chicle 1 nurth66uad on t' •Lple 51 letiicle 2- -- westbound or, Irondalo IN I!ehiclE 1 fallen to on the m and Tin str Il st 1 top th - - rt _ 1 ?. ;/74l / { ?J J 1 t_ ..... op t at e s right side b; .vehicle 2 Vehicle 1 s aln. around- several trees on the ainst to rest a in , ____, - . . , . g com g north shoulder of Irondalo. 'ichicle-2 .also,. spun__ -, ` arowld, coming .to, rest blocking the-westbound-.- ull Atar. 4 I '? F SS. rl -of_Iro J o June n a - '- --- --- - - NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - 9 < 5 6 OCCUPANTS/WITNESSES sr. ra rAr. °.' " H•,ru rna - a,- w'! rGo Itndlor3: !.I. 98117 %;+ uDr 9Ore ribs .. L: ullu! .i. 'u.l lrL r•il -. ----.?....n..•--*r rr,, 3A1'l i 17' " 11f! _ _ _: __rJ ???T+ ?:. ?.L..r.. tIT Ave, .Luilock, 'la. :11139 Rend/one•TL fI h0 "1 • ' r 1] 11 1 _ p` T 152 :r I{- E> ?4..`lU?Ciy7hrl'_S.l'-Lq' ml fi11 rIC/I;rrl lq:l ? ? •' ,1:f?!?10 1-NIL l1(/ G ? - - X 5)Il ? •'•? a_m .?! 54'-- 'M.t. _, , ti¢!:; rP?fc :D ?I 3? D,7 fti': ....f .. .......T ,._ .aia's ?!E is 2F "<c ??pr r ,MATE OF WASHINGTON P.q 2 of 2 rvut_t I KAHtIC CULLMFN REPORT am'"^'^""" hnu AwlNUmelR PRIVATE WAY 08-03-4-0219 ] j,AN.nc of suN 10 i 3 Oli u X U 1 2? V Nlr J ff urrlr NO WIND 11•]AN n e erson u a ON at []N C1v041UnN Na:RAhUUr5141104mnw -11 ,hS WNOV,6,lC<A ` - - r 6.6 -ITS Ix0, Ow U-Port ToEmsend ONirondale Road R' o4 vpAp NoN eatvsrcl vN ,Nn4uun.G Z' map:]tr°^t enwnN "- slvur a --- sorrel var- f rn It you O,s1ANCr lU41 NNUNIROA.vU VINCt. CUpSSS 4r iOV NIAVlyl,nAl Wy1 s E ACCIDENT •v. UnGVAM USIA 4 5 p -1a.ole Road MILEAGE CODE COIIISWNINVMV[D ,-N ?i,io l No nowm r 0:" ADS O wr.cv,ol. n n n4U s 11tv5:CnNG 5lvl.l pv ap°p UR hIEVIN:{ c4axuReloR R . - S" _ QoiA1NO NRCIfi p n a40Hmrpw.Gl ONIr ? p{•FD11ED o Vllcll O D - .11" S"'. IN-EU-1- 11-1 at S-111, 1 E51 D-All Pacific Northwest ::ell Power Box x500.00 1111AICJDNG1/.t - UNIT NO. 1 UNIT NO. 2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLISi 41ve4s NAar uu n4v IAIDDI 41wws NAME wu D4,I mI mf '- 51RtFIAD04ESS 5IMEIA .-S C11Y S-1 TIP Co. PMONE NO D I5 SIAIE IPC f . ", R 7 DRN14Ilcl-O SIArt t A Or B,vn VO, Da. I r, I V v V 51 CFNSf NO SIAIF 5[A OAIf Or BIRin ,.D j DAr i,1 OCCUPAIgrI Ix NAMFa InONf NO "ES w4Grvl NIGNI E OCCUPATION eA NAMt6PnONf NO MS wEIGNI rt Gnl I R 0CHECK (?I n,pf,s a..ie° aN ?CHECK (?) Enlcir AS:r°+EMnorfror ? r, -1 CODES` ] 5 t a,,;;"'•.' CODES ?' ] 51, a sv . T; uvrts , o,fs ' .1P•.. o .w .rvEr o o ;b:•1. o 7.7. o .= ; C sr - o -A- 0 1 0 «.11. ? „ o r NN r(AR ANV[IDODGF Cn[V.) tIIDPVT NOVAI srvl[1]DR CC4,v E ?rA4 A I E nfvl -.11.-NOVA) Vl 1--C ,vl 4 "?"• r ]e n. ao4 uunu PS•n ND. AII w.At41A11 No 51A1F H va mm N sA AA A No. A I x v[ NICl11WNi111C.T-- 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i rvlGl[1DINDNCAII NN 4tl I I ? I I I ? I I I ? ? ? I I x vlG151141DOwN[4 N51 r1R51 11- 1-1110 O EG11TI111 -11 BAST 'IRS, W.- tNO. W r] ADDRESS-11 N A E Ci .Nl4 ] E u AADDVt-11WRANCICO CRAGENI R A IN u .N E A N ]? Dlw%w1D A41A r?A IuN ?:'"?OC•' CnA4W • •of: aM".N DAMAGED W. 91D. n.,ReV.n 5 1S1 •DAVAGI 1Afolio+ AOONID ?RtwmNEO S • Ar C..AR:.r o.n•RV<V ? . IHV ?RIMAURO I? "'--"y' S ?IOwID AN?I N DA-1 f . • MAGI" .. ?... - f COI LESI . . ON' ..^ ? G SW > +I Iu NIG 1.? 55 1 .'.I 1 "t]i A? "o uw O - DESCRIPTIONOT COLLISION: M, EVAIVtN1.I 5rYET Ir Ntct55AUrI ]5 1R ...... .... ......._...._ .._?____ I S T. 1 I NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED _ OCCUPANTS /WI TNESSES u. All zeros ' " ' : ' .IsiJ lna ; ` N , r Dui Caii n: "I 3,1!)-3775 ' 11 3I 2 1 3 6 1 1 - . nA 021 fillofly Dr. Hadlock Va. 9113.19 •. !'LLC.Tal.ions ` ificfc7rari ,all "". ,u4 ?':?' O":.,.ra2.r ???.:.,. -- ; ; l -??-C1 • N, X1_11,-,J,TFryn Trfl,???lll1_/_1P _?8 1'(QG??• 17rE; 10-2-1111 r? /???•?-11A" 7.7 IxR?? r 15pj ? f Ix-x Ie ? 1 n w 9 ?st r (yr?v POLICE TRAFFIC COLLISEUN REPORT L?IJ TRAFFIC WAY -,c" INi NUM@9 PRIVATE WAY I I A F Of q N tM? O+7p« pAY y «ai lun wlo w.s ?. s.l IUSt ]u0 «OUa x COUNiv ZG COUNTY NO. /? CIIT NO, N-A ?URBAN Rn? Crr OR rOw« ?N ?F s ¢S mlE° P?{IYYI CµMACUvD. ?s 0A, ?: ON t95fC1NG-11, °fvf RWp r+ON NIl95tC1 ON ICI CI° • RWIF OR 51 [F C 3 132so Sf 11 N ? RN ? _ BIIWrIN Slxlrr M1 IxEll UIS M1DRf Ory x0 n x CI R 'N xxtll« f0 mllFrpBr O, OO - ' 5 C905S °IxFIIOR nIf n9f 51M If w?,l t nCC DE 1 mq'St\N MItEAGf ? OF CODf Amx DI.ORnmal. ? CGII;ON NVOIVfD t«'lEp r. 0 NO N-l. ?SG r ?II C ?VnN C IfS _L I M1 xury ?. ?n 9o N Ifq G519[IIORgO.p Ox xFIFRt NCf °y NFFR CIS [ROSSSrRf??ryyORxOnp ] ? x nRn o.mnctoNI ? LI v ? O e ,r yS200 S 4 c BIICI SI i9 91NaMl Or CPI[C1 BuC[ N OA;,RSNPMEI pa .Or R<IAI CODING AF S N UNIT NO. I UNITNO 1 ? VEHICLE ? PEDESTRIAN ? PEDALC D9 A N nR ^? B RFBB r?D,o<GDF .70 E,4C? g M q 5 373.9704 P7 88 11CINSf SIAIE ATE IVA1,5 2rL9R 111A. ro I 6o Z OccuxAr oN r Rm «I N0 -ft DR - NAM ITRED III 175 !c9 R CHECK P PNONI NO - MFC?t UiJ MR Blu t85 70` 4 0 (,,I F.snN Fm9.N-ArNOI- 1 .al O ' n ? CHECK(,/) min vfv NA ANfm«nnr nl wnoilaeul +?M % C DES ? 9 .. Ull •rv ' r CODES ? ' r t M1 .?sl., ,, 1 5I IIr r 6; n Q N ML AT? h n I p . A no V I S ? s vFn n uDG Oio.I. 0 : O O +iirv??i:" n"I•I O: ?i ? i°N ' I Crvty 89 Fc? OUFI IUAxI r+OVAI s U 2]-DR E T l R17 . FV.I v ?? DODGF_ pnxI,NGV.I IF I]UN ONV I 12.ur 2-DR. 1°PN l WHIr IernseRUle NO f354 E nux n.rE NO An H WA. ' C vtn col x ry J YAgT23 . toll AIF No IJA , All W pf NNNCAIWNNO AD 96F6EH l I 1 45o e vFn CIl qNI «CAI UNN IJH 3F 672643 50 Rtersnxmowryr• usl NRSr mDDU S/11r1E ?4S ?Rl19F12 xnoeu NO ° a vl9rpowNrx IASI N9sr mlolxt SA n1E AS DR6u?R Fryo. I ADDRUSaowNw N A su wryF9 4' T op9tsso INSwANCeeo ORAGENI R +z PQB. E]MPr BE.ATILEI WA , iN U.INCECO I N N Al - fJ Gol )D 4' DAMAOID ARIA o- °" µ ' , "•'. OAM.c o',wIA -•'ei"o' eslp DAS1AeF ^w^rN ?Rrmnwm lowro m ??w^vN ?Rt nu+m lUUr m°I ul nMncl ? oionos 444 S El AV V lover ? AwA: nr StQQO ' n U mtr+.I vn nl1 Ixl DIAGRAMOF COLLISION Iu SIUfi lr rtUSSARri i t?iw" -- CKLMACUTA W2D. Rpsi l ( ,? " o•- ? • DESCRIPTION OF COLLISION lust slr991rmn+rAl slnlrlr ra ARrI UER 6) W 8 - STOPCm Rr ?a?igL Ok) CNIMA&M - V .v r : • u , Amy ! Ir ..::: Z. UEW Z APF120AC GD -RE ARTERIAk, 51pt mr - E JI14 _ Tb0W EY R a P? u U _ i Tr (Wir , H15 ES O? ME: OAD I.DCbZZ) UP 1f ? [?-?[8j --1?? 4E-FiASFIELY Ret TEME TU Ru1J 11M REAP- OF L640 W11ICL1 14AD MOUED FROMTUE 5 bPSIG?J APPX I?q' LIP Th R y 7W 10141176 TRAFFIC -,ZP STRIPE A&XD NAA STbPP@D AGANJ PRIOR Z EfJT KX- -ME T k 1? P-KoDY PR•• axw PksSax-ms S W MED NAME, ADDRESS 8 INJURIES OF PnR? ONS INVOLVED ' CODES I - 2 J 4 5 6 OCCUPANTS/ WITNESSES rr .umn?o,..I rl.w si .cl zero s" 9r.19 nra lJOA)E as m.1 ss 41ADE1)C1eQD: llrvrO A (k) "°" ?A ^ ?" ' n^ . na ?I m 500K JA CL{OI 373 70q _ 11 •1x 11] g WAI p.10' 'M O•m ?,. ' ?;" . O 041 910, ??A.MB C " '?" oO r ?';.' ' X • ?E,Sr ?. .d.T _ T?SO -??, i .? .n ?D, _ i _ ? , ? D lol• Io-?l __._ D.n -- ar° v4j ] WL '5 ° r ^r tc ? p + .( ri J v ? a? L , r. M R POLICE TRAFFIC COLUMN REPORT 4J TRAFFICWAY Palctc HTNWAetRI 2 ? PRIVATE WAY Dolt orcSaLl a i :u, MR. Ix; AIn ?., I. ;., TIME lust RURINODUI X300 courvrr - o //- L»wTr ra. T! cm -A ?ueeAN DRAE [IN DL DN CIVORIOwrv F104 WGNwr in CfS ROUIf ON 51 F MIIfS 5 ?w ?r c oN ? 3 ygo•ao ? Clirv4 wtIN 51RFNOR R//UJJ.U' NOrv NEIRlIC-N NIfL 1P FC BEMffN SI4FFT 1-11 A PREfk ;1 MREPOST OSIANCt RFMI N ROSS51v[EIOP N4RtS1 MIlI VOSI .IS r N Fi5 t rt(r Or ACCIDENT MILEAGE CODE RAMP AM GAA O ' COSIISKSN NVIXVFD 5lvtx lFD ?5v liar.( ?NIT 6PUN NO. NIURFO_ .all '' lurv'Rfa'tU???. N IMfR CLe, S T1F11. .11RENCE OIOSS E 101.11 NO (( ?? F 11 11 CFS LCF VrONRIVUAMAGf DNIV 0 NS1tIIU DVfNiCll 27a /v1 KaINwtOr CI SIx11Ca MVOOwNf IT ESI DAMAGE SPECRLL CODIP101RF UNIT NO. I UNIT NO.2 D VEHICLE D PEDESTRIAN D PEDALCYCLIST s? uxNLRsNwE. wsl rlxsr mm s DR.-INAM, IA51 S • /l Aed 6 SrR[l1 ADORt55 /N S' O o olr PcaoF p SlefEi ADDRESS ?/?sul xlP COO( -ENO, 6?a/7 /?9 tlt oc?! R .3C 5 Al 9f/ 71AUJ t 3s 9 K A1E k F ks; 68 ( " E , C.S/iri ,? m PPrONf NO M MD i r 6 fvFS WfIGHI rEIGNt 9 2 OCCUPATION MNUN 6RIONF NO [vI5 wt GNI IRIGNt 3? R . OCGuPAIION NRMNAMf 6 uae <rr o DCHECK (el 'vrNnf AS:NfmPiorrr An.NOINteA` DCHECK(r2 IEASAN rAwoniorANOlNfu?` ?/ ODES P. D oA a 5 f 1., p CODES ? 2 <AU s iinM 1 5 !kc N 6 ur °r .a! fR 2 C ue 1 , at wM O . ....I O . ?:4'.IrP ? .w,{ O Ic: M f °° ? w ? uY° ? z9:IfR O . ;i ? o:v c l Nnr AR a L<N[v MA uEDARl rkh'AI Situ u11,11NVI V l vl IN 1 -1 MODEl1UARr NOVAE N rEa4 " F° b6 ° '? H 77 jeoN a,02 Ae 51,1E R ARExNmfND 51A1F m N ticuc X k/.25 4Jt} _ - cl ?b D- •¢ - _ I: _ KtndNUnw ra Co po -7 T 37 O L a u l 5GL 2 2 2L Eyy??netoow..fR Iws Pmsi '-1 IE Lf?5TDA1 ?dr)EJ naNf NO 56762 O - wNfR: Asl N. mloae .k + k' I?_ ADDRtssaaA*.tR 3,16 'sca -t /P ,er?aS?J E e4 0 3 ? NAME e A a INSURANCe oo Aef iM : ; R N AN . owAGED ARU ° 4 Dwr.?rD.w1A .?? ..s w C ,;, ;r,""„^,' n rnAVU n1ARGE I? N N ? I,Lnvr., ? DP • I r n PI (]REMAINED Owacr ul ior*B? 5 IT - 0 ? .w:roev lowEU Gtr Y 0? IF DIAGRAMOFC LLISION: nM Au NO4N1 LRN Ir wnSUan I n+O ' / \\ 1\ D[SCRIPTION Of COLLISION: Iusf sfvn[M1Nlu snferll Nee[su4rl Ilea- ?`'/ Tu?rurr? C?f'r i•uro ( ?? \ _ \ /?i9 TN Of- (Jjj7K 1DL Z/ (JE'/ 02 I T/YI • ADDRESS & INJURIES OF PERSONS INVOLVED NAME P CODES 1 - 2 7 < 5 6 , OCCUPANTS/ WITNESSES i?'iao?a»±Ni ?;:Miil sfk AGE' w Rnm Era + .S 3, nSii'0>? /c' H -w 1 loaf ur Amens E,r eY, AMe O FM' D" . O H ? 7"" Am' t"e ;ph- a J(?? y V P+" D76 Drt1+OQ ° 9 IueF .Ix»ns a a vovfDr4orA DAMe ?r°,"' D"?.. D D.1 wr N ,W ' d .rkwx NAIUeEa ?Nkxr4s AM. urrer "' ?;::'D":k.OV1,T D1:: eRH>I4AI KIe S ?«nu qKI DIYMrr C K NO DAllp el POE'1 ---? Am DArf j 4 '2- RED Nn -__ REED rws L___ s"g tr? i ? 6 0 rF r•? ? • ' v? M ., r)• aL y 9v?T ?. 10- . STATE OF WASh"NGTON P t AGE / Or No. POLICE T sO - I , RAFFIC COLLISIIUN REPORT L(`?iRAFFICWAY PIXICE COMPWNfNUMB °'? FR PRIVATE WAY a -_Qatofcou N D l +vr q ' _. I 07 tiZ jby N I . w? imE IVS[a.mxowl CoDNrr mlRFrr NO. Grv NO. rNwq W . . , X Clty Oe tOw 1 0 Qt Q N AM[f NODStP(Ef DgNGNWAY ICi ClS I% 90UIf OR SIaF rIRAt /? MIIfS QS pW 0" [.4l HtHC ON CE.ti7-Fr, /? A- 3 INrf45fCt NG VAr SIp[ PoAU L(•V, U /??`TO {'" r &b rn I'NON I[RSICIION pafl% F J MIIf POSt EAV 9LLL Y BEtWfEN ?? - F T tl% O DISIgN Od SIRf(IE Sre[ff CF.Oq E p[! C[CxO555r4tf OR NEARfSrMnPOSI / i4 ?, I M%[S ACCIDENT P DI AAS DArq IfEI '" Oi MILE E R 1.Q i ) } y '? M2Y q CODE COtIISW ?NVIXV[D ??tl(D??NO, NJUR(p? ? "IftAGI ?.1 +'nf n RD UVfn'Cl?fS INIFR CIS ® ?PPOMRIVpAM ON AGf Ir p ON w l~ IN 3 (RS[CN Staf104 ROCDOq aifaNCE a5 CRO555 1pffI0R WAD ; YY' h^ - A ? V Pf SUIr[D ?F C f ?? 9 OBIICISIRUC%INRME OI OBJECT St4UC%ANOOwNEgSNAMEI SI pA AGf SaCU CODING 6E g /lam/SO 1- I . il 1?5E'?5 S .s ' t UNIT NO. Ii451 jp-?? DRmp s NAME. usr RUNIT NO. Z ? VENIRE ? PEDESTRIAN PEDALCYCliST M' ° t RSNAMf A5t NR MI ?" T L I N D. KE_,S, ti-E Tom. sraoADDpF - C. •f/CI U vl C_ iiI-- Se "?• ' R ?? FEI ADDRF55 6 '7 E- t/FC_ Ry D c Z 5 ' srAte :I C D `-J S. J O fI'L' E , R . ? 1 E . ODE PNONf No. r SIAtf z DRNIPS UeeN Go. 'c'am srnlJGG Q7("B/.jai R " r.? 'rtl C)C E_' SC k,•EiP C/,// %,)-S7 rB I C[ 1 r? OcaxgnoN - NA[AE a v M noN[ No. U NSF NO d? lRS OlQ? ru GNI E Igrf Sf% L:. ^' DAIEO[BIR? w te C / ' . ? ET/k?l? ?P,v - Gm ac P oN r / rgMNAMF. PNONF NO. [ES Wf Wlr lflGnl IO ?l R ^F77/,C?+ ?,,g ,' ?CHECK (?) RFNCi[AS:NrASPiorfEniANantn"' ?CHECK(i,) ' w ov * o 9 _ _- ft CODES? 7 nwN 5 I aN as^',° 'cl? CODES qN EMn f q P ' 7 s l% 5110- l, m wl F _ 7 •I IN ( [s (.c / A.' C 0 MCI EIDODGE CNFV.I 111D.YRr.PgVA, Vsirl[la D4 CONV I uN01°?%N I ?bvnp ? vi ?I AR ? ' N ? ? . IIA. 1 vl MUDfI IDARr NOVAI .-. ? L' J7r? E PC, (r N ') D ?. rrev . T ? I YI 1 D , G YI ? ~T?r'.I ?w s1An ; N aA( EpRAnNO SrAtF H Y ^ /? _j /.n/A V[NKIt IDFNixKAr ND C 103 le-1 I . vfn CIE I N 4/1 13 91 1 I L s< I 1 ?N7 ' ' I 4 ? acrsnaoow+ee EAST Sl DDIF [ I.$ [ ;_3 / 17 PrgNf NO Rt I I :i ,y ? ..yy `?tP.uy St R(D wN D 51 NRSt MIDgF (' u. groReuoawfR W ?'L F NE l % lC ,V le ?1CC ?--- ??- ? SH[r IF N(LISLrIrI.. Pow DIE - I FIT ION OF COLLISION: 1 SI SWIIIMINIAI SIyII rNICISSA4v1 . "r nab "-? .. .I.?o? i. ?- r- ?Ff-... ? ti ?•c.TN v.v..- C_E'•t .Trl /w.H-T?.. . - t9:1 C-V iz' r h/'D •?> ?r. );Arr ,?d i esr? -: I , .. f. _. \ ? r { ?- ,?. ? r i.a r'. L1ciK-%• ?? 01. WC s: •v --..•- T-P' Y!- Y1`yl.. I L.. fIE(i'(. C3' 1,•?Y L. L. I"/'... rw. h°./ k,JINU YC=.<Af .. 3 At I ( L 16 'f / . f I L eV. 7L GL 77 e-AJC?t'-t ;Pca lE? NA, T7 (1- m I? 7N,e /•r 7C n5 Cr'rroa... .-1 fl J72 L u C-I l L E-r c, r•= c J t r-/T ,. l 1i? .?c?Yx iC7} 1n? /?lt<-. y J, .5-L. L U o (I'r n ? c: a ,, rrL • c r;• rl. / WITNESSES `_-'slaniw ...,...v • CODES I I I- I p 13 14 I S 6 rew .Dwr uNU NAAV -se 1 eE I s /,''9 NN?.? ,r 7 T l- N 7l E• n_ . -r---1 ? .- r.?L c rry ur y .+ _do.k ilu my M c ftiD x p 7t 'LAL r n wrY!F .w,w ( 1, I J , ?ry ? L - ? 1 1 ;K ' III 771„1 rm 9 ?t _2 IL STATE OF WA" NGTON EER?- l DP No. , to ' POLICE TRAFFIC COLLISION REPORT LY TRAFFICWAY POEICE COAUWNf NIYNBER ??a •' ;f DAr PRIVATE WAY -c- c •/?a DaY w rr 1 W Off/ u?sBy Y n IE ul 11 f]./IpnpylRl OOUNEY HO. CIiY Fq, iHR w, .p Li-o 5efbersa? ?6 ° 'y 11, Ell w °oF E]r OR,owrv ? E{NO Or aro4EnGXwgr gOUI[ONSIRf[ s[cl Ru AVtfS 5N H fi?(c') oN?+ll?rnAd 3 9.?zso wR?-+G c Ffl ro HoNINRgsfa or ?? L?1<?Ph ,P6 ravlx f mlEE rosl -/ JIG -' DKIPN f{DP.EICHI BEIW[FN SINtF16 SEEI D. ?O "1? - i? O' TLS ut fE CROSS SrRFF, O?^R INEgRE5 I4m lF POS r ACCIDENT A -A rEfl' EFf w OP F-?Y'E?I ?5 J?i.,?C.S¢cIVn MILEAGE CqR SION NVIXVfD SIVFR ,Y: CODE roue rv0. ORILLfD?NO. NIURFp SvIIIAGE ?Hr6RUN FurvMDrH TER %-RO fNSLCr OR ROAD OR R{FffRNCE • Ci VtNICI[S ?PgOw4,YDM1IDf CMIIY rvlsN IH CL5 GEOSSSIYFFIOR AgO P -.CTSIR- INAMEOPOR-5T-K ANDOWNf4'S-i °cfSUlrFO °STIXCIF Sz7?O „ I FSf. pAMAGE SPfCNLL CODING IbE I.?, e1 ? ? J' E UNIT NO. I 'f( D4 fus NNAf ?DASr IRSI mlDa UNIT N0.2 ? VEHICLE ° PEDESTRIAN ? PEDALCYCl15T ???: '?? ? pNYFRSrvAmE: ,AS, a s,wHADpwss ? ,*,.'??_ Iwn wp4FSS ? Er<? Qpc rAlt tIP ?? pNONF OY pENfRSIICt ^ 51AR D ( I All At-BIRIHY H S (a33 k? ?} v o D s rA-2 tail OCCUPAIIOrv XRM NAME 6PNON1 rq. 5 I- FfIG E OCCUPATION FIRM NAMfa PNONF NO. FYFS WFIGN, HGHi a \Van VS h1AV Vol (per R dCc > ? CHECK (4 R i vfHlat AS qrv rmw ANOmtR Al D cc] CHECK (.v) E o CODES S ] aA { s "° to 5 e cl°? e'T",°,?,° CODES 10- r ] w f ,Ai uwovEF OE As `rM FgMN a -AN , n Irl Hfue Drw .sn IF CAigs ° r c e D ? Cu sr 'u;??urro ANeuA ?{rc.tr ? f8.1.. p? K ;f M[ m °I A.cFV.° w I t°Aer'I?ovq, s[ z v ? K.. p.; l -73 m IXo4 v\ E p YYQ ,?'?r, u3 N surf IERRArE NO srgrF H O •A 'B Sao , 10, rv. _ V[HKIEIDF I CAIgHNp. R c D ?V L1? ?'?` "??<, 3 is 4- L NH51r &19, L-3 ` 3 s a g "11 4FGISR4[O OWNE4 -T 5l pIXE flgNE NO. O I fR DCHM[q: IASf IIR51 -L FMO. Ik'.w rl ] ADDwss Owi+IR W A S, e E• .?JL S A Q N ow*RR IIIt f r y ?• HAwaApDIR salrsuquce co. cv.w E LKMAG;DKEA yy G.. c.- N.1A4[D N(A •;? : ? w, Boon oa,, -1•x1+1, s?;S??p -fhha n y g rtIN S'f'RIKln9 4 tu 1 ZartnT?rf C?IocQKL?:,se kJ.?IQ N.`13ao? ?' T r,. h ?coi»??RBIi?;," 1 S' 9 4.,4Cdlic Qty YtlunvbwlF+ L oh t?aS L..6?arifJr if 5 u%OI:u 6rAlIDSI?Hw.I J..3. 1_4 Ji 9, P?..(l1T??in /.oV I Sat 'Q( >< r r Am. u t. u . U riR U rsN,. ,y a? eD HA?n[EU ?LfCK i' ?H I(1\rVr?1_? wXw M7-7-?{?'?• qve ?".:?v ° ( +?'i ?.A R NOYFD rgON ? ? r ? .. ^IIY .'c AErw T. 1V wrl ?r5 v ?` .? ( "? + c S..AwaaANa aADGw Au NC. i} ?AMe ?? ?cD.n. ?fi+ ?" ! q(??r rF/7.w/ u urta wlo4l 1 .. r` ,.L ?( ? .p (.q ry CT u E nl / 8..r??eD ' f ?a (O .L?rfr Arwovruer DAR ? ryE 1a o i R 7 ?C _ ? `- w5Y I5v INEV lm1 -uF-WAS NGTON G DOE? N f- 6 u. TRAFFICWAY _.• POLICE TRAFFIC COLLI I NREPORT roIKf CC- lNUM&N y ' ' DArE of cal s ? PRIVATE WAY See COUN Y 1 "m D . n ? ? v H 1 wq u y,\? F4 EN 4vl ] OURI ,? COUNTY HO l CITY NO. iHWA P r•'.N pN pE pN CIIYOA TOWN N faNO.Of slNttl xWC CLS M RAI Ix NOUIf Ox ]rRFE1C AfS'l A SFCI xRm gs OW pOF A ON ?\ tM 9fZSQ INIfR CI NG WIIn]INffION fJpN NIfRSECr IXR JJ y PREEI%. E MBE POS! , BfI `? ? 1 r ? µµ ?"'i' WFfrv SIRF[l a StN[FI Q, (T 4E A DSIgeJCf 60 MII / [. CROSSSIRffICW NEARtStM if M51 N R 5 E /I ACCIDENT RAmP OI q,vn pSrq ?? T` ? I 1 ?MjtEAG .? LODE 'E GDIII$IDN NVIXVEO % F I!D lOtgl NO ND __NO.INJUR[D SVIIIAGF ?HNaRUN w"s" I / HI Y OV[CI[s p pROPfaIY DAMAGEGNIY p gSUl1fD ?SIQfN 5 %RD INt[R CIS I NG SIREEIOR BOADOR NIEERfNCf UOSSStNSEC IPL.1GR gOAD O ] ? ' pT OBJ[CI SIRUCS INNnf OF OBJIR SIRUCS eNOOWNIR'S NMAE) ISI D-E BpE I 0'` CODaiG USE ?27G / i s I" - 1 5 Y UNIT O UNIT.2 DRn stJ?Mf: LAST fl sr mlDaf ? VEHICLE ? PEDESTRIAN p PEDAEC ST YCII ]! R /\ ? }-+ R ( 'SNAMF: Nsl 1 MI I I a -?'3' ^ ? { : SIR[ff ADCRF55 i Ei I . ] ?• 3 • r ]14EE1 ADDRESS t I yyR{ S- I CO ,r/?, PHONE NO D I S.Alf 11Y CODE Y,grvf NO /? Q O? 3 EJ??f t I ' ?? 'S IICf,.]EN siglf R IVfR' lK[NSf NO. .0 B H O D srAlf ?! :: !!?? ? //_? 2 rn Ul Q A. .. V DglEpwB Rln° . OCCUPAIIDy iIRM NAME 6 P NO. ?•?? ? FYfS IGn11EIGN1 E IXCUYAUON iIRm NAME 6I-E W. E! / EYES WDGn1 EEIGHI S - , R ? CHECK (11 vf -ASANEMPiorff aF.NOrnrem p CHECK(,')' CODES ? ? ] 5 E cl a u?O CODES ,4°, vfH Cif AS AN fmnovtf EAU AN"oriE?aAl N' HY rc • * 7 ?.ss °in:N 5 rx N a u ivc.cs IV Iw s s r'O ^ y' ,.?. - ''t. rte h Mnce p wweDEArA p VEHMY[gR MMfIDGDGF{nFV.I A1ODllpjDaEI.NOVAO x51YIF 1]DR®GNV n YfaR ? u+Ct 0Mc, ? o"fv p n Kai ? aiiay v WB?rrom 1 v.l moDEl DggI NOVA ' c` ? Y' A: ??rT{u . . E ) rlF EfuR. vl y Soo V J , E I Em - c i ?,?° Y \ ?-a AIEa AIE E [n <IXON 'HMy?t?l ]W? NAIENO H Y C qlf ]B w An A N n HKIf IG NIIFICAIpeJ NO. L VfN <lf ID rvllFl A 3' 37 ?V 2? 03 (._3 ]9 I NN ° YV 16. ? I a[clsnaeoowNfR: I.xsl nasr mlDa[ PrEONF NO RE sexfD w A' NfR: usl Flasl mID[%f ?.[? O H fNO, . •v ? -rw: ? I] ADDRESS OF OWTIER W A t ? I%1 NER 1G N 1! ' ,ws,aY. IR wvqu ADDmssa 1lNwf.Hnm y';^?fNr 1 E R A IN E - • T ? ? ?;,,, Y- wm%raD ARU R1- hl V }- ]2 K1C0 EYtI m. ?" o- ' I Y -r i ,.D. . NC cHA W ]f cnxRCr ' „ ? w4xc, N r,,, DAAEJiciD ARU ? Iwcl°NN ?I 6 t s IV:OttOii ul. DAm.r pd / Etpp LY " ?REmNNID UDaIV[" WN[D ?RFM iT O t5l FFF ' b f M BYOWD WAY h l'°] Mi 4 . 11 '? ? SraEIYM` r) ?BrO "' vca.rtrrllvrv Uf t.UELINION:\?I? Js O I., 4 u __ _ ?I.,PEK,f 2 X ?/a, ?u o ?c mow" ,V 11-1213141516 msa? ? ',54 }14 1l ?I? Wa 1L ??hn ? In YIS ?i 5 h 1 ,f r?;r 4????' PC r'.f 'TE r, mat)?Il . yP,?f f .'{,?Ela sir 1? L T i M1 ? 5 h iW?f 71 g ` 1@ I % )° l 1 . f ? 1 E N Y r a 1 Y l 4 1 ? ?. I ?RRii 5f r? 1 {leltl l? ; > ? y I. 1?1e s r k' vra, Y T R / 4 l r Y .. ' sevas.? I POLICE TRAFFIC COLLISION REPORT LJC1 iRAFHCWAY p«ICtcawHNNlNwnwx I PRIVATE WAY I WFt OhC«l N .. Ar ON HD A. .R x,N w4x 41< b rw., ,. >.I / C I ,„>?N u OUNiv i° ? F o u sa CWNIYND «N NO. ?lP II1WA oD Nq R , CFV ONIOWN EF1ok"""V rio F r+ o 0. 0E O IN f ICI CLS 5 ...IA xUUI k 514(1 CUIx F O s< r UN mills ? 5 ?W ?Dr ON / •A;aqur ka ? J /u?xil>G s IN1fR5tC1 NG wIIH f ExOAD NON NIFRSFCI ON pNN X F0. mILE W51 Q iiuitw slvHl - ?. GU / DISIANC[f DIRK REftgfNt[.fx0 104 NFANI:I r, I 11'S N 5 f n.50, U? ?F • .I '? v M E CODE 'COD"" P DIAGNAM WIA G«111X1, INV«VfU: StVtR Ix: NO NO NIU4[U I].v liAGl ?r1 Y4,rv Nrvowuiw ? XX Wl[N Cl5 irv11NRCHNC SIwIFI Ok ROADON NUIkINCt Cg05151NFEFOx NOAp P 11I . _ Qf Vf0 pROVt4FV UAmAGf ONLY I f ?l o?fIX<I! IOf...... NO ?SZGG C9IECI SIRUCF INAMEOf OB1LCf 514UCX ANUOwNfR'S NAmFI t51.0AMAGE SpfCDLL CODING USE UNIT NO, I UNIT NO. 2 - VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 14• Z ORN[v'SNM1E: UX51 n hiRS MIUDIC F /.SEAN Kf`F/A.e.n i.?,Aa,/nvvf DNN1N's NAME' USr NNSI mi DLf ?yNLG.P o4vp Ti °Z SlRtfI ADDNf53 5 6 SCHG.//1hC.TZ /?d SlxfEl AD04t35 T 1 L3 aSrF. 5 1 cn. `c- ?IID LDEA,v[d LUq riX43S"Y '?-/Sd'J D R 1 1AIf nvc«iF v,aNF NO. /vw.vlvfvd o.Ap H.?l3L;i' lY.J=O iIi'? 1 , Z NfR'SUUN N . 1-1 nAl -F% I I Vf R'S UCtN NO AIF A OAIE Or blvln BEAN-je to N?3' 671: !?A pl F, d, S'S- V O 9NIILC ?"' SW BS W/I q/ Z?" YZ / N OC CUPAUON {IRM NAMf ePHONl ND Lvi'. /:NGIII IgIGNI E OCCUpAUON NNm NAMF EPHON i NO F,f1 --F ,(iGHF R nn ter=Ewro Qel frta/C I„Ti ?rI'P?7 6LN ?.Ei :T" CHECK (? He Mm vF 1f AN ,N QCHECK )?) Nn1ASnEAiimlvovlin r+''v' 1 A E vI r° 7 S - `? CODES?? CODES ? * m . / e M" ' / / S 1 V[H. vI- -EIDOOGf CHIV.1 MCxIN1UAN1WVA ,?I,,Uw <(Xxv, LAN M.ul- ICHIVI k «LIUnxINOVAI It I. xC«+vl mD 72 TWDrA uA 1 02 E 7 C)la y S•E6 4 a< II J V 04 OE pU fHO All Anlvnn lr.U All 1 v1n C«Ok I N. LI A A(F-I(x HAU NO off ? ,ero u 6 4 I,?A C yA6117 r w/7 N veHKUlarprnlullDNfa E. 2 J[, 9 r 9 1 L E vINaF DtNIICA NN C C E I L 2 F l 11 6 3 3J R[GURRfDOWMR: .. r .451 WWII a Hibl NO O N14 Sli vlD MN: 1.. nx5t ID , rvl n0. 3i /YJ W LA ? ADORfss«osvNER N A Dxl «OWNFN 4 E Z NAME lADU4FS5CRINS Io,?w,OG IIAAAAGF .wfA URANCf CO. Ow AGINF /J JNi dAr.a R A , AllN IN AA o, I><w f ?e Er w,>r .., fl?,i' n,?; UAmlGfD lµfA F r4.' ., nYU fI1ANGl ri 1 .? / rol ? IO?OTIUw 151. DAANGF h-. fl v ?wFVA.?.i i. 33 LL ' AWA'VI ?wl NNID 111 VAA.A1.! l' ?1 6 I - Oni.ri u S 7.»? ?oA VD ? f- I.l A S fiOU - 1 C'^=,. DIAGRAM O F COLLISION: e?Il'?i iuciiiA'vr`? I'•'41" DESCRIPTION OF COLLISION: IUSt;IwHEM1NIAl S.wlln r+IC11SAI," ?: le SNO?LO /1 r' S!'kr/r S/4ti voif ,1 -.1 Dn I SN/ y14M v0N0 ?6,/ I RIiA< /x+I,af/O ,%, ! ll Ro n. ,RR`/?F.( 2 SA,O IAIC rnv?4, ! ?.AF 1 ?' ?V ? ~O? !>! AD Ct.Fr.l-?xJ /A, rGiCSdcr?? rl.vA r/4' n v f ,?,I) 'RS Jx.duK,N6 A"1' IA; [s,•E,r ..+?i %"/4Fff/--vF; e NAME, ADDRESS 8INJURIES OF PERSONS I NVOLVED ' CODES 1 - 2 a n 5 6 OCCUPANTS /WITNESSES Aca AI .. •. •I• .. . •?• . , . x 1 I +•?• N _ _ Aw `SoNw EG 6'e A..A ;A? = I S, X, Z s 7 E I . wwFSS E..Apwz ,?w ' " • N b ,I, , l7 ",. ? I. D N __ .mf ? e,?.. a drr..x/ ? ? a, = / s, l F / 21f? s?-7 i- A DMf 11 S L SeueSlaaAr3 m ' ? "?~•, "" o ? n r„ n 6a•• • ? ?? N - OAAW S,4rrrc< -11 A ,nisi ?.we rl~. ? []i::a. >Ir,AFHOarcEnrw.v ...,•. xKl a:vAloxE XfE ANV?WU Den cw ro.>r . v PAN X F,a,:??-`?6r-L!?? .17?•a?^_ . F 9u• ? n ,v,? ---? ? E d„ I,l F } -f; T' p i 5 F kit E V 3 a [f r a h S N.l 1 ,yy •sr t ? ?394.d1 ? 1? ? rf6i/ , xe'?T< I I A 3 t f ?f?? ? & ' ed , + r_ Ij?I INS l lt!/ .I .?q V `i ' l? I , F., S tr IFS o, t ADOM a? V NONINTE ". BETWEEN o vflNC OBJECT 1 ,„ -, dYVE)19 d, STREET f. v, utt x $ ? d [nIVER9 ?t 2 ; ;? ? + VENIOLE VEHICLE L F i RE 9T $ 6 PMISOF : r ? j s . LIABILIT r ? p p 'x NAME ANO p? ' E MO tL 1ST NJLYIY NAME ADDRESS +ank STAT LGv 'L ?Y?vf S :WOW 2wN xn. A ? V J anc . a , - - - - f - - ? .. Y .3 r. STATON '•' IDFFauLUSE ONLr O F ST ""` SION REPORTAh , T LS;. BD l AY OF ON TIME OF COUISION WTY NO. CITYNO. ? .. ' t MI E10Fr NFS w[a IrNn i j SA D uwUrE9 AM J? PM / l H b ApA?CL9 PREFI% ouiEaRsTALncoUE A SECTION aw L MOfl HIGHWAY INTERSECTING VATM'. STREET OR ROAD PREFIX EO MILEPOST ? I p.Od > LID flSECT10NLOCAT Of WSIOrv IWAP OIAGflAM DATA STREET ANO T T 4 - S REE ' ®© nAMO+a cnos.vxc u.[wsl On alnl rr ncl t L- „u INIE W ER C1R50. }?cwa slx[FFta?I FtwE? ? µE /J DII' FfFI ©® Y ? ? / /cIZ?D Q vLwClEVfnpE ?vf Forcrc ?oIH Rr iF Ln w IH w?. a SPEC. C OOS IRE •Se ElAxx 'f O W'I.c[LOwECr Ov[ ? .1.8 ?vEr.cLF P[uLSln..v ?rav CIXLS.On ?nrnux TRUCK nALI[OF GUECI StnuDKl o- OFOEJECTS NAME AND ADDRESS LOCAT ION QN © OT ?sl FVNN E EC IN ROAD g O LLI T WAY FEEF .II? [DYL S (FIRST NAME -CLE NAME A E 9 LAGT NFME tl FWGT NAME MIDDIE .".., ST -- ? ? pg, A PA ev C., 111 ??? ppESS ..... . rlOUTENO.ANCEO%NO. w0 STREET ADDRESS ROUTENO.ANOBO%N0. " '.. BfATE'i.- CODE W 9 OWVERSOCCUPAT.N coo Lw,RrF oRE CITY STATE ZIPCODE CRIVERSCCCUPATION yENSE _,' I.Lik.. STATE SE% F DATE OFSHIH F II AGE ORWERSLICENEENUMBER STATE SEA M F pATEOFWRTH aA. rf A ME Ty? O A M Ma /A. r A ale _ wA f} MAKE1 V.-0000Ot MODEL (fEOVMOMTI BOOYSTYLE 12 d i.) VEMaIE YR. MAKE ICHEV: DGEI MO DEL INOVABMT) BOGY STYLE 12 diJ I A - T N , 4 4r 00 • ?/ a PUTE NO. .:; 8TAT1 TRAILERPUTE NO. STATE L- ENSE PIA-ENO. STATE TRAILER PUTE NO. STATE _ W P $$ FHTIFICAT .? N966MODELSANEWERI OOOM[TER (MILEAGE) I,BBBMOOELSANEWERI DOMETER IMLLEAGEI VEHX;u,mNTIFICATIONNO. q } OOWHER:' ',II,AST'F/6yI MIDOIE NAMEI DRIVE.SU:ENSE NO. REGISTE REDOWNER -T-FIRST-MIDDLE-El OWVEliS LaENSE NO. 4 -1PA 4 F WT $$ A? ? pR ;y,;. pEET,CItt ANOSTATEI OAfEDFBIPITH B H ONMERSADDRESS (STREET, CITY AND STATE) OATEO 1 049 4t ' pp . DAWASED .n I` vOKIE "I ocas PMiSOF VEHICLE DAMAGED raPAR VFWC +`tY` / WAS THERE AU INSURANCE IN FORMATION VEHICLE NO.T- CDYERAGEN E TOMOWLE LIABILITY INSURANCE FFECT FOR THIS ACCIDENT ON YOUR CM OYES ?NO ?' v HOLDEA ADDRESS OEAIABIIJtt INSURANCE POLIC NAME OF UABIUTY INSURANCE COMPANY •+ , a C,ll .arc W- 9 s A ? IP UAdUTY POLICY NUMBER Gi ADDRESS CEAGENT v -I w 0it S", 1-4 H ,?L ?T l AGE -_ _ . REL,I 2NOINJURV: AGE . _ in Ckuiw°rt2 aIr U. N 13 NAME Che?sd?nir t Hronuo 6!l Ceg??ll4j. sEve li 199 urxf .II N e?C K ' 6c SE%AL/' 0 ` ' r -L MDSE oK/ Jrl-4-+ way CCAO-i j SEX 5 06 Q ? - .I} ¢ - j QQ 7 • ? E LC?t &. fa®-7S V6 r 1 1 U ® NI" 1 uocloRS n"u 4i USOFU w , MMKiY9T ONE THAT PIE S SIATUSOFINJUREO MARK FIRST ONE NMi APPLE S S orryuN o nuilR ?? IN VEHCLE IN a Enwn r IrLE Pruu ? ® aLLED I IYV[nE NwM I I caul ° C ? /E NO KILLED I Is[v[ni I unaRl ECOU r c I o E , Y NO .., ? 5? B? r 1 7®F rX -? 13 50 B? 70 ..i. I. ^ . I S L AI I Y ID FJIE ,? V m r MAN _. i Qr? =-DID O rwMr IwR12 al R Sa"aN LIM y. S F Alw I I M1 r.Arw"r ? OW WHAT HAPPENED (REFER TO VEHICLES BY NUMBER) VEHICLES POSITIONS BEFORE COLLISION "AI nK. jF,q„q Iiwr?K "'r„ ?•? wVtsraufo Br ? i ?i` n +! ( ) ' VFrYCI! M S f w Orl STREET d1 rYGnw%Y NAME g1IV0 ` v Yr. 1 ? o x ii nK a o Y. a,. ©? ? 0 1. - iA o ?9 rr? ,lI ? ? r ., o ? ? ? ? ? ? ? ? ? Q•.rw ??; - wAIAEw m ? ? ? udlo c°mYwD FAD. DIRECTION To DIRECTION u, `r w;- A ?. -'m P[PESfHAM wAA UYND A EA IQ9UEwNA CITIONS ICO J?Wµ%w AT J0 YIOmUE11 Fra C 1 IP L 1 E?irrn?wu• IYPEOFPO S? nu MUi II?Olnl rl RrVE11aLE MIaN9 DRIVE tr I {? pC^B 1RFACE rfr+(ArINr TII YR Y UGN 1A ON 11,1114, 1 O 1 t'.R Fr+ M In vlrKll L[, r u' GrLCA OnI.FN wMU1 1 r rt11 I M' ?R?1I?? F aura I C5kt-.1t I O SK µ5 ? J US Uanr r0 COh.I BTRAMJII MLM Q, 1 Qr I ?GNL WAY '/' spy f? . 1 ? ? 1 19 DR, ? 2 ?-1 2 ?RN-4 1 Q MWN I $A r? Ig J W SHOP SaIr D Q Nl O S VI ® ) Q TWO wAr '+luE ? ] Q ? J Q OVLIIiAKNq AN D PAS`Jrll{ [JI 1 ? MAn NG IIar1I TURN 1 ' ? B ? SNOW J QSNOAEM ] Q ( U BAR. Ett r Q l D ROAD INIEIECRANGE ? A ? E ? -ING Lf FT TUIIN ( {Vi4 ((V { V l . l ? E ?A'E .0,C ? LA RTS BAN-s""lI C] • ? rL1vw.G IN Q PI IL ?MANING I T R { , y ? DInf R OIKR S?ISRCIFII r0 lI['SIfs01I ? ] ?FIASrrIKi AUIItH LEY Q ! ?µIE I U N C] ! ly l rF ) 1 ?L N[A[YIMO 5W Yfwa DANO[A I. 1 ? OIIN'N?IdGS ? A Q IYI -Al ? tl ? `(%g I ff?TT Y ? LOW F1fi S'vS J, »i4'?.y:- AMKFR1tlvRA*. PAIAAClOR11G1 ?wv' ? J ?pf/IC[rllµrMArl )yl r ?sldY•EOron RUrra ON TOP! Cµ ?{5? r, I1 t 1 , S JJ ? tl Q Oi N (. I EC r ? 1 ? C[PNIATLO R C3 ? 2 ?OVaEO ? B ? YIOr'PLD fgAOWAY 1 l?I 4 ? ? in1 la ? i ?uNavarD C] " El Iiu(i Klul E OC/J 4. ivA 1 i ?P ? ? I I d N J i; 5 Z, \w POLICE TRAFFIC COLL15M REPORT L&TRAFFICWAY oicfa EWNOA"B }1 I ? PRIVATE WAY I Unn OI nni5? n UU S? rr COUNI? COUNIr nO CIIY nO iNW, u4,1 I ?? ?N ?! ?N Cllr a510v.rI vlfl Oen N ICI ClS R OU f04514lkiC SfCIIN ? 9l1/SD ,Q? M,rn s ?w 4qn• S O Nrtv,ea?r min smluwva,o Nmwsfn a.. ?pH? Evlna w fvasl mI u , euwrHr - - 514,f1 q 79 II t- <I6UVIC1(Mi nCf CvU5; 51Htt r;l• ',I mlf5 5 L• [? o+ n MIL Of Ni l[AG[ CGDE GuAM f:nin - ? _ (V VfU vir "!aln,lrn, ?E?JJII O+I,fU_ O G ?'? •I ? vl?[lli I(? ? xvOHeN UnN CJ Nf ^NL ? a' v' - „?r,? - 1 +xU CIT NII45FCUW. SIVLEl Ox RO,u 04 Rfi19[NCf <4055514ff10R.. -/¢?? r ul om.,cT . v .. Nnwl or oeuc sleuc• NlOanma Nnm- I'Ll ICOn NC.USL UNIT NO.1 UNIT NO 2 T $VEHICLE ? PEDESTRIAN ? PEDALCVCLIST axe A5, e.l Is, a? Rte/ y _-? 45I 7- 'Ana z - vu uOU M cCLA LANE D I nouxt5s N13titia I-J, 0. ? -111 no _ I upuyu R otio Ri - ,.f N5 N 1 M I M 1 E nw 12- R oRFVCY3 PEN,u 1.4 1.1. T'AD ? CHECK L?I CHECK(— ' n v CODES ? ' ] ! '1, 5 e CODES ? ] ? ; Q ; (2-1.4 U5 e-5 t 5 3 ? ? ? ? ?. ? ?,.,. ?t' ?•..n?, + m r!I a «fe• M a, 4I r, . - ,, k 4 w ?nx Nae. a ' C7loei ul E 'cj Z uCINA x„II Na ,IlennnNC ..f ,II Fi e C,ox ,n . "aPi ?f'3 'wa Iwre u V _ _ I 9 '? ' o 0 , f e, IlolNlr<nlaNna 3 L (oq 71 L HT 3 1 "7 q GA ti A.4 Rx1UOwN14AJ ueA miOUlt O Rfo? DOwrlle 451 n411NUU Orri NO O W Ea! GK- L E'S - ,VWI51 V OWNly n !5 N L 2 M r E ? - E? 9B1O3 1?1 ij In uOHxr,r nsux,na co ox.clNl - r w•ES R 5 , ! ° FRED S - ' x wE I N .r., [].r ? I: w u of 9 2 L7 I ` w: fix' 5 ] l o"oeY °_'_°_? OU i I k5z)OCO Rd'.` ?- Nl c,n uw n' DIAGRAM OF COLLISION; zWi1IMC1:uu? DESCRIPTION OF COLLISION: IIAf TUVi,I, SIn11INtCISy,eri - • 45 ?/ ?-?ILL,Ep 1 WA5 L5o.4j-)-;r,1za-D Ov THE 02vHs cc1 PAGIr Aam F?V V?L.t.E'2' /Zax1D, %L4C oN7a TNa , EWLce F I SLAW/.T4 Y?DRIt77i?( 7DwiJrcl?3 ?c 6H1.. vre-svmaZ 0SSwefC0 VCMtc i+'/A0S L.u,j Ca ovf ?U 7,vc /,U&AIL-7 SO NF i14-15G'9 )M• Uc),KCcS G.oL.Lr194,L 1N7)It{'S,Y32N'+? rl TSygn,00rN5AC ?TL'tiL45EL;7Lr S.3 Poa'"R?,SdvY7: pR.ox, Wt714 A, a ? _ NAM ,A 581N1URIE5 OF PERSONSI NVOLVED 'CODES I - 2 J 4 5 J LS ,u;l TI,vnlwrn,I •nn OCCUPANTS /WITNESSES n se. All wus " x nrv heel . v, LEZ1NOx 5£YY? A ZAHC I _ . ., w+-- : - ! . ' ' . N ,•, X >. 11-- r lalio f . a -B ILS, 39 0 I ?0. ws.R _ y / a,r A { • yr P3 _ T P ix' f ?LG, s 1r , 4t ?1 ,r,. ey,: F .tle t aM+ ;'• "I T , ?' Y ? r I I FrMd • aJ? I 5 tt } ?? ? I Ir 1I i ! c yI i 1 1"] , LL 5d w 1- .. NRN?'taN? :rip 71O., STATE OF WAINGTON PAG! GI INn ' OJ POLICE TRAFFIC COLLISION REPORT L4 TRAFFICWAY PoIICf COMRNnINONBfR PRIVATE WAY Ib? DAIf OI. CCANSIOrv •px rv Oll q lu ?, rte/ ., p „I 1 Iu5F IN4nOUN1 v 1 COUNTY - - - •,C3??? COUNTY W. /G CITY NO. { RAA ?D " / DN DF w enroll rown No.«s a enw"r NAM[L bQ' 0 eLS RwNaLSrxtefe u r ,, ?. vR Q MM1lS ?S ?W ? : C e ON ry?TO IRSfCING.11 IN[tl Ox-A. NONINIIRSECIION S PNYfI% f mllf v05f n ^ / UIYd /Co SFrvIEFN SIR[Ei, 51NFf1 It ? O•aO / DISTANCE" x ILxtNC CROSSSIxfF109 NfANfS..... .c In'1,5I °f5 E 0 ? Of N S -CT/ON ACCIDENT MILEAGE CODE RAND 11 -A COIIISgNwvIXVtO SFVFN IY Iif RUH SPIIIAG[ 10 KILfD NO I"IURED ? runpnplN %RD IMfR Cl$ INI111C 11NG SIREfrOR ROAOOR NiFRENCE fr -IIII CROSSSiRI 115 _ IOIN NO. . _ CY VDI CNS © PNOHRIY DAMAGE ONIY ?pfiull[D ?VFHCtF y 9a.3?SL S ODIICI SIRIX"'AMI -10 51RUCK AND OWNtR5 NAMEI SI.DAMAGI 5 F SRCW CODING Wf UNIT NO.I UNIT NO.2 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST $' 5 4 rVFV'S NAMt u51 HRSI r AA/r A LL, IvtR SNAMf 1A51 I I ATCN rTT - -CCA ,tI ADDRlss /o / - Qo. SIREF, AOONESs sv F oA, vo 7 f 40. I 7... SIAIE TIP CODE ENO D CITY -TI IIPCODf -1 rvO. c o /njq 4 7S- 3Ps=3294 R _ E,,, w 37 DNrvER '5NCI-- -T1 Sf% 1. m0 aArA r. A R 1 VtR UCFNSE HO. SIAIE SF% DA IF OI BINfN rR p A S' 4X,0 WA F 1 o I V A e- r a ? os ' I 6 -UPAnON vm rvu"Ia RK)N(NO ME -1,EIGHT 38?=ce2j' E NRM «CUVAI ON NPM[e PIgNE NO. 7fr-jjDo [YES Wf GNt HGNI Z - << Nrs. ?•--dt Hq2 -o.P R 0 e ,c Oa W-o T c l •O(R CHECK (?) fASAH IMPiorli EAif AHOTNIRA' ?CHECK (?) ovtlor Armriuuwl w ' 5 Illcr-, CODES 1. urrr °M CODES I? Y- uI r Z A /A31W /? s A/ Av v,i L rAx D--ICNfYI Z ruM - -II(DAR-AI IYl[RDN.CONVI -X z3 D 5 Z ac E -1 AAAI' lFNEVI -1IDAR NOVAI l a. ONV.I Y" 4 '=040 em ' « r. Y st PIATE N c vAlf AI ER RAZE No. cull H vDl.caox A Au nA F n AI l - T4...5 --l fwJA 224 4+4 e!f VI KI! IXNI IIUIrLYN tin I i 7 -7 AB6XC7s?ll02 L vINICIl rUfNI II II rvN I n. 7 E ?. I 9 8 Y 4 IF 8P /C kl RFWSnR[DON1,1R rA51 II451 miDDl[ m' NE NO. O Vy Ft ISIIRtDOWNfa: lKl IIRSf ml.O C. pio06= ?Aco / - of ItOA_ I 2 ORlsS d OwNly A N E A Ill Pa. BL+/. l/78 /'FR,?oACr GJA ri,P zY1r A ifADDl-C,ROU ANCICO WAG,NT QA/w,.tAt /NS:. S,iATTCd R UUN I T' P.3=1 ARIA E' ?r ??on tion AMAGf DAYEA s DQ(N/?r/;OEDn 1 c A I>r rUNMG CIIAV? ? ?AV%iV" YlAwnfD CrIARf.I AWAY ?RfMNr,[D a r I51.DAAUC.t E _ _ IG OO110S lV_ S aA ? -ID Ar s IowIO -AY 8Y E _ _ . u -11 Pn mIN AI cA rl DIAGRAM OF COLLISION i A°ow r¢tl u rvtussARrl I" hr lu IlRtSWRIM(NIAI SNfeHr Htelssu+rl DESCRIPTION OF COLLISION: s I f Cll?t / WAf wes r 6o-a f.?H4N CAC z b CAATF O VO: Cunrut L 4cL.Ly l044 ,4,.,e Hl #+LZA, D4jo'e t 2 Sr•Lor/si SbE Ago Nor Sax, Sf © YN¢Bd LS A LeIt6F /rn¢ /e,bNr aN I'MrG.cRO.t ?? / I?Fr Ac`s r" AAr.0 7NA•EF S,G" (41"[)j AS 1-o/ UTlvoj TWW- ?,rj t 4r. t.d N•?d GAYff/? i"titi4at /N S?(r,-f SAf4pcY i NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES i - 2 3 4 5 6 OCCUPANIS/WITNESSES jIPLa"r wnr?wu.A.ASUFIL ii sa Aa uror sIR fncr ,". ANI 11 , wIU ° °I u,wivr AM e ?<a'" ? •" . ?:Y D .Y1,,. AI Hss NAIUR a w ;?MUYI1 rNCw D AM. ??. '?:? ?.'. ?: '0 u?nlo uluAr ?AMn DF:"I?F".Ir.? 'x DS::o nsulauR.,;urs,.>r.AM s AHP X eAUCI CR rDNO AGn,cr ,r.mr %I Ur,PUOLO j4? n n%rCT ARNIwD /fin own or R,rpl oasA ArrwvFO SY own a ?°'wv3 °A^T r S A? _?? t ti v M 1 POLICE TRAFFIC LOLL NREPORT UnPWAFFICWAY A NUMBER ? PRIVATE WAY 1 A IMf courvrr a IY OR WN AMFtND.Or STREFIO¢NGNWAY 0NW0f 0 N C0=DM Mies (fZs ?w ?oF J210 ON 4 1, IMERSEaING WYTH: SrlifET AD?D //ff NONINI[RS[aION IfBEI% IOST / i /G(/ BFrwFEN SiRfEi ( IDEN i f CROSS SIRffT NURF5I MIE pCLEAGE Lv MrFS N MILEAGE IT OE CODE CIXDSKIN INVOLVED: [R IV. ARU N NO.RIIEFD?NO INJUR[D? ?WIUGF ?H1(RUN wNRR[R1R Cly C9GSSSirfETOR?'VaO , OFVEH?S ® INCOIRTY-AGFONLY ?pfRSUInD ?vf°ciE y??d 'F ( ..CI Sr - INAME OF CBIfa STRUCr -OOwrvER'S NAMn (Sr. pAMAG! copes 44fi Dtf sg0o PAIL - UNIT NO. 1 I UNITNO.2 ? VEHICLE ". ? PEDESTRIAN ? PEDALCYCLIST R' IXJrvf¢'S NNA: USl N VRSNAME: U51?? ' VlMr- Ft ft I+ya..uu?vW W/ct c otta F2 tJ.Pi srREfTAOORE '+: ET omu eZ /?s Bfc ?s - 313ao SrEb2GtUD oa- So maw /W C Ta Siwif 21P CODE CITY - D A E w G(rl i S S O R A2v*,1EIO A4 )ZV ly4-`/kd f % BI H uJ •? 2 NfP54CEN slAl ??. t NNO. 14 601 .tr AM G4 h'I "°A ""/ v eEVAl m GaY? 6 ? ^lp y Ja " ,r p, OCCUTAIION E-1- vES GHI Ef IGM E DCCUYAiION {¢M I. PNDNE Ens IGHT MFIOM .1 -A h ? FpN U /S aY R,' /s??l/ r ti ? CHECK IV) I, : nE OF ANOrHEeI'N ? CHECK (.? Na yEH CEF ASAN FMPIOnf OFANOINER. CODES ? 7 (°.wn 5 I rwN a Yn°r,°s' CODES 7 s T%D " I e ,.a,Y °H r Z N,DRE, k f , .:.DM p NNAANrI ? Nn" ? zs:I. El Ku ? °? ND ?ar.DN p MB I ? ul" ? SM. ? M ? nH. YfAR MA%E IDODGfCHFV.I MODEI IDART NOVAI SrnE1RDP.CDrvv l VI MODEI IDARI? VAI KUI V.I 'I j ?8 C.tw?PbL E 73 G /Y?z ,t/evl/RvLr A uaNV PU c yZ H 363 iJJ/3 srArE F---, nH oR;-J 1D4-1-`-`- L tu? /EE199? nHICIFIDfMINU1gNNO VEII t AI I7 J- Ir x S'2 Pyp Ce- /?JG i Y.3al REGISRREDOWNER: UST FIRS? IDOEf AJ ?. O F IS OOVMFR: LAST FIR51 E W Q'f-E S W 7 ADO "-" N ER u N rN eawo¢eualNSURANU CO wAGE NI R or°iu .n CIATION .F L I DAMAaE A.u DAMAGEOARU a ' S "'•T"?'D'"l eHARG/.V"I CHARGE ,f w[ri sID PfMAINfD esT ?DAMAee I 4 rr ' Id"i°iio: a fr. w«Aee ??MSr ?RfMANED ToweD w:r ? Idiunu'+ e WAY .1 I«k v?...: DIAGRAM OF COLLISION: IUA L INDU1f IN DESCRIPTION OF COLLISION: lus[slwnEMfNUL SMnIF NEC-) A eaSSAaYI BY A- .he driver g1 pulled out of Coyle Dabob rd and Q N headed No on CR tOF Ile stated that his sDirror R9 . was fogged and he did not ree the car coming, 'y Driver ;p1 raid :ac was Pacing; no mn CR18 half` on _ _ _ _ _ _ the roadway half on shoulder when struck. _ („ - Driver /;2 :stated carne and t1uLt nhe sa."I the van but there was a car in the oncoming lane and oh ? had no place to go but to hit the vun. ES NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 3 4 5 6 OCCUPANTS / WITNESSES i°oo '.U' TTEw-VAXli SIX AGF TAYL YI NAw /SF)Q ij/,C/ClJAelQ Prq. ; S7d u TiZ 5. F I ° '' ,y'_:I rmlu T 1' (ayL ?r for` E AMe. ?Y`1Sc' O" . ?C+ ?IU:IS. k+ R° ADwEU HMUREa R wnorROM OAMB p''-.11 ? n' ? w: ?A'",r 1 ? f iR i0 u J NAIUFOr A q' .DEwu N-11 rMe. ?AMB 0,-.`I 0,M;- D..' ?,11- E Y m +.G glefrsNyya.A .. eA AaENC.. - a' Oyy •em° r5JlU 0; .eo nor arw: ArrvoYEDeY DAre S / ?Xf I 3,.YM _? ,?,_ :d',: ' - c" •Iarwd'4 '4k IL Ri lAi t 1 ??1? ? \ qq I ? ? .,Mew , 25 t r f+: `V Y T r u Y6?j""• Y. n • Y T, M ? ^$ I . rka,?ES , 'N o' I"wu 5 KN, ;a .r .s ,w a f„ _._ _., -•sr.;- „,„.,, ??„ g f IM7 _ fYp 3 I VD POLICE TRAFFIC COLLIS E`9N REPORT Q IVU. ! MAFFICWAY . x"' ? ' 1 C V l YOIICE COM NI NUMpfR. - O{ NVATE WAY ? ' " wl W -iouQ, cOUN1T NFYND, ' o x I I ?) l .)Q ...? ?k I?£'E?J`IL? /? /??? ?UR9AN ! aN . S ,' UN cj UIN l CI OR TOWN OOi 4K10Rrl GHWAY fC1Cl5 AM 5 ROUIEON 51 [A]RQRµ IgME6 5[Ctl N ).?MFE??S ?w (p OI CII (?E.IM ON C??VRllli« U' * { N IfRSFC1ING tN51R[EIOR ROAD ONNIfRSfCION (/ / 'P 7D Q ] I x? . F ? PRFfIx FO. MNEYO51 /c, II. rJ IS BFM'EEN SIPFEi 6 IS1ANCf BDR i N MR fERfN CROSS SINff109 NEAREST MIEE 5I 5 ' SiR[EI O.OO / L?'I/l f?J l/ { fl 5. w M E W i ACCIDENT RAMP DIAGRAM W}A 11 E A2 16 " ? OI CO I DE ?(E l i CODE 9 . II Sq N?(O Fp;. SfVFR1tY1 [AGE UNIT RUN pVfl Cal '7 NO KIllfO??NO.IN1U9E0-? ?I _fUMnou[p ) Y fNIEk ClSD R fERI1,Gr ] C9015 [FLOU e L r g RE PROPERTY DAMAGE ONIY ? RFSUl1fD ? VFM'iCIE Op![CISIRUCKfNAMf OI OBI STRUCK ANDOWNFR'S NgMfJ ` (• BT. DAMAGE. SKCIAI CODING USF G 0 / ??? (,Y, / EY '.C-I $ ' ' r '. . UNIT NO. 1. t 5 N [ µsl I UNIT NO Z VEHICLE < ? PEDESTRIAN ? PEDALCYCLIST E? gME: asl R . IR I Cs ? , El _ n 1 ? n r?,u Mr1?ciP1 Z 1 rADD4e s - r? • 1't l l i"l ' ??,, 4 \" ?• SlRifr f55 GI , I ?'t5r- )oS (d1DIR:; A. 'J-wd. I -; A SIAIf 21PCODf PnONE NO. D SlgiF NI L?JIuW, WA 9cr3(>? R IP l.. I/ `\?ICI[ JA TI l G I? `F [ D9nfRSlprvu NC. 51giF - .f r X v .` P" brr. VI M `5 7 K7 N f l CEN F N0. nsl?rY14-V /G3?; AIE Ek DAifOYB RfN 0 OCCUPAi pJ RMNAMEYPNONf NO YFS EIGHT F OHI E OCCUY f ?h? rl o? J s ? j C IrR _ ?JI.'(S[(•.T CHEC [Yi? IFlLV.`-F Id S. No 5`/" g ION f ?M)NAME 6 PNONf NO. [/ 5• N?u[ EYES 13c R (r'?/l1 / G/E/ WEIGHT NEI?i f G?IS 511 f '4 ', ?'?, ;s°G ? K (,I yDf GU as AN rM%ovFF Of ANOmfR.A` CODES?+ ao ' k • . ? CHECK(?) al vfN<fas AN fMPIOYEEO e } ' g ) fANa1NF . J I A i I 5 1 aN j e;° "c'w CODES?+ a (rv n ncl „° [ a s. iMrv' C 5 Ik N e YcIL- n -- [s S5 CI 5 I R I _ ? U UbKF ? EbrirR C) vin Cil ? I'iuiuY WF"ni:' ? Ncr ? kAR OM M OIOOOGf CHEV [A K[ ?<b ??iN ' . . anK / I Fl(DA4I NOVA) 5-111 DR.-CONV.1 ' / ?l I'-lJC -) ) N K ( [V) MODfII ARI"NOVA) 7 UR 1 ra,?. E %7 f1 ML 'n' Y Il7- C U! v.HY.. . ° 1-/ 81c '- i • SE U 51AIf I4Allt4 ftalE NU. SIAIE I'I VOf GIXUR b l N ? , [ Clf IDINi f CAI ON NO , ( C k /??i C 7 3 usA? C v ,CIF Df NE I Al C ppww •r r,Y'IY Y :F f"P??' ,,;. , t5 ' / . I .II 1613)Zljl?l I I ! I E '%i/11O 171C.IZI?i1[/ISIDi?Di 'L EGS RfD UWN'{R µ5I 11 . !i ,1 M % ' I e I I 95I MpDIF Pn NE NO. f SIt RFO WN[R. l 11 D /. ) I ,I 11451 MIDO[E N [/) (. /"?f [/?/'`/12l• W R CJ /?j/•)fJ 'fit .? f F?5 . ? ,? I. f I] DDYISSpOWNlR 1 o R. N4 38s'b!op q . " I r ? ' / , 5 .if1+•tj l1 S 1?•9 w2 N [ v ? E ' y - NAM[YA009f53pIN5U9.WC[CO WAGFNI E nn //?? A 0A /IeI IOnro, / 4>i.J K"" R /"?K!1''N AJAV. &JSC- ?4{Y'/(, L4?sL q9 D 1 p YSaYA 7, AMACI Axu ? ya ...I .Rr [SSARYI.. Y 1 Or ? [ ?9rMA NID [SI. UAMgf,Ff I ?UOOfi G7 l '; 1-i ( 70-1 T II S JJ ??? 1ESCRIP110NOF COLLISION (us[su PUM2N1 l3H[[II NFCISSA4I r;.' ( 1.• I 11 .... C n l I u TIC. [i h 5r ? .{' .L,r p IF, E NZLrcI _' .77 I ? 1 1 9 OCCUP ANTS/WITNESSES Iusr 5°°IntMn,_ srtu k CODES 2 3 4 5 6 ADDU puI HAM'S r,gMl I; / I< ° ' mm' stX. v AG! 1 I i w PF51Y (rlCl M'iiY '" •un9us ? .' nRr Ur . .. , 9rM[I nIR ? M 1 N UAMe. ?rr.x Yr ?o. .n ?:i ?:° a • A N PDYn1 I IOi h1p S ?YE?rK.Mi r•CIYSN yr Y.ANK .ADG[On $IrK [ X I!, I I ?, I, ? ID.IU !•I rTK D MC.xD K' Kf V1D 1 ?` / ) "I(? • ?. ,.... InGmw.?? <."?.?IAIlNR:- -r.,n ..Y, cj-. ? :?' D [p 1 AH4 //'S•, ? ir'rn. 0yED YY lin ? iy' iw Y DAfI I ' POLICE TRAFFIC COLLISION REPORT JAI TRAFFICWAY 1pLR3 COMPWNINI3MBF¢ PRIVATE WAY DAI olcaus oar p ND TU r nmE c (USE )FDB HOUR ourvrr muNrr NO. arv rIIwA Qf ?rv C O OwN STRFf104NGHwgv lF5 QS QW OOF O NAMEeNO. OF CLS RWif OR Sr I IM C GvAlll: 314[JJ[1 O\\q ROAD NON INrERS<CIION \OJ BEIWFFN SIP[Er 6 SlgfEl PRfN% f IIf POST _ M - '//. OCJ REF PtNCF'CROSS StR[ rOR NFARESIM E MnFS 3 E . Fffl I' ACCIDENT MILEAGE D MIA Cgt131ONINVIXVW- vERIIY. III rOtgt NO. NO.%ILLED_ND.INIURED? S411N IX V[HIClES ®. PROw4rY DAMAGE ONLY wSUI SIIX[ Ic. CODE 11i"IwIDIH ?RD C?U 11 51 ¢ 04 HFfNNCE IMfR CIS OSS StRFEl OR ROAD 1?'.w /' /t??va? 'VV ?J 091FCi SIRI%:%INIMf C4091fCT STREIC%AND OwN[q'S-11 FsI. DAMAGE SPEWOODRIG I? S J UNIT NO.1 RIVfPS FNMf: WI Iq r D ?? UNITNO.2 ((EHICLE ?PEDESTRIAN ?PEDALCYCLIST ' F S MI Dl Td ? L'I ,?? Mack p41v[R SNAMF: IASI I I IX M 7-k'w F TR[Fr S llRffr ADDRESS 2ct,Y2r G1 D j tL y67 rid 2.Yi4AJ D . UI 31AIF zipco fN0 •c(y?yyU if C NOrvF NO ?S` 2=Y3u R Vc. 3y63?-.X7av SULFNSE rA F H A I I q' -ENO. IgTF x KF DA fOF eIRIH - SExTaI.M S-N I/V r F v D. mD ?7 v % V E y13 S INf} J'? MD zs sz 'x OCCUPAtION MrvNAfe R,ONF NO. FvES IGNI JiGHT E OCCUPAtIOrv IMF I. PHONE NO. rF3 wFIGHr 141GHr ?TV• Lis y" R ISO JE. 1•.? - CHECK(/) IING O-LRuN -111 A!.N CAI ? CHECK(/) 'CA 'N o O 1 w I ASA-K r AN 1 f E ° T CODES1. D s I m 1 I. 1 CODES S ;; 5III a s )) 2CM ? ?MI ?= ?i ?A ? u ?E Wit . N I- c-, E s l H ' C re KHKFFIIXNIIIIUIgN NO. L VfHCIf IIXNnFI AIN 3 7 FLSal 7gv21 N -)30 ?r3 7s 4 gewsnxooW*IFR: lASr FIRST MIDDLE PHON1 NO. O W s wNEq: LAST nnr MIDaF IND. ADDRFSSOONNfR N A NER JI E NAMERADD¢fua mwRANCE CO a4 AGINI k R I u,w PrvE'es . v dMIr.IDARU ' IMAG(D NU I 1 CNA¢Gf CHARGE _ I ? • DtlOr f DAAVWt tS1. O ADµI?Y e.P[AWNfD ' ® AWAYRIVFN D 01[MNNfD DMIAGF tS1. S Aw S ?Wb ? :°vnD "r er rovrtDeV. S N"' An H DIAL AM OF COLLISION: lu SHFtflF Mtl33ARY1 IN B'Y R?1 0ESCRIP110NOF COLLISION: IVSISUPPIIMINTN Sr4NHrxc[ssARrl .-. O `/ '} ,/ `.?` ?Fe.?? D? LIl4.? W??IW LLKU ?.h ?,p, G?.IZ S>? A ?3 ow1. Sv lcn,rs: a,v? -`-•?Y?a.? c3't rl.n. AIF..ber Flast•I:a.? 1 i?L.? y ?+I yJCLS ct?So ta)osfb,4 a. co .Pr, Iz ..'° Q F- f -tn yet z -..3 rh., , S W Z k r• w ? VOL.C- p K-T"..l L( a sp S k- jodsidgt? a? ?kif 6Ynrku 'I w O .6 UV tl ? .S uLk"A'Yr ry ?otl.? ve?+r?Le s i dM B %?s P - G""" t Y ?? . . s? 0 1HcL d 2 ' J f -(- ? b4 ' / ^ G L. f o a I h, ?? 1 ? C Lfi z ww ICDF n NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED r CODES 1 - Z 9 5 6 r - OCCUPANTS /WITNESSES 'Irk MDVirrNINAiN1 1'SI 9% AU1 IAIVS „^,I" RF SIq fHCr N Aw P . DCWFU urvroF xENf AM Y e CFA"' . 0 Oi tz N A Aw ?? A Ewess uqE ar 4 M%JVlD1¢DM OAMn 0"-.'0;%- ? H O N xwfu "."rl?gl?a 5 (IM nr QAMe p,^, ' ?,n . ?:i ? ,: X al)I GIIM.u FKf.31?W IP n' Mw ^ ?1O HFNI JI??wD W S O 'Irl>V rtwf I yr_0/, APP40 ner DAn Ili Ek.4 a7 ' a ? { .l1L 5.. '7*?? W_ Q-" W." _ ?Y?•plT SUPPLEMEf 1RY POLICE TRAFFIFCOLLISI Q REPORT PAGE OF IDENTIFICATIM21W tMIGU r01k? , NO. SEVERITY OF COLLISION ? FATALITY QQINJUR ? PROPERTY DAMAGE ONLY osSi DATE OF MO. DAY YR _ COUNTY CITY STREET, ROAD NUMLRR OR NAME COLLISION LOCADON ! I /'3 co 1 l I a BGY? ?? ??pA, I?. NAME NAIME - \ NAME DRIVERS a 'y10.r? vs v4.L+.1 EC.1CV d vs >; 4ES.CRJL'TIOi9r:C, _r7..' (USE FOR ADDITIONAL INFOR, T*N WHEN SPACE IS NOT ADEOUATE ON ORIGINAL REPORT OR AS A SUPPLEMENTARY INFORMATION SHEET TO CORRECT DRIVER'S NAME, OCCUPANTT LOCATION OR ANY DATA NOT KNOWN AT THE TIME THE ORIGINAL REPORT WAS COMPLETED.) The driver of veh..# 1 stated she did not see Yeh. #.2 until about 100E before hitting it. She repeatedly said everything seemed so dark. Driver # 1 had the slight smell of wine-.but passed -a field sobriety test. Her pupils were constricted which could account for everything seeming .so dark. Driver # 1 appeared under the influence of something, but could have been suffering shock from the accident. Her reasoning was poor but her coordination was good. .I have had previous contact with Driver # 1 and she *as always articulate and able to converse at a high level of understanding. On the occasion of this collision she was unable to complete sentences without looseing her train of thought and,-I had -to repeat--each thing. .L..eairf._to_her--several- times. - T 1q?RIHER/PEDESTRIAN NAME - ENFO,Rr: F,.6oeRWY' HAD ""N omgoFee (aaa2 p '' yy„ p .n,;. W?ywAKn? 6it.:,Arun?::'.: %p ANIIY ,- .. .'.71'Ll.c.._.. ... ?:,..LFt».f:.•...,I:"` .,,... «,..,.. M@6 rum. ?flliOE.lIEA?m ? ?. [ ? q ? DRAW pIAGRAM OF COLLISION SCENE IN REASONABLE PROPORTIONS, PRC44RIY IIXN1T KIIKIES AND I/KsI1WAYS. SNOW SKID MARKS AND OTNFR MEASUREMENTS. I -c y CAN .., _ .?._..r--.r-- .._?-.,......,._._. FI+a?. y Pf lw h?ltr ?. t:1?w7t'1t fF,? flP??;Ty RcAI Iv} iv. /ae. TSP• ?kwPFa INYISIGAIING pIK14'S NAMI ANDRANK AAOGI NO. .A[1N[Y 'APPROWII DY DAIf O1 NPYlll1 DI, w, AIO 1 TI.bT ORIGINAL [jTRAFFICWAY POLICE TRAFFIC COLLISION REPORT • .• IqI CECOMPU NTNUMBEP PRIVATE WAY 'S / / / DATl OiCOE 51 N„ Y CO $ _ .3 Rlx I I,,RIR I - I v. Iul f rIME IUSF 1KBp HOUR COUNtY E .SO:J COUNtY NsI. CItY NO. EMWA / ?U?eAN RAE CYORIOWN N FaNO.OFSIPFFTQR UHWAY ?N ?E D?IN MISS ?5 ?w ?Ol oN Cr,'r8" NOT CLS FRUIX ROUTE OR SIRE 0 SECTION c 93zsa INIfNS(CI NG rH, 519EfTOR ROAD ONINIERS[CI ON CNi /.SF GI/ff?R T-N FTVFF StRFn 6 SIREFi ' PRETI% EO. IT POSr en, DISIANCta I 190M REFERtN ROSS SIREEt RNEARESt MILE POSt ACCIDENT MILES S MILEAGE R DIAG9AM MIA FF[i ? ? ? t P't CODE COIIISION INVIXV0. EVER. NO. IIII[D?NO.INIURED_ ?SPII GF ?HIIe RUN lo., NO. LT''?? ~•A INr+oelorx N / IM i9 %.RD CLS R TIN STREET OR ROAD OR REFFR[NCE (ROSS STREET OR ROAD - T - nlCl[S 16„1 PRORRTY DAMAGE ONLY ? YFSVl1fD ?S1111I E 1 y 9 ODIICr SIUUCK INAMfOi OB+ECI STRUCK PND OWNER'S NAMfI 51.UwMAGI SPECIAL CODING USE S UNIT NO. 1 u nN'sN ME: AST l UNIT N0" ? VEHICLE [I PEDESTRIAN ? PEDALCYCLIST 9 "-l MID I D-IR SN E: UST IRS, ,I ??? W? e 5 k ltl AUD 1. t III_ ADDRESS GSTiLs STATE ZIPCODE P110N O o Gr//J O D R SLgTF ZIP OD PHONE NO. T 3 6 Z 41VIU'5 UCEN5FN0. STATE DATE i0 IN R,Y R 5 / I D VE IN'S II E- NO. STATE 5 % DAIEOFBIRIH X73 r0 Gil9 I? Q3 173 UCCUPAIION IIRM NAMFe PHONE NO. ETES IGNI HfIGHi E OCCUPATION FIRM NAMFB P;IgNF NO. ETES WEIGHT tEIGHi Z a R /JS ? CHECK (.1) vTHC '.IT ovEf of ANOTHfR:^E ?CHECK(?) FMRIVNf AFANOrHE- A A v 7 CODES ? 7 a i 5 I a ^I',° " CODES 0. a :. 5 N a Iu _ }i A ? h n :; x .pM ? -A- ? uI ? 8.1e ? w„ ,I ? W- v DM ?,.A,IIIANCI ? l uyKE ? 8.1,Ile ? G, K,'I ? P of H.TLAR MAlEODlI CHEV.) NgptlIDA9TNOVw1 STYIf IRDR.CONV) ' E HYEAR I E . nfV.) MOpFIIDARr NOVA) STYLE 13 DR. V.1 I. IXW IC[O IA PTEN STATE d iRNIER RArf NO. SrwlE H R N 07ULlQ VfH.' b?. AI N '7 a0 C 13 VlHKlf lpf NlliICATION Np. ? ."-o /;7 .l. 71 L EI If.IE IDFNIIFt N /' 21 EI0,90i IAm01 /19'l I I -I---N- IAST {1451 MlOplf PrNUNINO. J O W FIRST MIDOIE, NE NO. ISr[I?OWNER?:-y? USI I]._ 2 ADDNISS I-IR eN A POWNF9 ?-- sr /aN nc7`/l?Lt/?/? AMea wopx[asa lNSUeANCE w. OR? Ar T R µ ?Sily r, q?,-W?TpI - TTM A l0 A4U Tun " ' wo ° ? • •. n uI DAYAGI DAMAG[D AREA to ?a o.onbT: s ' , ! >I ° G: u1.luMwee C1ANG[ ?wevN ? REAwNm IDW[D cN-I ,°141vLN REMAMfU m "Y C] ?'w w sT,oAMACE r L_?°____7 DT _ C ? eY ? w $ ' A DIAGRAM OF COLLISION: SIA D MNAt IN-11--, .. .. NE !N[C[SSgRYI bT AOovOw? DESCRIPTION OF COLLISION: IusESUPREMwr^LSHE[TIFNECESSARYI Ucl -?o` / /jl9D? eFT Tued :Is A ?-O y! j ..../ Sim uG? oid ,DiP/(JL?2 '?' 2 ST9Te? /31e D r4 tXJ?' E ? SEC Q GsFT 7T/k'N Si©N?C? NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED t CODES I - Z 9 4 5 6 OCCUPANTS/ WITNESSES }uc''.EI :DU?I'wM.tiNl A111 St. ACE srAlus _ '„"," ,;;w ?:? 91514. ena MITI, nbE,S <vf r.f/i.? :rr---`-- ..?I•a x, ? A e ? : ?•? . ? „;T ? r_ , ntau5 r uugta we VIVO YEOIecvA ?AMe. ?F°I4.1 ? o . ? D ? YJ ,wis5 ryNlmt or = isu ?AVe ?'ET ' ?«.. U:I ? o T _ 1 N .? I 'Fr?!kytA'f?f•``-:a'ars(i ` - .' '.m't,1ef`" v rm^ta: ?r'Ixie, '1+dI'vFdAT. ?k'kdrrd?t t ?°?"t N: ?V7( ti? Yti E E VL, ? ) /i z t I Ir 'L ', 'N r t ?) t I H dk'?. I L at I'dt 7 1 I ?F 1HR 41r4 P 1 5 ( rl r tp f! i I t I !) y. ? LE y t L ?l: I? l °i I) n yy I ? ,I l r_, I T I `?r 9l`V v,- r4h1 P. rJ 4? 1 .T 1 F fyTi 3P' I I• 1 t _ ( i R~ ?r ) 'x r` r? ? . » R f? . ?F k ik°9 f"r.> F dT` ?ffl-:l A_ ..7.f?.l'Ki .A SY'1Y$?e.tl.': ?'.. TSS+'S'I rv+'Jpib r • .,rl f r-. l L v w v r93 Y V %,y J 'i,.b Y V ,".?.r ?E 1VU' f;t ' • 2 POLICE TRAFFIC COLLI I N REPORT 7RAfFICWAY ® FlOK CO NiNUMfR q " v DgIE O{< I PRIVATE WAY 91 l . ?,} II P Il Ho I D r rv vJ I lult wlo Ifl yl , tMF IUSF TROD HOUR) COUNTY COUNTY NO, CITY NO. fIIWA 1 Hl n 2 I I l I i , LJN E] E (:]IN CIYOR TOWN NAME6N0.pSikt[1O41RGHwAY 3 100115 MS ?W DOF H dl ?(o 2 iCICfS AM I ROUTE O45fk ? nluue.w U"1 ^URN' 19 A 1G , ' a ock ON CR INI[RSFp ING VAIHtOR gOgO NON I IL 18 3 o?,?y ?` ' i [ N RSECIION M YR[fl% f0 MIIf POST ? , ' orris Ave, tlFiWFfN ?!g DF 1? IS S,RFFI a StNtEI 1 0 CF 60R[ IOS iPO EEfafNyE.CPO W5531REF10N NfANFSIMIIEP031 ACCIDENT RAMP D G.-MIA - S f {[F1 Of MCODE E - L' ' COIIISION INVIXVfD. SEVFRUYr - ?t IOIALNl[S O. 0KILIED-NO NJURfD_ ?SV IIAGF ?NI RIIN M"SH D TIN Sla FiOq ROAD RRE{gfNGE 6" ' CF V[H C ? INTER CIS CROSS BIRffIOR ROAp PPOPFRIY ONLY ? enuntD ?YIIII li 'mm4mm S2®lo0 4 OB,E I ST CRUCK INAMf Oi OBJ11I kCI STRUCK ANO.WN1.OWNfq'S NAMF ? '. I11•"; E aS ,O 1 ESI ONAAGf SRCIAI COO NG USF -' iiPi'JJUUu ' n 5'1 DNIY•p'S NAMr ust UNIT NO.1 51 ID Da vNIT NO. ? VEHICLE ? PEDESTRIAN • ? PEDALCYCLIST f n 8 BARKER Sherman W Klatt wsi Robert E r slx[Elnopw[ss '- -y' , u ADDwtu - i'q. ',? r 2 Rt 1 Box 96 P OB 6 jf '? IY SIAIE COp ON NO. D S[AF 1 Port Pown E send ?n 98368 85 1331 R IQuilcene Wn) 98368 DE 85 3831 nt ' 2 UgrvlN'SI Cf NSfN SIAIF F% A OI N vY ,,. O I V N fNSf NO. AiE FK DAR OfO RIN •?' . .` 617D9 Wn M 3M 29 139 v 517KC. Wn m 5- 13 4g E q OCCUPATION i RM NAMEAPNONf NO. [YES WF GNl H[IGNI E IXCUVgI ON E 6 1-1 NO. FYES WE GNt HIGHi 1 w d , "` b 2 L bord Sam Lund 8 401 Gr 1 6 B 0 DeputflgJCSO 385 3831 lu 19 6 k ? CHECK (.? vEHI<iEASAN tMRVOVFr of A.O_,A' f0. CHECK(?) AL ;.`r,'qi ?` CODE$?+ D EASAN fMROVEf ANOi"fe. 6 's"q° CODES ? + 7 n d °s: p 5 [n O Mo ' I ?j aE??rA-k?'? ? Y2 N, `G ES .?' :,? GIDH ?oK.gll one s?yN,Dt ,?C:," N l?n.<t ? f HKr o JR 21: ? w u N:aRCrw v.. uRDM MOIDDDGLCHEV.?M DF0ARr. ?"' Nllafs pYMNAANGF ?.uDy<l 5 ?? ?G?.2.F ?1"r°.n.. i I NOVA) SIYIF (TDN: CONV.I EARYUM (--C 7) MODEI[O-NOVA) YL IT Gx4VI .? 169DN Mercur Marquis 4Dr SW E 79 Ford LTD IF Dr Sedan ICENSf P1AfF NO. SiAif IRA TER RAtE NO SIAIE H y V tH.Cp R WHITE IIU 691 Wn 1 Green C35876 Wn N AIE VpuCIF fN11fICAlIpN NO. C NI CLF IDFNrF All N j 699' I I 1 1 I i l a g9 H:21 If IH111 141 11 716151 1 1 1 13 RtG SRREOOWN[R: U51 NRSI MDOtf PNDNE NO. O (G SIfNtD OWNIR: lAST FIRST MIDIXF N NO. rq _;w DBarker Bertha mni W Jefferson County Sheriff 85 3831 same N E Court HouseS Pbrt Townsend! Wn 9836 , F NAMEeADOaessG{ NsuRnNUCO oRAGLNI ! "2 None R IN u AN L A DK 4 " fuAMAGiD MIU ?<IO;. ' ..' r ? $. J a ' CMARGf ?fqm rl0 ?ASLWmAA „ JLL i IJ.A/.S ?E y?'[T ?wX: f f[ one D' ' il,G- S yy? RtMNNfD ['1 AWA N LSt pAMgOE LLLLLL 'X? ?NfMMNfD sl0 0 ?.°WfoUY G D X99.0 ?ISao aw _ -.1 By 4 ? A DIAGRAM OF COLLISION ,u I Nfcfsu vl wN NDoMxDI DESCRIPTIONOf COllI51ON: IUSFSUPPl MfN1AI SN[Ff I1 N[CF9 I a - {?- '?y Vehicle #1 was south hn CR#18_arid slow ri applied the right turn signal-and turned into the ri ht read of vehicle /f2 .._ „ A ho was passing #ehiele #i R. ? D N NAME, ADD f ?FY R SS INJURIES OF PERSONS INVOWED + CODES 1 h 4, OCCUPANTS/WITNESSES IUSE fUVRl M1HIAl LRI, - 2 9 4 5 6 'k F IGR wn•1 L.ul NAMESI sfK AGL slgrus "„"" s R[srR efer ""Bertha nmi Barker ;p s ?) , ti ArbYnA ??+_ NAwal or - 1 5. .s.I .'?Y?+cav :rl .., ?AMO. O'c'J.'YI' Q2,". C1 H ?ri3ns/i 1 ? 'I. .r G.{ .,r I{ •• nir rte 1MOVIDIRIiM- ?rurcl ?r±I?lv ?.?iS' ?rantiEr wvESlgAtwG OOgrS w-Mftw?E SIp rADG00R vGfNCr w.n Rr ?AMe X •aKI DDPArnlto R%KI ANR Vm DAIfa REroRl FwnfwovfD Sr Dqn _K _ (damn. T--,+ AAO 1-1 i11n 111A 1 ,o 0 w' N 4 s }fit ?s f .2 1 ' i K N y W I; M NO O. a NC "Or. P? N O 01 O Q I ?;a. Y? 4 0 ??RRff '41 i ??!S POLICE TRAFFIC COLLISION REPORT L'EITRAFFICWAY 1'O IICFCOMPIAININUMBE0. PRIVATE WAY DA'To N ub l "ME 11111 E>p N IS,Ri IM, (USE -HOUN) n , J ? ! )I i ' % f COUNTY NO, CITY NO. ?UEBAN ? . [. C /C / .?+.•Ef ,.?r_5•f.rl ?q ?EF 9iJ'E JNAL ?N ?E pIN I CTYGR TOWN •..H NPMEC??i?FTOR H'G?HW Y l s w ?? L PP ECT IS R TE ON STREE E ION ? M us OF d.E,•• ON - .--ri?I INIERSECTINGWITH: STRffTO RO T CTI.N G ? ? l •?' SEMEN ? STREET d SiRfFi PRE{IR E MIlF FOSI: --?,r?j• % • 7 / ? ? O Y J 1 .1 IAN DIRE 1 CRO SlPffi S NN1111I III, ACCIDENT N S E W i .,A RNA MtA Of MILEAGE 7 /.• FEET C' CIX1I510N 1NVIXVED: SfVFRIIY+ 11 N lot. NO. O. NIIIfO-_Np,IN1UR[0 ? SPILLAGE ? li6 --- Of VEHICLES " ' 1 -RO I R 11 RfE OR ROAD ON REFERENCE ,ter ER Cm CROS 55rRFE20R ROAD •. J.? JT N p PROPERTY"""'ONLY ? . 111F. ? VFHCIE ., ER r/ OBIfCi5TRUCK(NAMEOf OBJECT STRUCKANDOWNfR'S NNAF) ESt DAMAGE SPECIAL. COD NO LGE E S . UNIT NO. I DR fR'S LAST UNIT NO.2 NAME: i RS ? VEHICLE ? PEDESTRIAN ? PED AL CYCLIST f C / T f DR WE R'S NAME: /n/ USI it V.01-TRESS Rffi ADDRESS 1 STATE D • i ? 21P CODE PHONE NO. %le:'[.,ti 3F.3v `J'"/ N R Ty iAt N / )?`? •? C• .= R ER'SICtNSENO STATE Ua'A/ V/fL• 5' f? -41, % /T1 OFBIRTH /i zA .Y? I V _ • I ' I NSE NO. ('q i7Ti1 /Am f4/ { • rATE f /R , FA • vyS DA elR E m 7' I'4r B OCCUPAT iRM NANF 6PigNE NO EYES GHT HEIGHT 'I?N .• C . E OCCUPAI ON {RM NAME6 PHONE NO. frfS WE,GHi HE- •C i I i '•.:,:. urirys It IT/, 7&-4,',, R ? CHECK (?J vfNICIFA :N rMHV1vf of ANmHEi * ? CHECK (v') I yFN CIf AS AN EMPLOYEE OfANOTHER, l , V•% CODES ? xrcu D d A i nM 1 (i 5 N oN / e Ass :s H - in: caw ?o.xcrcD CODES 0. T 3 n A ?: '"T U 5 Tn N/ a SA - n mlo; .. 1 ' Ill ,?C ! w, F NIe. VEH YE R ? wr ? u 1 w : .YA33 ? ra ? Ra31R : K'?or.DM p Me KL ? usRE ? Cs nR '1. ?rZI. A/ A /°i •7 / E (DODGE{HfV 1 F+a? f 1ID T-A) SirlE IJ pR. CONV.) ?/c ?' c?Y E „ T H V.1 A% 1.3 D/:?; . MODfI (DART-NOVA) 111111ID1,CON'.) hid Gf` f Sz?l; °A?'I r?'e .J. N I STATE 10.AlltN NO STATE I'I vF A 10 I fl I• / I .l•?/l V[HCSE IOE iFICA}aN lq :e ? Y'"i7 J "I;'I, I i l C L , E f 0 1 1 I N I j 3 ?ISIl?Ii/Ill: ibl'!I I 31:11 IS [GISj[R[DO ! Wi rIRSi MIDDLE PHONE NO. 3E^.S•3-4Sfr ADDPfSSp OWNtR / W [DOWNER lkI FRSi MIpIX[ ..?:>,.,• .,fE.., . /" M N HE ?I NAM eA--o" _IC. _ IHl E . _ 4P wvnmro Anu Dn•a1Na "'A •_,. n to R Rm "'N RAN (I .. : E no. CHAR" cHAece o r '? ` 10?0ITOii R ISL. pAMAG! 'r• ?^R`vI AEY ?0.[MAINFD RIVEN • E? AWAY ?RGIAIN[D AMALL {3 DANA! etof fi, , A AowED •, AWAY 10 DIAGRAM OF COLLISION: I INDI rE N09T SWCr rN{CESSARYI sr ARROW DESCRIPTION OF COLLISION (use stwPUME rAl3HFEi If NtClSSARY ) CL. r I :./?°CJI SI Ila, ,• /h •- H 1 Ir T .. ( 1 ? r IrL 1 I I .._E? - . r 2 , ? 1e l.1 r it ?" 1 it •fS e? ?r -? •' ,:C?l ,e • NAME, -0' RE55 8 INJURIES OF PERSONS I NVOLVED * CODES 1 Z 3 4 5 6 nE OCCUPANTS / WITNESSES rv« ? - N p NAME Aw S 3[R AGE 1Arus ';,?" ° ";• RFStu. um No A ro.EU H AruR or vrrner AM e ?Rl I ? ",_ 0 pX ?TaL,3P Ra N OT .. _ A N ppellf N AME AIUR d R MOVlO I-CM py,R. ?-1 p "r, ? ??' pain p / . . eoeff .. illsf .. rM IhOp KLRf HVN 1uN Twn: ?AMe ?P.:`E?i".4]?ty ?r"O..',m '?I R epA{ a NCY a;±, al KI D11fA!gt[NDP IOI rr?„YS;f«?- f -:".. " `?• .. :lr ..nrsr-, '?sw?'„ -tr.-_. Ke eET;D D tla MIT-! PM-OND.I wTF 3n'tEkIL:..F.. ?iu1'i?E.Iu''if `. u ?'? 1.0 T .A .I WW I POLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY WUCf COMPwNINLRMSER ? PRIVATE WAY DALE i CSU N Ol Y DAY el L p VCR.. DIS. . S.1 Kf IUSF }%pOHOUR) fAUNfY yyyyyyOOOOOO %_, cI1YN0. FNWA SUSAN ?N of CI,, ??:'JYORtOWN NNAF6N0 Oi SIREftOR NGHWAY MLES ®S 0- 12OF }I, ?,l,lnlllL! ION tom- i'i CT US, 3 ROUIEOR SIRE CION 3 y,?i o NIFRSFCtING VA1H51RFftOR q//pAp NONINIFR}ECI IXJ '•?!•? } / f ` PREn% f MI{E pOSt + BFM1VEEN STREETS STREET DI IANCF DRE t {RO R / H NfARfSt Rf ,CRO STREET R MILE ACCIDENT MgfS N E W MILEAGE RAMP DAGRAM DATA . ?r F[FT OF CODE CDllI3pNINYDIrfD E MUSN IOIAI Np NO KIII[D + NO.INIURFO? ?SPIUAGF HI IuvDHDIH .- c- m ,?'pRppEa DAMAGE ONIr ?FIRE Ltfp ?V[ICIE K I cROS551REDOR ROApR ?`???ffRENCf INTER CISD ? ?? /O S ,? µ DB CT SIRIICK (NpwE OF OBI[CT STRUCK pOWNfRSNNAE r, I fSi.OPMAGF r $PECIN [Op NG USf S UNITNO. 1 UNIT N0.2 DRWFR'S NAME: ?SI FIR31 Q VEHICLE ? PEDESTRIAN-? PEDALCYCLIST - _ M E l.l,tl?;I? `( I ) (,U11_I_I•f'iG"t•1 DRIVER'S NAME: UST IX R j STREET wDDR 17, - p ir STg t f D Et ADDRf 5 ?' ? . ZIPCODUF R;1 PHONE NO. { 1 / 11 I I-1.? l.?}.I?l 11 :P 1. /ly,•LI lT • R IIY ATE IP P 'L VFq'SU EN N SA 'I I N N A X A AG DAY I ; Yq. •? q i OCCUPAt10N iRM NAME HO ENO EYES GHI HE GHT E OCCVPANDN FIRM NAMES -NE NO ?'? ? •'-I. 1_` G?71.hh;, .i 111?1??? ?1?.(=13, •,t( (/??l R . EYES IGNI HF GMi ? CHECK (?) 'Sa ci[.s AN rAworif-N ? CHECK ( l I V OT CODES ?' D _AA' IL?I?H a ( A i '"' 1 5 e ,NO, __ "W v ) fH CIFwS AN fMgOYff OFANOIHEY? S• + CODES Iq,N Hr.?ll H • iv 5 LR g1DM `' T> G IN gID3 r?F•-..•,; , I? :. ,DM • ? ? CH EAR ' u KE ? r ? C3 el. !15 x ? AM - o MIA ? MITI. ? to 2' ? "'Al- , to I Y 1E11? ("(f IDODGH[V.) -7 (.A'7 V n q l lA C fl (DARI.NOVAI SR •) tTIEI DR.- -1) ?? (??,?i}f ' .JI\ SIAlF TRA EER Mif NO. STAI E H n Y R 1nEV.I MOIXI(DMI. VA) Y ( V,) VFH R qOM roxa I A iQ 1 !? }- C' i.L` 1 I C r? t Cl[IIXN C ON NO. ~' ? "? I Gl r? I I 1 I D VFIIICLE IOENIi AI I ? I r L' tGISRRFDOWNER WI {R5l -1 P{K)NE NO. t,L(,I)I? i 1`111 LF W [ WNER: LAST FIRST MIDDLE H N. IS AppRF3Sp OANtq OWN P NAME a ADDRtss ar mwRANtt co oR Act r . rv I ••- OAMAG l AREA d•h iO D • S . r i q FNAIGe3 ARU plop argow: c.-. 14-7 L• 7 Y 7CHARD[ CnO , rxif DMp E. 17 tS rO?OTfO? 3ISL. pAMAG1 ?^RSVI^Ir RR[MMNED. R 10P E 1 A_ DRIVEN R!AWNED E?I'• IG 00lIOM 3 TOW AWAY f ? ID AY er AWAY AWAY wwr er S •- lA DIAGRAM OF COLLISION I 33AY1 I •_ e'pR'H DESCRIPTION OF COLLISION: USt $Dp%EMFNIA3 [II IF fCt35 9r1 SIIE[t UNEtt ? i1 l ,? ' g t 11 SC ?,1 t, r I ! AT 6040N / ` ? ` 1 { n Lit 1 ?+ -' {`??:C'? ?'^UR 3 r?_•'E T -?', ,1. •,.? E r ? " ? •" I '•- ,5 I ?•} Ji E 110. f C. . 6hE a 'T1(:L:C•?: ? • v .. .. .. •.. °?r., 'r I ?J 1..I,. jJa 1. /v rL, _F- ? r 11 . ' ? 7 P ^.1? 11- ?K F cC."E- Ir(FE/? A/ J/AI /) r'L•"Gl { ' ? . u Y 4??• ;, . ? r L ?,. (,L . ..? / ,c„ Dili/Y?/? El?. _ , i '(( ';4 1 ti NAMML, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES I - 2 9 4 5 6- E UPANTS/WITNESSES is Awi'lEllvul'r?iAe uii SEX A6( uWi 'gW".U - W1- 81519. UIO ?'ct I f ?o 1 11, MCA Ne - ? ?NIT FNQM d .. ... - ?, 5 ID IgON ? AMs, ? rgR.l U"II 11 C7. ? li p . / Dpgf1 MAri?a HA E r ? AMA ? c ?o:n. ? Jx ? NO.I,v :? "t,.: , lfll.,: .)s.; r'gx?rl??.tr ,vw[#r?»fld t?E•Y-?';k`>;j, ?., .w, r..,.f. ?, r,t??nM ? , ?.µ`.. ,v ,lq+ }'F':..,? ?t, fv?? A LA tis -2 d, xc . ) 9h h I , A ?. aa i3 # a? ?'I i$ I M a ?{ I` 1 IYU. POLICE TRAFFIC COLLI L.IN REPORT ? TRAFFICWAV iVUCF COmauwl NUmaFR - PRIVATE WAY - - I DAEOEOm N 1 _. 2 5 18 - A. ? oRI1RI( ,L ,HI„+,?I r;"1 nmF IUSE 1.ro NOUP OS'3? couNTr r?GG?°d? Enu? nrcNO - 7? - ?`?'? fnwA. ?U A / DIIY OP tOWN AMEeNO.OFSTREETOR HIGH- pN pF IN N MIl[s Os w pof C ON TCIS . OH SI P[L M Q5 SLCT N INIFRSECtING W11H: 51 LOP D G N?55/ NON IppNi[RSECIION N/L/.pGL/.G/ O BfTVEEN /Ce.&wQG• 57RFET & - SiPFFi FR- EO. MI 9Sr /& l,2 / D151 CE dDIRECtIONifOM RfifREN F. CROSS SIaEET OR NEAPE5I MILE Si MILES N 5 [ W I[EI Of ACCIDENT MILEAGE CODE RAMP DIAGRAM DATA COLLISONNVIXVED: EVERIIYI F TOTAL NO. NO. KIIII NO. INJURED- ?CPIIIAG ?Nid RUN L13N {uNpvtplH IMFR o CL3. 'D 1 3dO OSSSIR[ETO RQ(D "N' - - CIfVENIClfS ® DROPERTYDAmAGE ONLY ?F'ESULIFD ?VfN°%ICIE ; ,'/ r. ? DBJfGi SIRUCKINMAf Of OSJ[Ct SIRUCKANDOWNER'S NAMfI fST.DAMAGE SFfGIM CODING USE / $ " - UNIT NO.I UNIT NO.2 ? VEHICLE -? PEDESTRIAN. 0 PEDALCYCLIST DNIV P'S E: LAST VDIXE AIVfP SNAMf: SI -IiFST G.- ? 6 G G w• SIR, ft,A(/Dp/?PE55 ]n'' Ate' v? SiRFEt PDDRf55 n/, ?'^/ / i ?, S /Vh y .I Y?C ? E CITY 5 E ? TIP CUDf PNONE NO. D STAGE ZIPCODE PHONEN ' I s?v s R toes 36 s-pia a 2 9IVfR'S IICNfNO. SIAIE F% N s °" 3 I V ICENSF N RIO. ATE srr w v Q1A % M DAtE Of BIRTH ?° li7 R _Cu- aM NAMfdFHONE NO. f EYES WEI GHL HEIGHT E U iION fl F S PHONE EYES NE LL: 2 N/ O R " ?? C' ?? °0 0 CHECK (? VfH Cif AS A.-0YEFO A o1HFV AL ? CHECK (?) DH rfF Ep" -ICLE A A ? Y CODES ?* D % '( S t a 's",° CODES III- t D a 4S 5 (nrnoN / e s n t LNIf3 y;f,Dm ? m. LAH o uw([ ? eNt. 2„ ? 1".11 v M. 1.0. ? -iAAAN(t 11 MCI ? Ic R: ? m. . CU V[H YEAR MAIL IUODGfECHfV.I ??? S1YLf (1DN?CONV) MOCEIIDAa[T?YNOVM ,- ? ? 1 -CHVj ? ? n NODFIIoARJvI'OVAI /f/? Y I DR V.) VEHLIGAGR UfrvSEFLA StAlf NAI(tRMIf N0. 5 FI EH. O N J ,J t3 R z GriA9 - - C ?? a/s/ C - - y? VE"ICIf D{Ntl.c. 11 NO. 131317-'143131 /1S161S I; L F VFHICIF DfNt fl A 1 ?I?/161/I a1?1?17 I ..I I I j, RLGISIFR{D,,OrrWirN-[a: IASi fIRSf MIDDY I1141"1, ?/ ?? '? N ISIERtO WN[R: 1A51 {IRSI MDDIF N N . l F- R ?? O . ?? ADDal550F p Wl,fa N ADORESS Of OWNE E .AM[d DDR(53dINSUR O. QAGFNt ,k: Z R .-I. A-ES1 Of AN - 1,,Sr 277P '71 DAASAGt NIA E N Cib " V" Nn ?. owt OO `u gAMAGFO AREA ( t IDI I y C r .p oI .R . 151. DAWAGt CHARGE ? ^Wi ^tVF alAWNtD CHARGE 1? yY AwAY ?RfMA1NF0 t f51,DM1AGE i°I I I ._ LO eonoH .- S/V OD IOmDSY, / _ AWAY AWAY ?AWAY BY- S ?,I^ - N DIAGRAM OF COLLISION: L INDI AI ORIH CE $SARYI YA R HIJTIF 1 DESCRIPTION OF COLLISION. 1115E Lxa[FUNtu sHllnFN¢fs3ARr NI I lV I ? , ) ? .. I 1 ° -? "1 r ? I i/E? ,tl /? ,yy GGa.C?l7 /r?G- 71J __Tit'//6'7? f - - I ? i ? S G T r > ? , \ ' 2 /.•JNSsr aA L cY CU. ? S ! fJ. rf`G. _. ?h " e >H6 i ib J r ?/ I> uv ._._,. I/ .? #? I r ,R L(LIC/ ? cam. ?w c cb aTu- Cer (J?h` y 2 6. 7excd 7-41; IWMXSacea(>' ' ` ,. i ? /nJ /iof?Y of !JG w/. UCy.A`/.//!I ? w I ? I ? , 3 STo n ? L motif > /r/ . F.ruw7` . ? F ,(l°eiuexJ' --- 4 . 0 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED + CODES 1 2 9 A 5 6 OCCUPANTS / WITNESSES 'I's Rfm"AL" TOR AGDIIIDN. NAAV TT 51 -- 3t% A& IF --- a a:r :a; of Sia. 1110 L NAmL NU.B f2Kd? ?°'?/CG- .? NG - ii 3 ' . .na1ss -I V/7 fi/ AlJt7?itL/ nAllpaor w1nY ?AMdpKRIR''p"",.Ups 011.7Nr NAm1Cv?/v.r Te,er.9evJ e, r? Nom?- 7s!y - - - - u ADDIISS ?p HMUR OI R MOVIO IRON ?AMT, 0L." ?c ./Q p ? .De.YSS n W r4 ID/: YCt E uN o. x / ni%nw11?s°? wLNC Ss K1DS?C f J ANS. ?E.."0M{ .021a?'D'0 s?tAa 0 -f III A na IIIH An{mDR DAn .. .l?,i ?GL ;??i•? Ii.-tr?6::. Po. .. P .rl 3 i1 1? i D ? } ? "! 6 r i POLICE TRAFFIC COLLISION REPORT LJ'TRAFFICWAV IroucfcomPUINiFIUmBER Iie L J ? PRIVATE WAY . AT ECOl11 LI I.N' TIMf COUNTY DA rR Wx ±Mw IA P[ IA. FUSEa WHOUR] COUNTYNO. CITYNO. iHWA 'i ? r l + I 1'7 0 TO - 'Son/ ??/? ?UP$$- DA ?N ?E ? N CITYORIOWN NAMES NO STRt?i O??GNGW'AY CL5 AEMC, ROUIf R f Sf ION ANTES Rs ?w of ON 2 NlfNSsSsa NG VAIH SIAfE?OR NONINTERSECIION swvn3 .°?° pRF11% EO. MITE Si ? 1 BETWEEN STREET 6 STREET DISIANCfe of 1 iROM ifRF ,CROSS StgfEt gNURFSi MILE POI ACCIDENT M tF3 N 5 ' DIAGRAM RAMP MTA MILEAGE D FEi Of N SL CT D I / CODE ' COLH TOTAL VIXV[D: fR tYI mLLSH TOTTAL NO N?AO/ KILIfD??NO INjUREO_ ?SPIIUGF IT- U ,NnOR(RM ? OfVFHICI[S "? rAPwKRIY OgAGf ONLY %.q0 CTIN f gNOgp09 Rf ERE INTER CLS CROSSSiRFETOR.- laa ? pFSULTEO V[?iCIE OB t : 6 W J CT STRUCK INAMf OF OBJECt StgLKK AND o NIF-7 f) EST. OMAAGE 11 sPEC1Al CODING USt Si?od $ ? ' UNIT NO. 1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST a' S ORrvER'S NMAf: UST IRS' j MI -E DRWER'SNAME: Is, FIRST Al z A ^j STREET ADDRE 31r( ., S NEEL ADDRESS iY STATE -zipCODF PMONF D IY qif IP N f N7,4 w '732 3! ' ? e R ONIVfR ucE r+s N STATE f% B IH I IV R' IICEN -NO. IAIE % DAIE.EHRIN RIFU d' L. t7 Lo - W,4 1= mo 11 I ZAY 63 V MD. I R rR AV B OCCUPATION FIRMNAMEE PHONING. EYES xYEGHI HEIGHi E OCCUPATION F IRM NAMEe PHONE NO EYES IW HEI ?, s-wE - s? I D R . GHT ?[HECK (?) vlHOt ASANrMpIO,IFOiANOTHER .l ?CHECK RAL -1-VAFASA CODES ? * 5 n + i. 5 [ ( e iMAO [<T aH renRC SQ NFMROVEEOPANOTHE CODES ? 3 n < ii 5 u 6 w Ass rzM clroN In _ SaF z wuYE1 Np N N, l "I u ro I ro AWIxwHC1 ...... • ? M.", ? 8- 11 cs K;1E ?r° v Nlu s x?y l- ? AMRAPHg1 [1 MCI ? 89,11. 11 -14:1111 ? ?,H,.. l R MARE (-1-cHEV) EL (DARF NOVA) IYU(a DR{ NY) HYEAR ( {N V 1 MODEL (OAgI NOVAI l ( 4. NV j w +( G r I dt J - ' ON l Q P ?) 16 ? STATE lfq MlfN 1AlE /t LAJIT T H I V H. OR 1 -11" 1 .11 , A ro aq VfHK1E OENIIFIGTKKx NO. 6 IIIA o131Z101611 RIGISRR (DOWNIR: I,ASt IIRSr MIDIXf PHONE NO C ` VfNI IE IDFNDiIGII NN I R i f0 J . ,A S ~i9C Z ?O ?/L O WNER: Ujl FIRST ABC., .z la ADDRISSOPOSAN(R .o. Bo, za z Ct! m. w r 832 W N E A WNER JI t . NAMtA ADD.l530t INSURANCE CO. --IN, RI. . 1 U -NT -114.? 1 Q M/ R Da MMAG?D MU 4 I V pIVAKatO AAFA CHARGE CHARD[ OT""rxi OV" GHI ? t _ nDH S t51. DAA4Gl ?^91VIVI pfMN N[D ?ORIV[N OREMNNED AWAY . ESI.OMAAGt PiDP f• a ` lOVA00r / l AY IOw AEO Y BY S IS DIAGRAM OF COLLISION: lu U A I—— SMtI B N NORTH [CESEA" A DESCRIPTION OF COLLISION: Ius[suPHEW NIAL SHEerBN[efssAgYl i may W ---- . .. . LJreliiZC$ w/!G N.SO4NL 4a<o JFRC?_.. O ' ' n.,Ird?aNt tr .t_4 T O F 4rAO . .0,2E-1LC OL,,F e C FrAaacRO _..?c a - ECLa/ ON.. TJETi7...S/7P _0 h4,40 _ A _. NAME, ADDRESS $ INIURI SOF PERSONS I NVOLVED + CODES 1 - 2 3 4 6 H OCCUPANTS /WITNESSES iGxn ?oDnloWr -11 AW six :ce reTOi _ '",;;" m i Rtsm Ufa 'K( . is A H DDRe1s - AMe- NAroR of c l ? AAf e ? cRl ? "" . ? Rx' ? i 1E.THlp x r io A H Dtwus - AVE. . ... .. _.... NAruR a R Wrv1DrN - :1' ? Ame ?FcD ? DHr.,? RJ ? i °. a Fio ADB113 t1F11 IN eYi ??MM ?AMe ?rp,( ? ?Nx ?iirlV 1 ala 5 gAxV t KA eADG1 a Aancr D? ICHtD Ka ARnND DAnorwlpRT ArnaTDEr wn g ?? G z I ; 1 723 r R M i4 ,U r a: C. Ihn ? = ) F1 ? Ic 1 t I I ?. 11; . ?15r r7l J , r MOTOR VEHICLE COLLISION REPO nl -, 6 A7E Of COII:SJON DAYO 4SON TLMEOf-CALUSION.i_i COUNiY NO CITY NO 1 7 ^ / ( ( E MOq NE D f 9 I OWI -0ly t _ AM ?Y BNI f i AE; 4s 1/ I 15 H y T.000NTY -..: CITY 7OWN N6Or MILES CO 1:1 _ x'. _'. TEE .,.t..CITY TOWN ;a?..;.. ,yw Ll3 EFI ? C T ? ON /r n./.tCC4 w :n npM PP Y IA Dn. GIYE NAME pEET-noAq ON „INSEflSECIVIO.MTN.eTREET OR HOM:::i...,.... - PNEFx E? MLEYasi.; •'M •?.!S ac° „ED //.r.(: luCr CF /fL// ?r.??? /fNOO/ Oe NONINTER9ECTIONL 1 ^ OCAT OVe-t,O-Cu"?.C'O '' .?u.. _ tY4MP 0 AGHAM WiA J BETWEEN I IF AND BEET I- - { ^bT ®© R E AVECIWOBrPEEr HKnw,fv nWEE MIMBF0. Cn BwDGE 'OSS ±a unEVOSr Ox OUifvwalAVeufxx. INTE(1 iE5 eL5 rE ?°•' P tlEL"" . .? ?, K... - i n5ECt10N' TEE! ©® 0 . •G HVMVED ? VENK E E K ?VERKLE IE O? piNERIWNIEI /? /,? ? BRE!"COpEL E W ?E9 ??VEHKlEO ECf ?E E -LE ?vF.KE SIPo.W , ? ?KTAUN OBJECTSTRUCK. ECI SIP VCKI I:R '. : :..INAMEOFOW _? ;. OWNEROF"OOlECTBNAMEMDADDflE59..._. Rj OAOWAY ?N ? " AFAR .P. . _ FEET EoOE 01 - ?? C ?, If DRIVERS LAST NAME „" i pE?Ny ,b .. :... FIRSTNAME .MIDDLE.:. C DRIVERS LAST NFME _r-... ...,. F .. Ewvq.vfD FIRST NAME :??? MIDDLE I., f r Zt? CI wER9 a STREET AODgESS-,- cau OR LE )/T NQ,ANQ BOX NO, IYERSOgquPARON_„ -HE mWIiwo STREET AOOnESS 99 :. iiol!IENOm . xpo• M? ATE-/`n?6/zIP.DgoEiEPP fps . LITY iE CITY_ STATE: 3!PO4BE: ORIVEPSOOCU(!ATION•:,._ NEEw °D? - /G E / •^ - DRIVERS LICENSE NUMDER ...: «".? TATE SE% : DATE.OF. BIRiry[.•, ,AOE, IVERSUCEN9E NUMBER :a:: _,: . STATE; .SEX ;j.}DATED ql Y A °?" ?lJ v % i_Y Yy{? ..pis ..:. u r Ho v.RMn.B ..ABE• E' VEHICLE YR_ MAKEICMEV: DOPGEN . MODEL(NOVAOAfl d T) BODY .B7YLE120R1 " VE lLEYR- MAKE :DODGE).._ M;D NOVA,pAFRI?':. BOOYSTYLE(2DR) _ K 0. LIfENSEPLATENO.:: _;:. 9TATE.1.... I. TPAILEflPIATE NO ..::STATE,,; ., UCEN9E PLATE NO.. STATE' TRNIEfl PLATE NO,, i,.STATE.i;...-.. .a VEHICLE IDENTIFICATION NO : INNIS MODELS I NEWER!:.:: ODOMETER!MIL AOE ' ' , a E. I VEN CLEIDEMIF CATK NN4 '..(ISBSMODELSANEWER),: DOMETER IMKEAGEI Js REDISTEPED OWNER._'._ (LAST-FIRST-MIDOL NAME):( „i:v_:.ORNER9 UOENSENO.,, . ': /- .. PEGISTEflEDOWNEP?,._.JLAST•FIRS'T;MIBOLE NAMEI_':'..:.:i...-i.:DRIVERSUCENSENO.,;:;, v_- 1' '.Eµ •,LY' J, J OWNTERS ADDRESS •,,, III-ET CITYANDBTATEI DATEOFBIRT" OWNERSADDRE89 ' W a F !STREET, CITY AND STATE)MTEOF SRTN, ?rss, A C7 ', ' '? PA(jTSOF(VEMICLE ---- 0 BED •iA!]7 ^ -. . :j Artpc T - PARJSOFVENICLE DAM AOED - LIABILITY INSURANCEINFORMATION•VEHICLE NO. 1- WAS THERE AUTDlAO9ae uHABlurv lNSUgnncE } COVERAGE W EFFECT FOR TIS ACCIDENT ON ADDRESS VOURCM ?VES Q•-NO . SCS.4. NAME AYD OF UABIUTY WSURNICEI`Ol1CY1gL0ER„ .•_,:.:: y. NAI^F ADmEST arr....:.': •, ..:.:...I rE NAMEOF UABIUTY INSURANCE COMPANY, NAME MID ADDRESSOFLIASLSiYINSURANCE ADENT: G . SLATE, ,- _.. .. -.777 _-_. UABIUTY PDLICYNUMBER ";. IST WJUPY 'ADE 2NDINJURY I iE PEPCq Oq AOpiKNk SI ;.( NAME ., ...,. AGE __/' -- //I ?'C' OTk NAME I ADDRESS L • SE% ADDRESS ?K ? ? .. C : STATU90F WJURED MARKFJTST ETf1ATAPPLIE9 'E STATUS OF.INJUREO ?pW[ !.VEHICLE 06 NOrlpveuq -5511E MARK Flg3TONE THAT APPLIES ?P !KE LULLED IY?'[PEI MNORrI I r ?DpW WVENICLE USAOHKO 011. 19 Na1N0 'E .• P-- I ?YtD! orp",E! 1 ? pfD N NO KILLED 19f PEI ININOnI r ? 5? D? 7Q la I ?1 r11 H ??' ? f?Cl II .I SHOWNORTHOYARROWWCIRCLE ? 5O B? ]Q ?• •" nDK^a. / DESCRIBE BELOW WHAT HAPPENED REFER TO VEHMLE9 BY NUMBER) ` 1w a' n cr• /?1 C ?u' ?l'rE I ".gin/?{?i ).... -) c E O 'wJRtn] wa«A. ' m fc' ?-?-TPVE e?- S.4 cC )z<f -6+LkCL(-Cf>_ ?l_:___l ?? •rnen DR r.er° -/IC -/.. '!2r J Ct_ lr'L___L,LL4lL_?f.LY,.?E. Y'lY _ VEHICLE NO IYaq ---OW 3 ? N S E W ? STME ON TRDEi DO Iq.WAY NAME OR NO. m pnICIKN ... n ltOAllYfiANavO ' f?+S UDUly ?inweD IT M V[. CLlAOCCIw [s ND INVESTIGATED BY ? PMK0. O I 1 - 1-R• j IOIMAI O?O 1 TCJJ L"J [3, . , ?... ? 0?:'.?.. Ot?O"IlCI 000- I 1 IYC••r11wY ? ?? ? upEO "- PED[91pMWUUSAYO DD[ 1 Q c . I ? ? ? ? ? ? ? IKfR/I FROM DIRECTION :>TO DIRECTION a - ROAD 9IIR{AC! - , WMM ? ] WNKWAY ] ? ^?R • ? [rov MP D S _ . ? u0A L Q OTHER t ' KMCAWI 1 M 1MINT COMCTIONS TRAFFK;CONTROL -tc-1 V[rKl TYPLOFRDAD V I^ELt C ORT jn/VEEIICL(ACTIONS . . .01 ro• ? 1 CJ MY ' E3 -;4r a 1 (,:J OAVLIfi1T roT ? Q 1 Q yO4Al5 ro ' ?] I ?wVC?Ow! Q 1 Q pIL WAY V[reCM KwtSK ONlGMOPR Ql 1 Q GOING STRNONT AHEAD ? ] QWfT ] QRA.eD ] 0 91^O t Q DAWN S Q DUSK ? ] ? SLOP 66N Q ] Q iV.O WAY Q Q OVERTAKING AND P/SSINO SNOW ? O ?" ? A ?ICE OTHER A Ql00 y OCHER ? 1'CVrI • ? LOBANK .l0IORElCkT OMKSIPEEI S ? L S0? Q D Q WELD SITwr1 ? E Q R sH,.. LIED ? S Q flAS1Vm6 AMBER ? O ? noADR51aL Q A WTfRCHANOS (LOOP/ RAMP! ? O 6 ? O .3 ? MMWO BIGHT TURN O A O MAILING LEFT TURN ECIFY O S ? SP MASON POR AqT 6[[WODAAgEN KOY.INOVNAYI.1AKI1aa 10 pAglf S ?01PCL?AIMO OTHER F ?SPECIFY ? S (:1 NI bONAL ? ! Q ormr n-AGMM k1EY ? L Ol[R TUWAY. RN LANE/ ? L Q MAKING U-TURN L Q BLOWIN G El / T' f L O T ?Q SiOPP[O FOR TRAFFIC ` 1 Lp U N { ? • O OTHER wtc.,y ) 1+M1? Y Q I Q NPMATED O S p LTOPPEDATSKINAL U M1 •? ,, OR STOP DON ' + + { ? 4 1 L ? ?1 J 1 I tF IIYNIVn MOTOR VEHICLE COLLISION REPOR ' ^1t ON iIMEOF.COLLJ910N DAYOF.GOWSI_ OA E OFCOLUSION '. .. . p NE9 WFD ,XU FW SAi ;4N IE , I ?purviY o cI(Y NO ,. ?ueuM. :. :: - I rj 4 PM : ` lJ? ? UML ? :'-.I WN ....:w.-; O .':.Cli O Ic' au,8ce MI ES.., COON Y.. . '..,, CITY. TOWN _.«.r:.'. nLE ..... _Tj .': /., t, J FECtCWL 6ECTION'. AUI(.CL9 REFI?f G' ? y,1 y n // De / ?/t?/"S:i ., ?r•.n.f ,?if Y I°J.®O '' I? 1. 7 .. '??.5 t MDI •,.,. GIVEN E F STREET, ROAD OR HIGHWAY.-. ;._ ....: WTERSEGTWG WITH; .STREET .Oq ROAO...-: L. PHEFIx Ep? 25 (1AA1P O -0 T NONINT0 CTIONLOCATION OF COWSIO. _ h BETWEEN STREETAND STREET . J5 Th „ IF xO, ®© MANO?CnO35viO?M LEPO]iOPEOEnNFV NO LWOUMXUUef0.uWWE NiER tR CLS, OTCs `c[ / XE UU?"' g tl. ?- , M[CIION. FEET OF © ® ? ? / ? 'F T? h wC cow SiONwvaVfD ' LEVE C QVF K E&C ?OIXFPIw'w,FI LNO ?VEMD G EGt QVE D E F SPEC CGUE UyE . ' T - , fvFwCLEe f A' O.-f- DNON QHi nUN OBJECT STRUCK ?: .. _. ,.-1.. - OFD[IL9..rl1U: -.' '.OWNEROFOR1EG73 NAME AND pOGRES9..::;.! LOCA INfl0A . - TION ?, ,, ,,_ O© 0VL'AY, ' FLOE f0 E _CT FEET • • F MOPE TNM • • ' . DRIVERSLASTNNAE:?, .FIRST NAME.. ?...:. MIDDLE:. " ,wO CAn9f0 wEPE wvav IN THIS TNB SUSTNA I STNAME ., RST NAME rJ t.. 1,.' MIDDLE F ` 11 " ^?.f /?/'ll /' 1 n 1 2' - ? /'/ LI 11 \ 1.? r Y 9TREETADDRES9 '.ROUTE ND.AND BO%NO MORE THM TWO EDN]wER STB TADORESS ,.: _. :L_ NOUTE n0. AN08 %NO U 130 in E A ^ ?G 3 S, IO N AT A G ?tP CITY, 6TATE B .GC t ,.IJP CODE .. P//gIVf EOMOU n n ON ALPCODE ORIVER9000}1PATION :. ,TTJE _ , ,, 8L`} I LI : x / ,j' - u C / Y / / ? 1 / ?l lrt ? ? ? / M } ? / / .::...: _:..6TAiE SEF SATE of BigT E.: AOE_ ER NUM fl OR IV S L CE N 9E I - -- i t / 4/?7'7.i,yr/sG/b3 tl?l " . rl?:< .•::.L STATE. 9Ex- ;:. GATE OF 4IRTN AOE-, 0 11 RS NCEN9E NUMSEfl L Ps, W M f D? E I' VEHICLE Yq. MANE ICHEV: DODOEI-: MCOELINOVA-0MTI 10111TYLE12 111111 .:,. VEHICLEYR... MA%EICHEV: DODGE)'. MODELINOVA•DART]....... BO YBTYLE(2DIf.1.':.. LICENSEPLATENO.. ;..STATE'..: :.: TflAILEq PLA1E NO ;.;._ „ ,9TATE.:.T r ' : .LICENSE PLATENO .::.." T 4 N ' Tii i i i ! LJa . - . VEHICLEIDMTIFCATIONNO _,.,_,IIBSB MODELS&NEWER) OOOMETEfl IABLEAOEI VEHICLE IDENTIFICATIONNO. ,.'11888 MODELS a NEWER) GOMETEq,IM0.EAGEl H 3 5 S i COS +v REGISTEREDOWNEq_ (LAST FW9f MWOLE NAME1,:i . DTVERSUCENSe ND,,. .: {EgE00WN?EjR,__IIUST'FIRSIT MIOO?LE/yEA"?{)E7 i",;., OwYEAS UCEN9EN0.,-.;,.?._. R 7 J' ?L ! CC /I!I?/ '{Ilr . OWNERSAODRESS. : (STREET CITYMDSTATE1 OWNERS ADDRESS. (STREET CIT AN09TA .. a.. :.: .. OATEOF &gTFI .. HEE l.f LL( G ?J 59." PMISOFV HI LEO( ADEO , ;:_." S uMfOCOSt T.t EI .:. _.:: -:...e. IOiEPURVEHCIE'. ,•_.. '..... ,.. ; P TS OF KHICLE DAMAGED -:.' F ia' v WM THERE AUT OMOBILE LIAIFUTY WSURMCE YES ? NO ' LIABILITY INSURANCE INFORMATION-VEHICLE NO. I" COVERAGE W E FFECT FOR THIS ACCIDENT ON YOUR CAR . ' NAMEMIOADORESSOFuA urYINwAMCEPOUCYHOLDER :: _.:..:. ..,: .:,. ..-. '....:.: '..' NAMEOFUABIUTYINSURMCECOMPMY:. ,. _. ..,. ,ATE ABE f • ;.- y ,/J/' :?'•,,,,//„ 9x?.? I? . in vPf l lLli.ifT'vt Jn ? < ,/)k . ? l/ t / ANOADORESSOFLIAMUNINSURMCEAGENT.: UABIUTYPOIJCYNUMMK.. .. .... NNA E .. I / ,. •JIwJ<Y' A,Jr IJI!' I I .? / . • :d• ISTWJURY . /OE 210 INJURY: ',L PAMTERE fOAADDTwNALUUUn E91 ,. ME ! NAME ------------ l/, f? z - -- - I i E NAME - SEX ADDRESS I. -- BE% M 4_? Gt=. ADDRESS _ L. IF_ UIDE? - --- --- .O - - - .AV :,"%iDN roeTDA. ® 1 N°Oiu,` t LC ®? N ' STATUS OF-E0 Q ONWA KHM:IE ? MSENO[R = -: ItILLED MMN FIRST OaIXwO IYVcPfl ONE THAT MM Mn MWwO lu?Wn ES iiv Pnn IIO STATUSOFIWUflED ?D ASSEvFRHR NVEHICLE m NO LM --AS w0- ISEVENfI T ONE THAT MPUE ONOWBUNO N lu ?+Onl '. 9 POS4E I E I DFPIN E," DP[OL],nuH D qiv'+..,In L.N ? SQ 80 F EIC I 7? Qn0E91RM Dr,I, Il,vmrr.w ? B? B? 7? s. &TOW NORTH BY ARROW W CIRCLE I-T.-I-1 THAT °ii? wHw"AAY Nuci aHw \ DESCRIBE BELOW WHAT HMPENED.(REFER TO VEHICLES BY NUMBER). . _ -1 --L. ?_.L!-•.1 4?. ?? ?CLi / 1 ?...?-?_ MK vw ? 2 uLipna .. VV> pu l _ VEHICLES POSITIONS BEFO VEHICLE N 8 C W RE COLLISION BTREEI OR HIGHWAY NAME OR 11 NDw uHEe ON[ OntC,?ON vf.,cu l[o.LLY •iMOWO !a ND vEI«cu MOALLYFMFFD - ND PFMAmwA• VFnCI[aCV•p K• NO BY INVCSTIGATED Y ?ri1110t ? ^? La1 ? ? ? r i? , ? ? ? ? : o : ? row[ ?aoeTl. w D,H nI rK ? ? ? F ,?( ? ? ? ? ? fi3- G«F w°•'^°" ? ? ? ? .. Z7O mom. DIRECTION TO DIRECTION ALONG ' PE0/sTWM WA9 V1P^ 1?BID(W1LIt 2?W-WAY 20BIIO.MR 10 cl iiwuf e?µa?OfnEn ROADBURFACE MATHER UGnTCOFIDTIOHS. TIMFFICCDN- RMCAPAI TYPE OF ROAD BRIAR/VEnNLE 1.7101:0. i .. rtai .rt b I ,cXla oNfl Y > I ? w.nl ?Itc?. nn ND[ l uo x; vIXCIE [ ID o I u] pv, 1 ? o OVO4 1 C] OAYLIGnT O , ? S .s C] 1 ? are WAY 1 DOING STRAIGHT AHEAD ? ?1 ?MY 20 AAI.4 E?DAWN ? 2 ?BfOP SIGN ? 2 QTWO WAY ? 2 ? OKnTAIM0 AND PASSING ? 7 ? *IT ? D ? 'wW 2 ? ypYANG I i00 2 ? DUSK [T I ? ? ] ? YIELD 544 ? • 1-] FUSnsq R[D ? 2 [j RREVER OAD SIBLE ? • ? NTf.RCNANOE ? 2 E] MAKING RpNi TURN ? A ? MAKWO LEFT TURN Iyry'` E 'C! ? C] ? O1HfR ! ? IG TS ON DMK SIA([T 6 C3 lIGHi3 OFF ? e ? fIASHNO AMBER GOOP/MMPI ? f ? ALLEY 6 MAKING U-TURN ? ? ? ! ? OTHERY ISPlCYYI a OMI NO C3 SrIYlY LINITS S M l,DNAL [] ? ? e ? LEFT TWO WAY- TVIN ? e ? SLOWING xl P RlA..ON FdIN0T 6l[•Q DMFG[R ,A. IL ? OTHER r SPECIFY ? I ? DF/ICfRIRAOAIAN LMFS ? f ? STOMF.OFORTMIFIC : q•tl:l Ya•w [H L,APFi / I ? S ? OTnCR, SPECIFY ? I ? BfPMA1[D ( STOPPED ? e ? w.,{n^I 3 fJ'-. n AT SIGNAL slat ?'? J Jt I 1 T I <<1, r?r ?! ?'??' ? r -...Jtd?ml'w4--L1".c^:.h•'1?..1'a.- __ _? s_... _ , yr ?h7i. Ar..rc:?' ^.._u.a [`uaeil?:S:+. _ .._ ., ._ JOFFIOIAI.USEO T .?. . ?. _. 71 Y.. fi?? CTATF AC WACYINATFIN.: _- ?Tv r. _.. ?.... ?...AOL CATS OFCOWWON:.. .. MYOFCOL USION TIME9FCOL UWON 8E R S qx NES WFD U 9 UI AM 3 0 -1 // 3o PM COUNTY - CITY TOWN O c0u Ip ""NO f/ ?y? ° ??/? Ip.w AL: ,. . , Q tAB.E9.. Gtt: TOWN 1„r ?N ®•` .... ?cFFE V, ©OFC ;M cuM nOH CtS FPEC[ pyt prlS 1 E SECTIGN c?VE NMIE FSTREET fl0AA 0NNIGNWAY .,,L.ANTERSECTWOWITM. 4111"TOR ROAp.- pgEFl% TO M EppSi A. iFASECT10NLOCA ION OF COWWON ?. , %/-• d 1 ? : _EEN ETREETAND 1!AMP . p C RnN OnT?. ' ?.. STREET ®© NAOi WO0C b5Wp ui[vOSi on OExnivubvi.wN a? uuEn SwroF - ECTwx: If Er © ® O 11_.: NON %RO IN fl LS IR RaN , ? wIOLVEp VENKLEVENKIF ?YFNKIE-IXE INER d ? n0 ?VE-.-OSECT IwNnFI ea ? ? a ? FNKLf 7yl,PDE }ASE k y 7 ?: ids. STRUCK __ ?wx cauvwl ? i.RIN E/fiC LE - .C t n .i. 6S' r1sf?),? x ? 1 dar. a .... ..:. ... IHAME 4f OBIECra PVCry'e,:,;: .__:9WNEn OFOWECiS NAME ANDADDRE55 L?ATgN Imp ADwAY C0 . • • .... '.: I '? FEET ©® - TOaS, EPAppBIEOT - P- rN p RS LASTNANE MIDDLE' iwOC a 2 WERE _VE ORIVEfl9lA37 NAME.a PAUL tE v , Mw,SGNON usA _._ /] ._. flOUFENO..ANO Bp%Np. nEr TWO STREETQDRESS :.y :- 3 2 OD" 33/_ w? 5WEREA ft9ulEtl9u0eoxNq 0 6o zc? i f - .._. HTATE jLP,000E. Wtv"SPPPUPARDN OatuKN CITY: e. .. 9TATE .;?.._. - ?. ZIPC/?Djr,; 4TIYEPS OfAUPATW!i_._? ' 7 IC UW.A/ 1 N)A. gad 0.°P .SYYExiaFPDArIawAn -;, E RS LICENSE NUMBER, STATE SEX, ,,DATEPFBIRTH AGE del ?NFI? m !Q 9 Z 0 j IY .. ._ PRIYERSUCENBE NUMBER 'STATE' SE%. _GATEPFplR7y.',. :,\pE. t Pc, o O R. v j 50 i ;77Y E tVA X DAr rEN r ':F LE YR. MAIrE1- -------E1 MOWLINOVADARTI,_..,. BODYSTYL EI2 DRI .. VEHICLE YR. MAKE(CMEV OO4GEl:.. MO4EL WOYAOARTI ::.. BQDY STYLE(2 pA.)., ERCµC 5rAi JUAJ ra AI, A6 dAN OQ 979 CNEV. ;c A¢-wl9 '.. ENEE PATENS. STATLE "'I TRAILER PLATENO. STATE / UCENSEPLATE E S •/ :'.. ,TE 9/ 7S _ 1E.... .-/TRNLEN PUTEN STATE... Ce 7 -7 A _I IDFHTIFK;ATgN NO. ,;-, :....UBEB MO Sl NEWER),..:. ODOMETER IMILEAGEI VGIICLEIDENTIFICATN)N NO „x,(1888 MODEL56NEWERI .,. V97 OOMETER (MILEAGE) "i 20 /3 CK x '? ' TEREOOWNER,"..,:. ILAST.fIQSt..,,LENAMEI:...:., DRIVERS4ICENSE NO,.. REGISTEREDOWNER-..AVAST. y b ? ?' .•°-. _ FIRBT.MWOLENMIEI :. -" " ,DRIVERS UCENSENO ' A'v QEF_,AJ LG D. 6XSt.*.JGJ _. ". CAS 2 ?. 9AOONESS ISTNEET CITYANDBTATEI, :..DATEOFfiIRTH OWNEREADDRESS ISTREET,PRY,AH9ST4TE1.98S 76"': TEO?BIRTN? ,I ' ' CHOW , WA L'Y2 OS 52 p ,Lc SOF VEHICLE DAMAOE0 Ai[p COSr PARTSOFVEHICLE WA ?OF pAMA0E0,;,, Y ET AE WAYB«aE; Lowee aJeA,Yr se F of G4 f . pa 4' . ILITY INSURANCE INFORMATION-VEHICLE N' 1 LVAR THERE AUTOMOBILE LIABILITY WSURANCE ANp ADDRESS OFINWLRYINSUMNCEPOtFY MOLOEq COVERhC'EWEFFECT FOR THIS ACCIDENT ON YOUR CAN YES ?NO n NAME OFUAWLITYWEURANCECOMPANY:. IpMEy tN @ ?a ME c. cs zrz.so wgs9 9sa6fr C ANOAODRES901UA&Ui'/WBURNICEA9ENT E .f , He 5 A rr re. E IF to Y.v n y¢styl O WURY ./-0E RFPMTICRApdTKWALWA1nI-7 NAME ....... ,M-+E _ SEX; ADDRESS a^{ rD HAM,f9 M SEX r ?A] pOCr EXtENTOINAM 1018+ Om h - ? NO TULIP fNLOU - pOCiOP9 A` ^ ;y 5rY NAM[' FS Oxe E ,. STATUSOF WUREO MAR-OSTMETHATAPPUES._ u AwxAr rAUOCroR, ®? xwY ?{,, a Y _. [R WVEHICIE ps.•uvG E1DV mAaIwG WM:'unLF STATU90F WJUREp MARKRRSi ONE THAT APPLIES ASY 1=1 w.unr vuupY ?- IN IC rA:EA NX1E0 VEH LE PSAWa10 nOx. Apl 06LBLF , ' - NHI ? 6 BHDRI IIO P?If IC IT ?PAaaENBFR ND KILLED •Ig[vFPEI IWx?OPI? PO OPCM ?/uI11 5.. Q ? [8 N W NORTH BY ARRpW WGRCLB ? ? I 7 ? G? e? ?? 1, Y p,OVmA?N.w OAOnAU '\ /DEIICR BE BELOWWHAT HAPPENED: (REFER TO VEHICLES BY NUMBER) %L "' ? ACr rK QlrlM rlut ntllEC,S 1 \ I I VF NICL/? A'I. T?RNd7? ONYO C6??? R •^IA .. ? •-• .' ? .?•pxWA. NuKa Dn \ '\ i AuGT__ 56E'i ),?A.G.._._ ?L.!Y•_-A'Y-?,---Bf _RbtSF _ ?I c ar ' WWIXr ANp Lwow I.KL...AAaw , ? , s??- G?q,¢=, __ Y?H_!FZ staLk,E BgcA: ? *, . Via- , \ ` , La,A HDN r ?oa..ALse oA=... / - : Te+EAi t.oYC a AC_ v S! [4'! . 44 .... ... ._. TRA b Q / i I I ' k t W*a N II E W ? ? O ArutO wAa WVENOATEB BY DV IITREEi OR NORWAY NAME 011 Np pltd'? ll0t•Ar •tw? Vn! ? I? -- HOLE pOCpKp ? nitW ? ?! . ?• s , C k 1: etta q IorK ? ® ? ? a.. ' r / 2 ® C3 13 ®. ..O 0; ?2. Ao" r 1p? 4 L I VE. AXI. u•,.N 13 C3 ? ? ablo TNUHW.3US.4 t?WDEWAIK AplULIK C 1L1 cno•LIa 1 WALKWAY ? 7 ? bN0Ul0ER I IN ? ? ,.._ .. A ? CAOSfw ® ? ? ?•KAII .;AMU 'DIRECTION ..tP 'DIRECTION. ! ? V' py u I R? . ;r E CAEW ,.•. WFATN[A LIb1T COHbiIONII - T /`C011TROL KKCAOxN . uA TYPE OF ROAD T,EI A a OTHER 'C ' LHKAr NOI ' M r t DAYLgNT , NOVt I No • 96NA19 ? 1 ? ,. pUVE,VVEwCLf ACT?OH! NO [Hq1 S MWAII[ K M2 KKCKOH[blMdYl 1 : f , 1 a A, lT:? A T r MY E IVEY ? 2 ? 11/:1A10 ] ?SNO,At1tl J ? DAWN ] ? DUSK F?t ? 7 lJ ltOI eIGH ??q t O ONE WAY rR 2 ®TWO WAY t Po•1G IITMIONT AHEAD ? ? 2 ? OVEnTANIIq ANp FAlSWO 4 T .? y •t { ; ] Y10W ? . FOO ? A DAAK.IiRFET ?L[ ? ] ? YIELD BION URN O A 13 2 ? Mp0.WOl[ ? ] ? MAKWD nONT T ?. -?' L ?K[ A?6 C[ M a? OMER ISP[CMV7 l+Ata ON A O pAA[ IrPEE 1 I ? FLAsH..o NFD ? ! OIlAlHWOAMBEA ? • ? WTIFICHAM" IEOOP/MMPI ? a?ALLEY ® . ? WIONO LEFT TURN ? 6 ?MAKWG 1 r 1 YHd {:. 1 1 @ f ?i , F Y O IOn NOr 2[LWDDAHtLER aYa w BAR. a ?8rR[[T LOHTa [ ? ? a ? AN SM, ? a ? TWO RaN U"Tunes ? a ? W.DWWO T+' ! I1 +' ! l+? r EAL ?O '? Y r? . tu,A.[ral.y erct L-ECIFY ? 2 ? Onle[A/rLAOMAN ? ¦ Ot L-13 - ? I ? ATONED FOR TRAFF.C t I ,( ? ` KR inrwY O 1 ; ,.Arco Cl ? a 0 aiOM'10 AT !TONAL I h . \ 1 ,.T 4 . .d" A ! f??f11¢4 M f]jji, L?SI?2TM WON + ?1 I IA _ ' ; I . r r Lt?l ,? t t.l'. x 14 I. -' .. k&sYCG4rD °a°»sF?a?'/". ? P{(aa q' MUIUH VLIUULE COLLISION REP .? o- La. ¢ A??'ra uw Nd °ruES w¢o°iNUPNOiPF SAT. Noun FCIXLW ,W NO. (I l?_7 ^• APNyrESNEl cOU v COUNTY NO CITY NO. f O aw ???CN ° N No.DFBPEt nwdWAY m,cL fj 9.3?57> 'E YY! WTEPEFmWOMINLrbETMPOA ON ?R RD ?[L PgENt P: ¢OP 51 ?E 8R. t - Po ,PPFfu eC m ?O m ?t.? . -ST A t NIGI n Er . - sNOwNEAR xrePSEm¢n nn IT f ?y wr © P R e F[ • wAV,NDV¢FxuMEE NppE ® AAADID CPOSSW4ESr MlEPOSTCP UrENTIFYwOIMpJ.wA. R.VIP DuDRIM DATA', n [ "r " rERSFCrgN• IF M l? oW+CHNWLVI' f POWW i ?- ? ^ MALFPWHB 'PApSiWIED? E I ?1 F DLEE . .EO ? n; B P? M" f?N --,A P,pOdACMEM ° NfA p¢ ER ND?D E¢ PEE snob j oB. -,.A, u9 0 6 1 k11"?M1'. .. _?NAME OPCWK PUDW WN O BI CTS NAME AND ADORE55 5f cC.GOre mE ?? • U? ° $ 1 h DWVER'SLA,4TNAME n NAM 'F-MIDDLE wO C.wS f ' ?? ..'. wETADCAN E. ORIVEA'SLASTII--;.. ..... ... W NAM MIDDLE 'Vv da?Jr, itssr? Ic' coETMµCR EEN/tl9?ClJ joat? c , aa STREET ADDflE35 ROUTE NO. ANO BO%NO:.,. PEREdEwEnt STREET MDRESS.: NO. MDBO%NO.-._ / - / [NURK UE¢A M STATE EEPNMTE r, OPCODE DPoVEp'9000UPAOON cOwEON. CITY- t *F GTY p?>?> _? .- ??JI,//?i Li?? .`/ `C ?/ICj ??? ^^ R[PORr F01w ..-'. -'.•:.STATE . .............:::LP,000E.. OFYVEq'9000UPAT x OgIVER•9 EN N A ......DATE OFORTH. .ApE .. No. oAY rI. • _ DPo ?Y G'K-??IS' FSic>v A» M F VEfl'BUCENSENO.::.. STATE ME% ... DA ADS. .7 /-3 oAr A. VEHICLE Y0. MME----- DOOLLE( MODEL INOVA-DAq- ALPISTY (2DRI VEHICLE,YR -MANE ICHEV. 00E1'.• D l VA•OAq .- .. DOOM Brri >Oft) 7 °7 r j _j/ > . '."LICENSE PLATE NO. .:'STATE...:.' .:..TRNLEA PLATE NO... STATE. y. •rF-i%7.? Irv _PIATENO.:. .. STATE.::.u; ?i.OTVJLEq PUTE NO... ....:.STATE :?: VEHICLE IOENTIFlCA0N 7 NO-, V ?yJy L° /17 "`St1. :- :. .:., .. ... ,., .. :,.. VEHICLE IDENTIHCATgN -...::..: .:... Y' REGISTEflED OVWEfl (LAST-FIHST#IIODLE NAME(........ OPo 'S LICENSE NO. HEOISTEflEp OWNER II/3T-FW8T-MIOpLE NNAT EI._,•.:. DWVER'EIMENSE S? L OWNEA'9 ADDRESS (STREET. OT', ,+Y •? .. .PATE OF BIRTH OWNER'SADDRESS MID STATE( ISTPEET, CITY AND AT 1 a.- IAO My 1R. • PMi90F VEHICLE DAMAGED . - Y p q : ?- un?fDPI 9Er io ARTS OF VEHICLE DAMMED •{( -+• "r LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- S w S` k WAS THERE AUTO MOBILEFOR LIABILITY THISACCIDEINSUMiLWCONEYOUqCAq YES NO COVEgAGE WEFFEC T ? ? [t S - _ i NAMEANOADDAMOFUABIUTYWSURANCEPOLICY HOLp ER . NANE• AppPE¢L CRy ? R HATE .a ..??e. ? NAME ANO AODRE59OF LIABILITY NSURANCE AGENT'. On . UASUTYPOLIDYNUMSER ISTWJURY: S NAME ..- ..: 'AGE LNDWJURY: .. IUSEEFPARA ¢pf?CH?FORK?ROPK WMNfs(:.. .. TOTAL ADE v o NAME .. .. ' E 4, AATURE SE% RRR••• ADOgE59 II DI MURIES MOUE ? ? WEENT OF INJURES M DID F i aP Po"E Mw[RREROUIRE DR'S DO E%AAINATION DY A TOM ? y pD NJES REQUIRE CTOR'S ?? J Y STATUS O MW F ['UVRED M E%AARUPoDN BY ApOCTOW ® ? NAME I DOCT MAA%FnTST OVE THAT AFPUES. STATUSOFWJURED. -:,, - M ' • / ?Q v WVEMN:IE NAME oeAPUxD gaAeuHa .. FI CNE THAT AP U 9.. - Nd M1 '. LOLLED I¢FV[p0 I'LL ?DNVep WVEMICIE NsAavIG HON.ouAnuM P054BI? - . cesrRAN No.-_ IMwoR DOTC PF.riAC.1Ir OPAxurwfp No .-..._. wO° 5Qn Ba no7nu°"NeTCI' I FE O PFD[arR AN d F ? B? B? 7? ?ornn wI n •. .r 1 MOTORCYCLE SAFETY: ?HELMET USED ? HELMET NOT USED ? '?N MOTORCYCLE SAFETY: HELMET LEIfO ? ? HELMET NOT USED 'SNOW NORTH BY ARrgWWGgCLE . : I IvLYCATEd MUWlAAM O . .. - - DESCRIBE BELOW WHAT HAPPENED:IpEFER TO VEIIIClE9 BY NUMDERI' ? WrMTNAgfN[D J. -?-- _ I rPleem[eurlNnNArrcRieere 'I` -... .._.- - r0.» Wlu9d Y[K a»»rN6 x ___ __ !( 6TP[fr d NWfxAY FWrt1 O» .. .._. [s NWBtb .-. 1. .. >. M MKP [Ad IqE Arq blDw - - omlrc-roN?a?mA nr?Arwow - _- v` I ,- I I nnlnaw.A ------------- M IYAIO ? ? ? ? W N)IMnI ? ? ? ? Ngfrw•N ? ? ? ? .r,.s?vl• NoNdL Ff ST vENxCLA If A[ y WVEBTN oN BigfET OR HGHWAY NAME OR NO M[mIlOx LL0!I LLDALLV Ab[0 lHCLe OCCUPLO nATo ?, L? ?.; D? :f 0' ?:? D. '.FROM '. DIRECTION TO " 01 ECTIO M MK. [ ? c»o".:w "A [ ? m »A r ? LO1»A`0"»D 'A [ ? w owAY uD[D ILi RnI1DMR DrM I? s y1 µR0?'i[l [rEfwr[v 1 we OF, AD., , I`.-R-VEHICLE ACTIONS ..? M[ MludLl ,. v! b[ IDWLnd[dMDIIPI- ? N ? ONE WAY ? I ? GO¢UUTRNONTMIEAo [jr ] Q TWO WAY ? > ? OVERTA%WO ANO PASSING ? S ? WWAMftg ROAD, ? G ? MA%INO RIGNT TURN PJTfRCr1ANG! ••? n•euM. CYCLIST WAS USWGT I?w[»NA [? r >?s[%Ap» P<L.STRIAN/PEDAL CYCWTCLOTHW:I COLOR. I?DAA :?Lmr POAD WRfACE WCARI[q "I CONOr[JNS ItsdLPt ?MfF[;COWAOL '. NK1f // dpppp I ?'(MYIM]HT KHfCA df1 ?' 1 ?IL11Y ' ?O.t 1Gi > ? DAWN O CL O SION" > ? RAAAw > ? wG% > ? [ ? Y" > ?INOWVa ? irLT ? > „eLPSaN ? A ?K(W I ? fpp 1 ? LNIRIT%OblLT C) A ? fUSHP.G R[0 ? ? OTHER S ? IEPLCOYI / ? ',"'(IT LEI ? S ? FLAwnn AuSER ? 1 ? SPLCVY [ Or LR (?y ADWAY CNARACrIq ?.111 ? / ?AR MONK L^I ?Z. r II•-} ?I ?ADWAY M/p n1YPL ? I ? OIF[:[RifLA°MAN r .Ir.VA T 111w/( ? I ?it pW;WAMPI ? A [10 M,u[Np LEfr nmN 1 -. ,i {;.r ? S ? 1VAIlly A . ? C] 1 MAKING U.TURN WAY y 1 Y {-' ? t '?, Y5555''''. ? S? to UqN C] S? 6LOWw0 ap I 4 1 1 i 741 ? 7 NEw[Y ? 4TOMEDPORTMFFIC J j 1 t 6TOPPED AT" AL 11 T y 'r{? Y1WA?'^ rS , 1 I '( A ?r P I ti ;?I f t?; K9 t 9 IT'l t r z U rr?yCOO I ?? i 1 a / t j r l c l i ?F 1 - pp gryrugs r w ? '9 1 1 R y r j E L POLICETRAFFIC COLN REPORT XTRAFFICWAY rollCt. .. RAINI NUMBER / ? PRIVATE WAY arr NO. FIIWA couNrr ND Ducat p%r COUNTY I'll US DME • • lun • rru F., NI-fn IUSFSEDD o' a . ?UReAN /Gj URAI 1 o O ? N CITY ON IOW owl', f 51RtEl OR NIGH WAY N ?t C:]. ON Coe WIfO? SE<iKKV fCr CES A M I'N- I ? 3 ? NRES ?5 lV O,Q ?Wrq IN gJCNNG VnIrI 519Ff1 4ROAp ?NIF95fCV.QL<.CY /?D /GG M F OS O?y,,.,N. : pgFflR fO ? SIREFi b STREET Z iWffN DISIAN aD MlFSr N 5 f CW 555rRtE1ON NFMf51 MNE 51 U AC MILEAGE LEAGE D AGRAMM RAMV / rFFi F / CODE N " RD SERINGS RFfI R D091tE fRENCF COtI SpNINVIXVFD SfvlR rv. f(I fiR SPII'LAGF NO INJURED- ? ? f ILIFD?. ?,/ IaO !K). t wuo.?V'irv 7 I/ INIfR CLS CROSSSriIfETORROAO " ? Al O C`-CLES Gfl RORRIY OAMAGf ONLY ?cEwl1FD LIVE Y Oe1ECTSt41M:K INAM1O105- SrRUCK ANOOWNFPS-1 EST. DAMAGE SPECIAL CODING I6! UNIT NO. 1 UNITNO.2 MIDMF D4rvFq SNM1E ?VEHICLE ? PEDESTRIAN ? PEDALCYCLIST -- I LE N51 I RN - S of !/R/??/LIM.E: [J LaSr fIR I• ,^? . 5TREfr ADDVE55 srRFFr Fss G ONE R RM- ONE NO AtE 21v CODE SI D H r srwrE FI G ??j 2 R f T 51 NIn SEK I Derv ' LICLNSENO. Alf % DAZED B9 N YR MO u D NtR'S IICFNS NO. 1 9 444- " I eAr 6 :2 2 V I . . I • f GNr EYES GNi 1E •d MO+E NO. DC/UR IIV /{ E GNI NEIGNr iIRM NPMfbvNONF NO. EYES OCCURAI ON R ? CHECK I? vwafA A M or AMOrrvfau A Al ? CHECK(,') Nv wcif AS aN IMROVffaANOmfe. Rr a wen rut ° "r 1 r S '!ncew a ;A;ir CODES 3 9 % °sri'n 5 u aN CODES ? 3 6AS S < i iv : ? ,2 mfwlES t D: ` ? Av-- ? u5" ? Eo:rl. ? ve,YKU ? R — sfl'°Ne a+1O'" ? - ? N ? 26. ? t ? r:ANV .t C?:FV mouL IDARr Nov%7 Iv .1 RDR TEM MAKE IDODGFLnEV.I Yfn LIOANI?NWA7 iTIE IZOq .COVV.) .I - Y MAK I rN N - e - . s 2?0 E D / 2 vfn O4 Nh rNrF ". SIArE IfR RAlf rq: PiE H -COLOR ll'F?SFfiAI N A RAIF A 1 V AG V C / c . c 0 he rEN?tF DfNlrfAll N N vEnlctelDENrIYKAnoNNO ai L I 1 1 I i E ISRxfDOWNfq: 1A51 fIRSr M10Mf' ilGRM1RtO VAwF4:? Wf 11451 M:DOIF vNONF NO. W A Or owNw IS ADDgessaonr+tR i- r N E -'_.__ A , u:AN 'EHT NAMta ssa mwRANCtcD. oR AeeNt R MtA OAMAGI?I MFA NA.c ?+ri E;NA4Gt CHARGE of iiowe r? a D"' DR1vlry Fsluouebet 5 ?4tMNN[0 A lST IINAAGF ? SWAY R "D ?AWAY S ID.OrI /??++ ?. TOWED o ? I + S eV, AwAr e lr t DIAGRAM, OFCOIIISION: 1 unemeN AL INUUre NO41N DESCRIPirON OF COLLISION:. Luse stwnEMwruslfFl tees5ARr1 _ awe rrtussA4r1 ... er ARgow .. .. __... z", J:? _c _V/2 ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED `CODES 1 - 2 3 4 5 6 , OCCUPANTS/VATNESSES ?w:oo?uai:iiiNSA Oi xz Ace rAlus '" °" 1 4es14. enR i Rb NAMI ND U410r rW ev ?AMB. ?c'-b -1` ?'A . ?CtiY ?" RV ll NR ui x ?D rgLVA ?AMe ?Y.aAKF?wl .v1r ?u 0 ry tl Aµ115 N 1 i K LL 1 - NAKIUVf 01 Urrv fS SCINl11?. ?AMI ?f•i"r?[MI. nNw ?ilrvrnvyr ACMISS eA1MA 09 AGLNCV IX1C1015.AICNIU la]1Kl ANVIVID DArIW P1 i Vllvl AVIVOVIDeY Ali 1+S+?y? dl et ?( nv,??1 ,10 ??Lyf v Smn9f >.ao N9s !L _ .., .-. ,. ,.?I_-. ,. a .... .. ..._.,. J POLICE TRAFFIC COL NREPORT ?TRAFHCWAY POLICE ..PWWINUMBFe 2 PRIVATE WAY I DA+f ufCIXUSroN D r C Il ION E cOUN1Y (USE4LIMND NOUaI x 0 w. COVNIY NO. CITY NO. FHW4 2 o o C J FE song /? 9.? ?RU.k N ?E ?IN Ctx OR IOWM1 NAME6N0. Ut StREElO G IR RS pM ROUrf ORS E SE I— c c u? A _ -14 F ?5 ?W ?Of A ON 3 9ji E95fa_G Vely; SrREfr OR AD NON INR45ECt ON PRfNa EO. MIIF PO c Q (p Ia BE1WEfN StRfE16 SrREEr Q'QQ. ] pISiA ? NC[6DIRF afPERfNC .CROSSSiafkr09 NfARfSIMIlEP01 ACCIDENT R v DIAGR-WTA MnES N 5 E W MILFAGE FEfT OF CODE COlUSroNINVIXVEO: RI IOTAI NO. NO -D_NO.INIURED?j_ ? SAVAGE ?HIT&RUN WNI=IVB -' FNjF9 Ct3 CROSSSITI ORRCNDR ROAOOR REFl4ENCE ® .`] Di VFHICIlS ? PYO%RTY DAMAGE ONIY ? RESUMED ? V Q[ F???Q - C OBJECT SIRtCR NAMEOf C91FCT Sr ( 4CCa ANp OWNERSNAMF) EST.OMAAOR IItC-CIDI-11 y) S UNIT NO.1 UNITNO.2 ?VEHICLE PEDESTRIAN ? PEDALCYCLIST s L DenEa _E; usr FIRSr MID F RIVFRY NAMf: USt ? f D ?y a 4 lx ' + fcN A n SIREFI-ESS SIRf ADDRESS _ _ E?N V t IfY - SrAI IIPCOOE PHONf NO. D I rAtE ZIP D P N T / 7 0 ONE R S 7-23 /P 2 NfR1 UCEN N . SIAIf DA IBRIH 1 R' va.uM SfA A O RiH oN? - 7 0? yO - E- 25 (IJ F c7 / 'oP IXCUVAIICN F4 I ° g MNAME6PtKINE EYES GHr Hf cnr E ........ N / FIRM NAME6 PHONF NO EYES GHI HEIGHr Nft rc RE, O R TJJ2EJ , ? CHECK (,'I) nAE NL,m o.E aANOmee. ? CHECK(FY) w IAE LA v EH nF As AN ENHOrFE a ANOrHER I CODES ?? 7 a A i. I O S t D Momx. ,tT . x.? CODES ?' 7 oAar 4 e. 5 ucuoN ? 6 5"IOA ?I ]> o 1.5 al v X. C-. ? R. ? g ? zs 14 7. ? ? i» ? ar ? r'I' t ? 4a<l ? R h ? i 1 +t -YEAR -.1DODG!H) t IDAVIE A St YlF 1]DRK Y, .xu Y H v,l moDFl10AR ? 1 VA) R: 67 G EI ZMpi L 2 p E P? n, u I 2 R H lKtNSF VIArfN SIAt( IRA ER RAZE NO. SIAIE H A CIXOR A I C - ???• WHT. L- W 7 ? I ]Y VtH <ll IDENi1fIU1gH NO IGSRREDOVMFR 51 i _ vlH CI NrP VI : 1A II451 Mlppf PHONE NO. ( RS LEAD ?. A)ONE Vy IS f OWNE4: IASr FIRSr MIDDIF /AE UO19 11 CJ ADDRESS OF ONNIR GIE CrP•c ORE. O N E A R ]I NAMl tApO4t1SOFINSURANCIC dAGFNt IN D LA/L J>ORz Q Y R 01( a 6hp, le 0, r2rERS r ] WMAGEDMfA ,ncYi OiG»N ? .•' I;AMAGfOARU cHARG! 1, O OR. (tG. CKARCf • TOP 'a FFi0. t t51. PAwG! ®^RIVISYN URlMUNFD ?4IMNNED lSI.DAMAGF 9- 1 AWAY f ?f G•- cl t(YNFD ? AWAY BY: S IO YOTIO? /( JE/ AwAY BY: SooO DIAGRAM OF COLLISION: Eu nu ! ROW DESCRIPTION OF COLLISION: 1W 3wMEMENIU SHFfT If NO[s RY) I -- ? _(_? (. , '_. I :. ? ® _VEH. *Z WAS STOPPri.n FlT R STOP fSEtG-N ± ._ f t AND V4H• µ/. 6?Zjc_D 7b SroP.STR2k?lv(, I ?/rrl K'2 dN 7NE RE)R » NAME, ADDRESS B INJURIES OF PERSONS INVOLVED ' CODES 1 2 s 4 5 6 -' N OCCUPANTS/ WITNESSES IUN SUP,,., aq Id ADDIIKWAL NAMI AMl: SI Sli AGf IATUS IynIH n MI %SIR. IRCI {,, RaHsu.F 7oE J. Clw VI Glnr, - _ l A pr I DD.rSS D I ,( IUVId rN .N 4M ? AM Y r ? l I o B '»' . W N ? r°ni, A N pMISS AMI NAIUaId .. Y I B tMOV10IYOM ?AMB. ?fOIRI ??om. ?N? ?iF? VY b . HO -. A t qq ` OMi1f .. INMf? SCfM pV ?AMA. ?cl?C»Ibnt ?N ?i° I G » , ~ I yr Ar a nShAM1a Ahl B4 Id /4FNCY /C ?!. ICMC IVIKI` rRIND D.II OF RIIO4t AP.Rp{tO YY DAL/ x D .1.11. nF / r /S 17 . fl.L C 0. ]4nD f 41ro as »' O O ? m ? t$ ] i2 t. T ??V I?I K R r f r s ??, tR ,«?...u rIF. ?J!r ,+•,I !? t.?l. , ?.ini r,? ..?ss..?jrti ,,,7 { f ? ? 1 ? d E . .. Mb's .ffi+ t. ?F 1? S ly ]1? ? I 1 . 1 f' I' U,/ I f ? ? kl r l f r Y1 ( 1 ? F - YE ? - { 1Ewf 'h r'"ry a II+ , I L cT Tr 1.., '; .. STATE OF ' WASHINGTON POLICE TRAFFICCOLN Dr No REPORT ?TRAFFICWAY Rq JINnINUnatN ,?, PRIVATE WAY• . AI l 5 Av l iIME CWNtt ?.?'S --. I2j .. l aA. YR R ;r 5 0 r (USFRbOHWRI COUNTY NO ttN0. imvA. ? C. i3o 11 TEFFER, ors /lo HN pf U", CHYOR IOwN AMfdN00 fEt RHGHWAY CIS ONS _ ,t Grv L -4 GGNTEL I•a ?ij F Mlus ps pw $or I G tiE ION _ T- r:f - 315'0 !5 INIERStRINO NRINs OR ROAp NON INIFRStRION RREII% E ,?-??f??i. BETWEEN STRfti d SiR[Er ? ?T(O ?I 6 AN d01 Mll N 5 F •CRV SS SrNfE OR NEAREST MIE 5 ACCIDENT N D RAM OA E ttEi MILEAGE r q CODE COLL15R%J NVgvtD: tRlrv I OTAlNO. NO.IIIEIEO-?NO,INIURED?(,? 0SRIIUOE pHTe RUN I NiFll Rg avEHCUS ® ? rROrtRrvDAMA.cE OrxY ? ai'sutrzD (y(SySNRl09 ROApR E rn ? vfaciE HI.I ??? v s "'s'?,r't" ' I OBJECTStRUC%INAMf Or OelfRSDeICd AND OwrRtPS NAMEI Mom AGf SKCW gJgNO -- N o? tSz N s 150 ?? ?t uNITNaF .. ;•, ,.. [ ..?... 5. :UNITNQ X,-. 0 S MKLC p'PEDESTRIAM. ;QPEDALCYCLISr". s Ntvs NAME: Ins IR NE .NAME. uu IRtt ADDRESS R - , 9y..,? 5 O ;L21+SD L ur s Ate zlRwrEE rHDNENq D SiA E R ' • GINEPSU NO. I;a rAt I I W%:: Du- n,oeavAtNr. NHAMESgpNe3TCA.+ C„ORi-. ErES IeHt HEroNr E - ION FMH.Aifemot¢Hq L C1 Ens tcHr EefcHra hey . ? CHECK (17 vm w n IY N R U CHECK Lo 2 5m ''°NfO,Y°"OE + vfH f ?AN " fgF", CODES?t s aAU A n A %rH e, CODES Pa a: al ?qM %RN; f% S SiIMWr mrGS' ° SAr.N Da ? A... o p G ? R. ®K "" p ru Y p Me.ANa p vEN. YEAR MAEEIDOOOECHfvd ulDwr.NOVAI slvle aDR:c vl Y p'?.2. p'"'"Ot p?"`'aR? ra eY 1 EID ?^ (o LI CLCD 2 R I E SiA[ RA UR MTENO. SIAI H. N q U-}E?N?- 4 S{y;, nHlgetoeNnrlCArtorErya, r `uA C IDfnn l Nq..sR M1 .I L v HI t P2i ID4of2+5,5'I ! !0?2! ! ! ! ! ! t ! t ! ! t ! ! ! ! I f. RFGSRREOOWNER: UST r St AUDDIE REgNE NO. O 31 I, 51 nRSi' 1 WN ADDwss A'}R 0I?Py w N ?. NAMFa.3aDnssalNwRANROO.aRAOtNt E I a`";?} ? I?Mry???fy,? ??? aii?a CHARO! ?S? MAYOt ? ,/ftA ? I! :??'1 jtt g,& f IOIOROir 5 t31. McW'A AWM"N RfAWMO. RIVtN ORCAWNtO tTORt n Jl y t i ?} Illy OEY ?. WAY lY AWAY fONITO y I yi „ ^? DIACRAM OF COLLISION: iiann rs.._? e+Anuow tH DESCRIPTION OF COLLISION: Ilzs[SwwxNr,u sEaeri raaswYl 5 ?jf !' ?? .? I.: $ nR,l ?77-77? __VEN,Aw l-w!4S_WEStBe?3 ?I~v v. $ t a ttf - T-f I-7 "-1- - --p-7-? VIE H• '? b L4DTo? CE _SrvP/?,Z?p ._ 5- ?5` 4 ep_ n .. vd . _ 7 SczD._StoECugYs_AG2oss---r-RaLf;:7 oMrtuG_;`E ? ' ??' ? ? ' 'to _ReJT_ovERr_ AN_ Fiu$A(vKluk..n_%T ?N?H? ? ? SSTOP S -- -- ? ? •I . 5 ?;y _ 5S ]En T? r y I?i r - y .YN r `Dlg,mc•J1" n }T POLICE TRAFFIC COLLON REPORT LkTRAFFICWAY Poucl AwrnuMwR w •/ Z [Ff5 N 5 E W' OF S R (? MILEAGE pVEN ClES Q PRCRII-DAMAGLONLY ? RESULHD ?YTEHICLE I/ •^ OBJfCT51RUCR IN4Af Of OBIfCTSiWCK PN00wnf45 NNAE) ""A", SPECINCODrNG USE -- ?q?L ? E R G - ;6soh doss F_w -.r- - SIN(EIADOW IRFf ADpNE55 ' ti22o SecfN NI. wa 4 Slo 9B3-S39y R Thf ¢. SIAIE % y OCCUPAtION {IRMNAMf.FNONf NO. EYES -I HEGHI E OCCUPANON FIRM NAME. PHONE NO. ETf3 WEIGNI FIEIGIYI - V!N EAR EIpoDGF{NEVI MOOFl IpA4iNpVA) FSITLf IZ O4. CONY) TAN I .) MOpll NOVAI YK I] FOCITI S -N, W a ssp N R a '? ,y - q` r° t I Y0. O 7S0 8S F NAw.AOOReSS?/ wRANCe eo. fxACenr R , u,ul I sE y. ?c p N paMA AelA r" ' x '?'' %. PRIVATE WAY DAI u caps N ca s DME cou tr cou"rv NO c rv v . l No F"A USE )app NDURI Ey ( 7H, /? O y?? QURBN Y Y OR WWI HAN QN Qf Q T. A 1- NO Of SIRFFIOR HIGH AY H:t CLS gWIFdSf E F : )4 , : 1 /O MRF s ?w ON 4 INi[45E f C IN N SFCION P4FN% WffN Statfi . $TRE / f1 2`7 OISIAn<f. pl t ,CROSSSIRE 0.NFAPFSIM Lf PoSf ACCIDENT NAMY pIAG4AMMlp -., COlL15gNINVOlVEO' -E4rv / CODry ?SPIIAGE ? r 0.W o FIG O RFiEMNCF NO KILLW NO.INJURED WxpHR '" / I tOfM NO If9 n _ _ N CLS p03SSNKFfO?? . F E pIEF? , { ,r 7 5 ! UNIT NO. E -- UNITN0. .3 Q VEHICLE. ? PEDESTRIAN Q PEDALCYQIST. DR v r F: IASr FIT. MI of • pN nwAF: vER s wv It we, h-ad tv Y SIAIE ZIPCOp ONE NO D I Y SIAIE ZIP PNGNINC,w ? DO " . R H I IV lK NSF NO. AI DA .I4 " ? v a i „? !Q :. 113s o?!•t'l?/oD 4 Iv) y j,r? w a / o G t0 R Q CHECK(. a n ?:• - As N HOYFEO A.-" ? CHECK (? Hof AS AND koYFE afaNOrHE NI v- CODES ? ' i KT rxrK l ? D a / S r IDN / 6'3"AD ' CODES S.a? s n 4 it S u 6 "'° ?r .Kp ;ss" M"t KrN , N InI o', R ° O 1 7 , QAMNN- Q ? f Y . %y I ? b:RN K %qt- nN soI.DM ? « x E ? u fE ? b:H. ? ? % o /G ?'C A ?¢e </ Nus5ta15 Z ?l/L E P4-r F U mo%8/8 1 Yµ _ T ` ' STatE IPAIIE. HAI, NO. SratE H vfH QO4 I r4 Y oy W h c' Lbh' e WFl993 Lf?l4 V-41 e ' ?. ICTE UIKw NO VEHICLE IpFMIi L fHICIE OENIi . IRST ' RIGSRREDOWNHH -T F 1 I I S ? M ' ? WSr IDpIE PHONI NO. R I-WOWNE µS1 F m.. u? file ¢ IT h c/ I:L .S '•' ?. " • f,DN 'D'w'C?"j CHARD! CH RG[ ILK DfAM?GFO MIA p pN r _ •s v 1 ID r f f51 PAMAG[ AWAIIN c3H, fO r yAWV VN ?RfAWNFD It's rn VeD o G E E D•____ii a f ?( /? ,? ` ? W L a . Gn ?? I I u • N D AGRAM Of COLIIS wprurt NOarn p N ON PTI .. _ -. O F COLLISION ILae sUPHEMfNIM S.RINf NIU -- SSAR I M[Tp NECCSSAILY H .L T • t e - ,..___ Z ?? V4I I ry 1 b1 I (~ a! ^ w e f.et left s - w p+ I ! q n .4 ? it 9yf NAME, ADDRESS & INJURIES OF PERSONS INVOLVED 'CODES t - 2 8 e 5 6 ' ' I wusur^!"'Nra swn .. OCCUPANTS/ WITNESSES dACq IN>N4 NAMI31 L% AGF rA1LES w,?N NA. wi Rf S,a IHCI M.'rK?r • g•? , i nA f Yr _....-_.. _.. _._ ..__ . N ° I R 3 ' r i Arwlp Ancgw KE .N, . u?Mnr O.ua. QE11 ? ?p» NAM! ?C2}„r r E + f ` f"' ? _..Rwr'V-? . N%KI ? O' • ? N» ? "Dwv NAMI • F r Q F ??CF}v1 cY+l l t F I P I ? -. . '5 N AMalfl NNRNf v _ I1ttvtp L' Msr. QAM ?.V,KE ?[NbNr ?Frw ?ilx,F AIN,G p.K'la1 NAMl. FEhR OR AKAhC • ?wtl ` II 1M1 ey':, '. 'Y' + I F 1 KI DrSRAICMO FIX %]AYNMp DAIlp NAOfr AIPEpvID.v lMIF X ¢ (C c? FS Sd /9vo /i?'E? 7 Z3 8 i r { 9 + I ? ? Vf 5(t )1 ,? rIG ')_?"1 1•.?? I ?.Z• S` ?? ?if, Fry ,7• a .?a F ? f.v ?r• f• ><. a r!. 1••••W : r, 7 .S..Ea ?. rfAr??.K A. ?FI ? 45??N+I4}Ll7hYiaM? ??l f I ? I r " ) 3 C'. ,I K 1 i t ?i T WWW ? ? t [ 1 J I 1 I I Lr. 1 I I Yr 1 1 .. - I -•S L ? 'I? 11 f C r 4 .. S L J HIS ,`? f71 ?' I _ I I ) 1 J `? ? Y •a? t t r) v IL14J7 ? 5 I I a ^A1 F PA,' PO LICE TRAFFIC COLN REPORT U& fHAENCwAr - fvu NFNUfxeER ' [ ] PRIVATE WAY --F-l1- IAy IIMf COUNTY wuNl-. OIYNO. {MWA URe.W o f NTv CIlYORI OWN f [I WN ? fCfCly $ O S O ?Of 0N- STREET 0 CEeDxnl iPoM Rf .CRO5551RfF OR NtARf5TM1lF 51 MESS N S E w of ffFr ACCIDENT MILEAGE CODE AMP DI AM DA. CIX11510N NVIXVED: ENIIYI 11''''11 iOTAI NO. ^ NO R LLED?NO INIV4ED?? ? SP IUGE y N VvE.fIC1E$ I? SI PWPE9tYDAMAGEONI1 ? vF3Ultf0 ?vfMitlf WN IN t I'P' i ?Ir[R py 1 ?OSSy1REfTDR NAD RD - 2 OBxCr SrRUCX1NNAl Of Oe1FCI514UCX IND OWNERS NAMF) fS1.0PMAGf I SPFCW CODwG16E 4 ', S UNIT NO.I UNITNO.2 ? VEHICLE ' . ? PEDESTRIAN p PEDALCYCLIST..: 3 2 W1vfR'S Z' fASf NRS I DRWER' NAME: UST 1 l $ I ti NARS? A. p/ SIRff1 ADDR SS ,, EEI AD RE O1Y SfAtE IPCODE PHONE NO. o. UJA. 6s- A I A?c 1v- D R I SIRE Y S t -4L1 !2 2 , UCEN Srwif X DI H M . r D lo I Iv l NO. E MD. i Dw Lx z q - r ' 2 _ mrS NN ExP qNE NO. s RUSt£ FYFS GHt HEIGHT 200 c7_11 E R CUPADON IRM NAMFe PHONE q. EYES G IHFWHr - 0 '? 0 CHECK ( vfH SA norFfA ANOrNEeLL A O CHECK(?J HICIEASANEU-OMClFA fo R S x s 3 e a CODES ?? D e 5 ucroN CODES * 7 n •„ 6 SATE 3i a NIf3 INA"lles yY"° p wMNAAFXI O w ` O 8k6. ? 3' O CaG ? AMNA N E ? W" !] ? uEHVer. ? I N. YEAR MAxf IDODGE{NfV.j f9 FI IDMINDVA SIYV:14D9: V.) ('E WD P U E V A) 1 Y.) M ep ,) 5m / H. O4 l Rw SfA1E IRA TER HALE NO. IAif H vfH.CIXOR l -1 1 - I L- 41 e , 52 p tMCI( 1DEHrIFKwIgNN O. 2:3 40 6Y R}C14 E . vfHlClf D E A E . - N 1 : ? RIGi51F9I00WMR: Ul 11451 MIDDLE PNONE NO. O R DOWNER: 1131 FIRS! M1 An Asc?.? V 2 Aoo4essaowNee N E wN R • . AnfeAwoD4EssaIHwRANaco. O4AGfNr L ? I A I R ' RS E[?- ? - ? Mu D CHMOE CHwRGF• E°i?r''uc?n?"OONN f;xMAGF AF ...a1 .•.. D WAtN ? A ? HAWNN S TC-D AWA 6y: ww fOwFO ?=er: DAGRAMOFCOLLISION A.4ow DESCRIPTIONOF COLLISION M '' 2 S SSaPP!ED_AT THE ?34 slop Pm_ sc?p!? of CR?'t8_ANa _ * l R ! ;_ :.._t... , _ 71uNk6NG.. rHRt._.V?H•. a2.. H9D _?T9R_TED T?_ " ' '. ? X 57RULft. VEF?, el, z HOVk. f9YiERb T .-9Nb _ ?N Se . ?, - _ • _ . . ?. THE.. Rr..RR • . I° NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I - 2 3 4 S b OCCUPANTS /WITNESSES .p bDli(o?FUieu3a ii , xi eGi dru '" " "•', _ ,' ftSTK. GlR yKY' AMI rn . cD.e55 wTO4Ea NeeY. AM f E3 I" = OR; ?i8io ' war 'u + eDress NAru4e a ._. 9 MwEO r p AMe. ? ;-" 0=. O TV ? _4 i0 wl No ' . ENNFtS HA?rDP. .. PE ?AM. ?E::Eo?l..oH:' ?? Hv Sloe' 'c ICEr NAw erwR e+ x rr; ? I nwa II RoENCr fl .lEl N;f onr+rcl ?o 1xODNrf ' / J T !d''?T o ].00 H.S ownanPo.r wrrrovEOer 149if r E I,trfq. i 1.`9t'. l { ?«. rv1R. , 1.., . - . n?^r4t:"t H.a , ,l,r .:c ,? T . A M F T "vi I J' r. D SSW 'o i_ - E L f I ? ?, uy;,n)f yl 1 a' I'? r 1 ?_ 7 irl( iY ( / l 2 v1Y ; it. v9 M 1? - yyggA 7 Sao ? I?'f l `. ?. Ct?r ? 1 I r AWir?. r I f,l b I+ )' y ?i lfalc rT•.• ,. I ?''?) - MOTOR VEHICLE COLLISION REPORT NO. _ LDATEOFODIt[SIGJ _. D Non W f , ne(({W??OOIILtiUN .w , .,...IVAEOFCAWSON, mux r» E9 • COUIiY /NU J I ?rJ ? •• f ? i? Yo J ? IO S? PM ?c. i. : : /V ' -:•'?COInTYe_._..,_,.CITY.iOWN" JZ rsDrr C?n1/oE/c aoE MAE9'. O®.:, . ._.,,..CRY, TOWN .... .._ D® of DMSYS:w Pr1EFlX s Pc3g5» Qn[a1smEFr GDPe SECT xT r 50. ,„. GVENAMEOFS FROAOORNIGNWAY ,- im ?arr, . ,?•?i ,,._WTEPSECTWOVATM: TREETT)RTD ...;[, -r?y ? '- PREFULM EO J•?: WLEPOSi "r$ n ? , . / 5$ i(/6 G f NJN IN[ERSEC(ION10C IOHOF COLI)SON GN/H.•?-GL<fy - ) IP![? xr M' ?« GAGIIATM?:.MtTA ? 4 .;EET AND STREET PETWEEN _./jP l f 6K5. GYM :.4Ji'Y ?F I "6UL1 ?N © n.snonocno.4wIVAEPOaronn%xr FV NC.LAxouuln n.x»ocE. Mfg E v[f ''` %RD NTER MER 0.93 woq y. ?rFnxooD alAfnD ERE ai11 f?f D"PD"Oln ??aa, y+ ?, -®I-EVEHKLE ?v[rv?CLE NCrttE ?Dr »r J ?MO» EONECL' / rR+w D LE O Y 2 SPED COOS USV Et... '?1 >(.y.?rL ay .. ? NpK -?O FwC[ErEOnI»w ( j 0,., FLN I- « + f ?OFUECT STNUCN :.......?-,. Inu.EVOVaeCfsflNGq ., ,< OWNER OFOBIECTSNAME AND ADDRESS INroA ?N © OWAY ? ? 1D f l E Y' FEET 1 • • .. ONIV'cRBIAST NAME - FIR9TNAME - Mome r-.E 1. w w.. nvaLVED • • .. '. ME Mn%IL GHVERSLASTNAME FIRSTN A S-rAVNEy Lu77,LAAD ow Y? •? C0CIL L'7-F_ rZ VA A) ':iREETADORE9S ROUTE NO.AND BO%. L?a 15 -S;: k; L - , I£. nNV rwO 'N,=- Z' STREET ADORE59 ROUTE NO.ANO BO%NO P1 t 13 (o X 2 16 fl CITY .. -;„STATE ZIPCOOE' LAVERS OCCUPATION IX „nN CITY ?; - STATE OFCUOE GAVEASOCCUPAIIDN _;;?; $E/ TY?f l?V q6 IJocroe h D PoRrrD» ?o R^ -T'a' psGp .lll ' 0111VER9L1CEtl5ENUMBERri-„y:?n.+..:i.? r-.STATE DATEOF&RTH. POE. ORIVERSUCENSE NUMBER .. _ STATE SE% ,. MTEORanTH. AGE. S f -AV-NL 'S (072 XL Wu X f g 13 33 ?6 ] C Oc L 7 c w M F WV I6 So 39 VEHICLEYR:., MANEIp1EN.-0000E).-- M ODELINOVAQAFT; EODYSTYLEI2GE)• - VEHICLEYR MAXEICHEV:D000E) MODELINOVMDART).. EODYMLE120R.)?:i. I hleveedrs LSD S E 4 . 77 bob6rc dIce, "P stet _ __ LICEHse ,EiTE NO.:. .:u;: STATE. r•v ;;,TMAFAPUTE NO , :: y?ATE 1Na-3os Wu EHSE PLATE NO.. x?-?ca7?, . STATE- V/,t/• -TRULERMTENO.:... .-.,.STATE. vEHICAEOENTfIGT10EENO.(.?,;y (1Pl9MOpELSbNEWERI:..s OOOMELER(MttEA0E1 - VEHCLE IOENTIFICATgNNO. ;, ,;; -Ia98B MODELSb NEWEfl) ;' METERIMEEAGE 107 04y ta0o ,P-r7 So. L ?o wf 5?8f7slr6Fs REfJSTEAE00WHFJE.Y'oHILAS?'FEtSFiOOLENALIEk??.. ":'ORNEr1SUCEN9EN0..: ::, ;: PEGISTFAEOONMEP _':', rtA9TFIRSiMIDMENMIEI ?. :.OPoVERSLICENSE NO:;•, ?.y 1.SrAAITON ST'AVNC h.0P,S sr-Av-rv2-5671& L•cu -miz DA4ufal.. S .. OWN E"PE$4?l_:•_..:.. {+'-Tr?EEf.GRY.ANOSTATEi pRL1VID6AIGE PRO FESfieA,At (fE.Ob DATEOF&RTN. , g5?],. xE ? T3 .3? OWNERSALIDRES4 w::_::. (STREET CT•ANOSTATEI 'Po R'T 7awi.2'N' 1?T ( (30X eL16 /k -.?r.?s? .. DATEOFBIRTN';? . (O cb SD PMT90FVEIECIEDMUGEDSyyw iAIw Ev?i.OrlE REP O ? % •k' PARTSOFYEHICLE DAMAGED ?.._..-:;? i•. EDw?{ ro? . _ t • F3 5 Ono / F4oNT ML T ca .. L Q _ S WAS THERE AU LIRDILITY INSURANCEINFORMATION•VEHICLE 0. 1. COVERAGE WE IOMOETLE UABIUTY INSURANCE FFECr FOR THIS ACCmENT DN rouRGAR YES ?NO '.'NMIEOF W&LITYIN9URANCECDMPANY.. NAM N1DAD0RFS90FLMBn![Y PISURANCE E NOLOEN';.-' •..' :. w E E EP Pn .iE Gt$P??. SArL f- 3v7-a/J1o 7exrls NAME ANDADORE99OFlMBRJTY WSI%EANCEAGENT r ,-..:, „i .. '.:: 4iY SrAie .. EP LACUTYPOUOYNULIBER IST YVJURY.. .+ .. ... NAME AOE 1 1= TOIAL. 2ND--Y. '.... IVSE6 PNMiEn[rOnriOn AOMRW4wAAafs1 .. - r.••... : NAME AG ... .. ADDRESS w r, NArF' ANO--'-_ nrDF.M%.ES r SE% M F 00 - S M u E __._ ao".uuHiarac -..-I r_ro mcr[K» ® -..MnArKYInrE ®LD' o-l- AwnAroxxr Axoerom .N[ H .. STATLACFINAM ... - MARK FIRST ONE THATAFP E .? ... .:y?i S Q IAMENW WL LED R(1 1 ?INf +WNn 1 PE OMPUwf I VEHICLE ?vw44R0[R O KILLEO 19fvEP(ID uNp,I r-f IIE.C Onv rViP ?IEIKSrIN.rr ?JrpfP wnITE.IN ? 50 0 01 0E1el 7 QPEDEar»AN ?ore(a -111 IN 3 0 0 TCl 70 e v1UW NORTH BY ARROW WpNCLE \ "".,.«':IN"°.EEIED?.?x°i(:. ©? ?.ci rM Mrnre rw er a a' OESCR9E BELOW Vn/AT MAPPENED:IREFER TO VENM:LES DY NUMBER)Y}'xb ..:.;J I •?L..Llo.cl oce.t-?ro». ?uxkNS.y_ /v -?-.... GOM [.v]Cr `?'o S•'i-OI? ?.e.G.en.AQ Z C Q f f ?a C Y- hZQ? I i f r% . i ?uNRe?'riKA:ai'?.frrnmowfHOW W o< R. ) r ..A e. _ ( [ W .LD L P --- --9- Ivl i ? .' jA 2 J4rrEi.... (?r? ?cM_ L1 `>-+? Vim" ` r??Y••`fL.ill1GJ , i ??aJ?') `.NEtd ._ _. _ _ 5Y? riLr _l.,, far Of . U VEHICLES POSITIONS BEFORE ve1m.E N s E w COLLISION oN sTRH:ET M 1.twwAr NAME DR Nn o?eeiiwa vine:IK : .en r.A.eD N.a P YEHC`L «<? n INVESTIGATED BY D'.: na 0*14N K r.H W ? D fa O D m D k7 ? D ?a »r1 ^^an " D D D D AL DND c ' no4 Front DIRECTION TD DIRECTION rNMSII•W WASUSKA 10 &OEWKM 20 WELKWAT 3? s110.m. .?rhl?wy. a0 fl:"cw4( .A?OTHFR I%IAD&AIIACB -,; 'MC•[NYI v1!prE 1 ;_AlUE. AA» I?a.tKUf • .^I. LONTCONOfION9 1DDAVLIWI rRIfF,,CCOYoTF I A:-l-I v K DI 11 D SICN.LB nKoloo'. v NC! IEH ?I II?EONE W.Y?N fKAT Vf ncte ACTIONS v C ( • IGrvld MIMVDxN`?r QI1 DrKIMBrn Lw MTAHEAn ?g '/% 1 Y'• 2 OR.-4 2 D DAWN ?q ? 2 W woo SION 2 g TWO WAY ? 2 ? OVFRTAKWOANOPAS&NO ? 2 0wfl ] ?EVYOrAHII ] D GuSK ? ] ? WELD SInr D ] D Rw.911E ? ] ? MAAWD RKiNT TURN D 2 ? N [ ?(O[2 . 04 6 TS I?Ff ? . D rLA&wo PLD ? . ?IY IPCH VR f, P ( ? NAKINU LEFT TURN ? E ?K''E y OMA D DARK.9TRFEi B D -1 011 ? a ? ILA!Nwln ANRLR I (ALLEY PAN ? S ? ALLEY ? b ? MAMM U•TURN - DlileB ' •7 vcllr 1 nEaIY) L 3 a D.RK No ? s wl K ti ? ? R Two w.Y. ? D LFIT ILRN R SlOV.vq ? ? "••Cf SLLn • »LTA.n O pN(0l11.•"` ^' rdllrCl STPLFT IIGErt9 F D V(CW ? F ? OFICLR.RAnMAN LANES I[ 21 ? F ULI nTGK+lD FOR f.0FIC D S D DTNER, MFOIV O"" ? I ? 91-111D ?7I D AT yy S ? URSTCl W. . Ir'L' ..._ ? 2 ?aWDFn FL-Jr o ? 9TOa.ED N[POAnw.r ?GLRa?AKnn"A%LL'9ET, ? '. .«-..._,,..,.HpMenrmn? , ? N`«f"o NIC .maer.:+r..s.eia•,trs?utnrmumr.: ? T ?L a nrn o. .-n,..•-„c zrrrr?I • ? ID ? in.:1i ei.?Ic n...-•rv.nnr-.myR.nR l.a.rn»,,.a,... .. (k n R..: v il5 ? ' bra ?. R I 2 41 Tyr ; ;a^ t '3 s -r L i.. l I 4 ?: 1 ', tr} r nJs -i4 Y e' Y . t T ?q' y:L t?Y SA ?' l 9 1960 :40 PM w ":.? nIR? eoIWTY?a.,,n,.:.e. GTY.rDWHx .MAESwO© .s: vx,:x.em.rovm.-.,. ......+. T ? f r ' ,,::. ADM<ts P U F P' E0 ?E x [ i 1 . r;l•SO N 11 OLO Cl?. '{r,.:?ii El® 1 " lC l?' ?+ S4 •'^h WNI6. Fta?y?.N.W2 ?4?REET.IgADOPNICiNWAYrv:?..u.a : ., WTEASECfW01MM SiPE_E IHO a OAIt bra Rota -L?R CAiI»aemL PP"'Y' EO1rF > P zs t J ANN MM1EPOST 1 fk; :L^ ?Y• ° OoD• NONINTEPSECTION LOCATN)N OFCOWSION 4 ?; y?,f-iq GU /-s •F !% PETWEEN /l STREET AND STREET iU.MP A? D4GgM1 0Ar-1 1 'x1'. _ Q© "?• n•anaADCnOSlva uAEfaar ORKIEKWVwnr?DAyrUreeK.Bwaal. 'NON*. %% AO t W r a R 3T d 1 ? •M-• ..- PStCrKw. ©® O fur ? r g f•r ?P?1 ,?A1 /?1 a?a ?p . ?/ { •fiKQj'U IL.I?F.•!Aty ?vE?u.v EWCte ?vE OTE rORC? E ?arnfRPVwrU / OnwvrxvtD C ? f . P ° I v? ns vE Ear pv on (^I SPED COOEUSE y-• m " o vt clF L _ !?p s K wAn n causun ?WrWn r"wS.- OU.IECTSTRUC%..... .,..; .. IN•ud Of CNlRarercAl.1,•-r:X.,:..:._;-OWNEROFOSIECI9NAMEANDAOOPE99. :..:a. LOCAT IN ROAD K)N WAY '??•?"s"" ?® p O IPAw OlIGf FEET W " DlUYEASUSTNAME ',.: ....:,....,..:FMSTNANE :.:..-•r. .......: NrCOLE: _ WEr?Ewx_ _ O,IIVERSLASfNANE .. ...... ,,. FWSTNAME . ,.•.. ,. ,.MWOIE'-., LAcLcl OYene 1. WTW' STIIEET AOpiES9 PDU r CITY STATE PrATgN-.: M1150 STATE PORrrow l, DFIIVENSLIGENSENUMBER ,:, .-.. ,:...- STATE SE% ,.: DATEw BIRM AGE DEVV LI -MNUMMR ... ......._; STATE SEX OA .g:- TN .,AOE? M INA{3 MA WFl M Mo 3G IFS 1 ' SrNL ?S 562 Pz ?'Fi M f e CLE YR. NANEICMEV.0000E1 ... MOOELINOVA•CARTlyI': BOOYSfYLE120R1 .;. VEKIQEYR., MNtEICNEV.00DGEh:_ MODELINOVNMRR...- EOOYSttlE120fi):_::i q-1 V W DR' Sc r ?? 7 Z Gyr L Roar Pu_ LICENSEPLATENO... :.:.STATE 2MO oe-7 W14 S(o3 Y[MKLE%)ENRFICAT%)NNO--.:.:'. •.:. (IBtl8MO0ElSd NEWEPo:: OOOMdTEq IMK.EAGEI ':.._.: ,.. VEHI MEIOENTIFICATMNNO.....__118ABMO0EL3_d NEWER)..::. Melm Pt%EIGEI f (? Z 288598 5o ka Hax sG 655' IIEGSTEREDOWNER ._;.,:- fUSTSIPSiMWOLENAMEI .., . .._:_ORNERSLICENSENO_, ^,__;:, PEOLSIEPEOONNEP_. ILASi;FIRST;M100lE NAMEI..........._OrbVERSLICENSEN0.:...=;,:. U GQc? OYe. S}pH L r, OWNERSA0011ES4 ?. -:..::'. (STPEEi,CRYIwOSTATE1:?n.':.:.. .:.DATE OFBWTN,..;; • TEAR OWNED ESS -, ISIREEr CRY AHDSTATE) DATEOFBHTH , n • S ^ L W OAV rFAR TI?/ P T90 •ENICEE DANAGEp?-.-: '..::;? .. _ ? . I .- [3 PNIBOFVENfUCLE ADO ': .....:....:.:_:_.:... _._.:...........-. [arw.rFOU'asi - ro s L E a ` ? l S ?O LIABILITY INSURANCEINFORMATION VEHICLE NO / WASTHEREAITfO EILEUMUTYWSURANCE COVERAGE W EFFECT FORMS ACGOENTON YOUR CAR YES ?NO ' NANEAMDAODRESSOPLMBRITY WSUfIwNOEPOGGY•IplOgt NAMEOF UABIUTY WSURANCE N vMf ,? . 3 E rner SrY,i?t\ zn s? f•_IP ?P56S S4• Pep NAME ANDADCgE93 TY AGENT_ PO -r__,:•?,... LICY NUMBER ?, - AGE.: 2lIDWJ11gY: ..-:.. ,:I sEPAPATEPfPOR1FORAaD KWALwAXRSI :.. .- .AGES rrs: NAME OT?e' M _L1.C?CL 13 rolWp NNAE Y.Kne l _- ADDflE55 ?•}• 1 1-PEf S7? IIG __ •? LU_(,I_ W_ Mx SEX Ex E VV?? . o awls lDWJU= ? ' - -'--------._..? Poc ow o o A _ ® ? ocro s . O Lu E ©? ? N eo 1 STA U90FYAlUnEO MAPNFIRST CME THATAPWES ;STATIISOFIWUPED MAAKFIg3T CNEMAT APPUE9 '" WVENICLE Dmwe noN CU ?R Ir VENK:LE ..-.... IwuN Nano.SeelAwOSVq E•an NO f KILLED IsFVEnfI N?raw 1 ? KILLED 15EYEneI I? p NalR ? P? 0A FICI HD O pn a ?rtofarwAK O tif re e? p..ar.I AmIE.IN 13 50 60 70 ' IMER wRIrc v [j 5? 8 7 UgWNORTH BYAIiROWWGRCLE -' DEBCAIBG BELOW WHAT HA?PENED.IRGFER rO IENCLES EY NULIBERY '.. i: wea aI ' rACK VeWaf .rn MlDw /117 _?i?tY-'P?..,..-?v??AL a7srta.y? _,-4 45A SrIR rIDCwn .. -- '7!`14=1?('/-_' _ ??fC/cf_r?l,r/s2. .?Q:-- EID '. ' '"1- r ; 1 1 yr •wsu/.:,...??_?/r.?. .J?1_.nG..-__,y-5rl,??v'ei / - stm . y s` _ P Ca'e c c_ e e / O / e' "- VEHICLES POSITIONS BEFORE COLLISION LSIrICIE N E W OK51PI i ORKKMIWAY NAM, 0RN0 S Ko al•ne ..one DAIarKn vEncu Mn¢Lr arAnC..d vn«CtE wrY.PKfo 11 rrAnffo wo veNeu oecw a WvFSTCATED DY r.re ? fff... yyy IrPAK ? ? :..: r : • I ? ? 1 3 ? ? ? ? ?Ar ?PpF( t ?6Argv ? Yj IOIWM ? ? 11 / 0 ? ? ? r aWM nmrAMn ? ? ? -o- C Aassea : - rR C DIRECTION TO - DIRECTION IA W DESR% V WAS USNO 1 ? YT.— 2 ? W..WA, 2 ? S i { - IIOtADEK K ? CI?x4wwA S LJ 1c,1.1 Q. S OTIVEP ROAD.'AMf AC! WEAfKl R, LM TCONMtIOWS TMFFIOCOKTR01. --I, TVPEOFROAD FMrn WI yr vE?tt! v bvf .?I C ? OPrvEfl/VFNICLl ACTgNS N.EU ? , ? 2 1r tl f•t<p0 r ryI I W' o.tK? 1 ? DAYt N ? I ?? SI .S ?1 1 ? OWE WAY I ICWCKnnIWM8W1 IYII 1 IA OOIN09tgNONT ANEAD. _ Q I 1 pW 2 ? RAnfA 2 ? DAWN Ia 2 ?? STW _ 2 i WAY I? 2 Y? WEg1ARIpArrI PASLh ? 2 ?WET A ?w, l [QDUSA ? D ? YIfto GON ? n ? POAU ,w,xL ? 3 ? IAAKWORCKTTURN ? 2 ?''rIOW t ? /M A ? La-130r FT ? A ? FLASNYARfo ? t ? VITI-11-1 ? A ? MAMIN(1 LEIT TURN ? e ? Kt S ? 1•JTYGIYT ? (IAR SMFET ? C, ? ?ILCOV RAMPI lUgnnO AMMPR 3 01 . 3 ? d ?MAMWOUIURN IIAKANO _?d? M TWO WAY PlwSONPort KOErb ONAfw ,0 9rNEi LGKIS ? A ?IW NONLL ? d ?1M IU'rln fu ? A ?`Aow,^ a.Yw„rrCl ... ..- I ?50PIGIY ? ! ?ow,ctR.-BADMAN _fS ns.:cEVnnv+Kn - ? l ?STO FnfORTAAIFIC ? • ? OMtfl :aK!CIR ? 1 ? fPAKA1ED ? A ? O 970n0 OKAL ? 2 ? om o ? B ? SIOfPlD W MAOWAY ? B ? KO 1P ft 2 UAKIm 0 ? IO ? TAIf/IWCfllµ! A?nlllKAMt. -•'..^ J• ` • ..AGE }, < .+•,••' WaYiA Yr.?f?'u1V.•r xss'LhvtisYYn+».e.abEt Ke•nLn•arL "!'Y M1L ? 11 ' ? PAµlD NDf`S?IKVr I2 ? TNM ?If Nt[RIM1 ? ?N ?Y2,f ( . ?'hI 1? i , .."? nr ? ' Y `IM1?? }??Y^ 'G '?jjl?t??{t!? w M9 ?. M?i AI "• .'??Ir• A' H !? }' l k 'Zero^'r TU:k.. 11? ? W? I11 I i ? rv ''I >?R! u L, X,p ? ? { 7a i Ph'r_' a I ? ?` W TY" .fJTr TC MINh•-. • wr MKf9 r?N ? ., ?:.-.r Gl .luvMw !?5 '?+?.?Wry r}?ywro?'? SY Ti Grl ESTPEET,PCTIOL ATK)N OFCOWSgN MgRMM1,0AT N STREETAND STREET A r.7ME rrgr N PuierOSi ontoinrnan uFP.wore. WTER WTERi%AO•cr !/q%rtie%E?Ffwo_ [ © S ,s NrLRU FEL/ ® DF exow E,Pearmre ?i>gEFIF'•..? F.sj` i 13 h? DTKW. cowSnR wvowED (- ® Le.K n r .. I c}, v Le PAIL ? tL rP Q eRIwIIrX EI rOI,LNO ?NRKtE DBIECI ? USE .1 ES ? ? vD.cle WOEnw ? ouAVON O AvH ' OBJECTSTRUCK Inwy O•WECrSiPUCrr1 -.;. ::•..• OVmEAOPOOIECTSNAMEANO ApORl59 .-..-TIO. .•_/n,?::,,, 90- '-- E . v :. [[ - ? r 1 -: . . IF IICAE THAN , I ! FEET O V ? : • - ...i., DRIVERSLASTNAME FIRSTNAME ,.'MNOLE.. rvN C,AS OWVERSLAST NAME. .. fWST NAME MIDDLE .. °e vK wNIwLVFO .•. - ?' T1 F S? \\l \ 0+? r COUL OP.w .• `.. STREETAD011 E :.... ....:...y.0 ENO.AHOSOXNO...:. _HE iNAX /wo STREETAOIXiE39 ?.' :, wPeOrN wEAe t. ROUTEIIGANOBOMNO. . a V ,\TA? 1\ J4 ru?AEO-A CITY :..:. STATE .::'.: LIPCOOE GEVEHSOCCUPATKIN ..; COIUSIOrI GTY?.., STATE ..., .Dl!COOE„ ORNEASOCCUPATION Ly"y??? ?.a-0, .' ' - ?. . 1 N G,LU??F' Ewer FOPM ... "c ,?w.: . lS DRIERS ENSENWEER STATE SE% OATEOFWRM:. AOE - ORNFASLK:ENSENUMBEII ..... STATE I I SEX GATEOF&RM,,, AOE.. h I,p u F u0 DAY r VE CLE YR NAKe1CHEV.-0000!):. MDDlLI VAAMATI -: BOOYSTYlP1200.1 vp.CAEYIt' MAKEIGHEV -0OOGEI MOOEtINOVA0iWT1 : BODY STYlE12CR1.. C 00 - .. ;, ,. LICENSE PLATENO. STATE •.TRNIERYUTENO i;,:. STALE..: ,.UCENSEFIATENO.. STATE.: .r:TRAKERVIATENO:. - STATE., _.. ,. : .y , /EHILLEIDFW11F1G1TK)N lq.., .. ,,(1 O0SMOOELSANEWeml:, OOOMETERIMKEAOEI VEHIGEIOENRFIWTpNNO ._.; IIB06MOOETBANEWER) pOAIETEr1 IAIXEAGE - T _ r?n E'er . E n. y REGSTEREDOYMER ILASTiWST?MgOIE NAME) ?!'': i, ORNEPSLICENSENO„ ..: REOLRTEREOOWNER :+...; ILASTF4l T#IOOLENAMEI.,,,z.... 1 f :a ti l.. !? 154, OYMERSAOOq IS ET,CT'ANDSTAIEF'. I, '-.:. ...OATEOP9RM,.. ;- OWH013 AOOPE'S4 (SiFEET,CR1'AMOSTATEE ..: ,:I DfMTEOPBRRI,•. My rEM M Ve.A. R? WAS TH`GE 4& W AUTOMO&LE UAEIIJ CCJ S ANNE 3 N - y LIADIIITV INSURANCEINFORMATION•VEHICLE NO.T COVFAAEFFECT FOR THIS ACGOENT GI YOUR CAR ? YES Ly NO NAMe wIDADORlsewuARlurrnwRrHCEFOI?HOU,E»+:; ? , w....,, '.,., r,. _....;,:.:I wiMEOV UAauTYemuRAxTEw4aANr :..,,_,_..._..: - ? + ?-? • w.e Dry _ , STA.e ' - m A y ISTWNRY l,: .I46. MIN.IIIRY-••. KISE V !RVOR/-ATTOHK A - .. - 'iW- NAME ADd1E5? ____ SF]lI; cS "?.{+. Nun ,[ oocP""?ioA+-® / _ LJ.•I - ? wn?ATU90F WURED r' MMKFWSTOH-l APPIJES '.. STATUSOP WUREO ,.;. AIARN RRSrp1ETHATAPPl1E9 :'.e? p MRUVO rxOnrW A,BIFAT - NVEHIGE gSABIp O NP`IOMABIIIO wSVB1[ ' P WVEXICLE IDLLEO ISEVEPR MwOR I KILLED rINMEI IMHDrR .,.POr "? . Q KA ASSFWHI O Or P,W E/CI, FTC IT _ ?woeuF,n n.o-.` ? 50 60 7? p.n eR Un rE lr. ? 50 6[l 70 ,.` Sr10W NORTIISY MROWWGPCLE DESCRRe MOW 4NIATHFYPENEd IRFFE)iTO VEHKtF98Y NUMBER)..r•i?i?n 1 dr?',:•ur? A i? ? ' F.ocAlEUrIFwDAORAM O '. ••;?• -. ... ?.... .. --__, .. q- 'h" rmArHMFlrRO VS...?tM.`L? \__L.f.1.5Y?__? lye wurwrunE ri'? e U.N oI1w11S°"/rwH FECOa?rwq ^.??. ?1(c_> ZO-=?.ac.? r'• rKU:??..aL J , r 5ee? W? V'ebv\a•.J tt?tsa21.?-4?? ?? TAEL/oIIHDHw,r rtmrtw»'wwf / t{NznI y(f?' 'vENK;IE N 5 E OuA 910 ? j prWN ? ? ? W?Sr N ? ? ? P[DES1RAN wAR USAw A, 1? ON STREET OR HFONWAY NAPE OR NO -11: R/ WS FD WS W LIO 1?OOEWALK t? YALKWAY -..S 05.o nO q _.. ....? eNOssro 0 TRAPFK:CONTROL PHICKORI TYPEOFROAOwu vL.EUeM rc?WwcKRane Ao 1 t ?? 1 ? ONE WAY pW t ? TWO WAY ? D ? REVERSIBLE HO? ? 5 ? ? Rum E ? TWO WAY. ? LEFT TUNN VH15 w+TralYr?yAV:M1'Ny ;? ROAOSIAP,ICE MEATIER UGHTCORGTICHS , ""f ' '? • FrIC• CMI vl Kll w I ' 4V V aLI e , 1 ? DAYLIGHT I (m G'Y ? t ? RNNM t ? OAwH ? t ?N!t O ? n.Ho_4 S ? mu ,, ?t?SNOW 4 ?r00 A?O-KSIHEf } L ?A?nr '?i%iic F 5?°c Kil OFFilr ?'! y RR ? 0 ? SPECMr r ri . ? v-HI UGHrS l :, l• ' wEA,AON FOR MOTwtIHQ0_m T OTHER SlKf ? I ti' 4 t t I I Ix hPN+Kw Pt/+ VITlf.-f KIXNA /iCl 5PlGA ? t ? STOP 504 ? 0 ? YIELDSIGI ? A ? FLASHWO PED ? 5 U FLAB AMBER ? ? TN sioH L ? T ? OFFICER/FLAGMAN ? 0 ? OTHER, 9/GFY n . ??IRAFFIC hCLL OCCUneO WVFdrgATEDDY ?i E ?DHeR n. Ainol ` ?:??' III?Iqq iouca ?aoMan- ? ? m6WRF1 DIRECTION :.TO. DIRECTION' .I iRwwi?R 6UOTHER pRIVIRMNICLE ACTIONS ..- ErADIE IcltuoWi ae« Fa 1 t ® 1 ? OOINO STRMOHr AHLAO ? t ? OVERTAKINOANOPASSUKI ? D ? MAKWO RIONT TURN ? A ? MAKINO LEFT TURN ? S ? MAXINOU•IURN ? 0 ? SLOWNO • ? T ? STOFFED FOR TRAFFIC ? 1 ? SEPARATEO ? 0 ? 5t STDFO A3`04 T ft T v ? t ? ON0E0 ? . ? STOPKO W POAOWAY W ' } ? D ? LWGAO EO C3 'O ? TI om LLA EIE OTAMMFROM ? " ? PARFEO POSTION.. I `? t 7 ?5 a - kl iL h 'Y ? 't ? MFEINNOIENTERW TRAFFIC) H f Ytr lfY(f l " YMM1 ?E.eXI ? 1!'? RAOFJNO I1 y,q.T+1?yLUy l 1 l i l Yt tw 1 @ J4 ,j _? ?.wnorM Y l 1 `i'".(Y"W 4fu111 T Y r "T F t , r ?yy +? + x u ^J ' 4h ff 66.__' v i? r t ""'r5 $r tA?E tiT T+9 ? I? A .w }J K'S POLICE TRAFFIC COLLMN REPORT ® TRAFFICWAV Ppuca' wrnuMeER PRIVATE WAY DuEa : r % FAA- o uH w H t. IUSE ZRW HOV9) CWNlY nra. co clttNO. tNWA ?URBAN D. CIir ORtOWN NC'CGO Oi Sl pq iJ,GrHWrly,. ?N .' / wY FCT CIS 7 ROVIf 0R 51 1 ?W MllEr IL vrn ON I? -? 1NI ER GVnI SrxfEt OUROAO NON NIE43KI IXx ?r Cl - I-/O' 5 t1 "? BfIWEFN SIRffI f SrRffT Z? OSIANC 6018 FrgM NEifRE CROSS SIRtEt OR NFA¢f5tiM1 WST MR ACCIDENT ES 5 E W PREEI% EO. MIE POST /? TO Jv o(? t:J O• : R P DIAGRAM DAlA " MILEAGE IT OF CODE CIX1610NINVIXVfD SEVER tt. MU51 fOf.I NO NO.A IIfD?NO.INIURFD? ?SPIIUGF ? i gW1 wNDRD © r A INTfR CLt CRO55$IRRO4 ¢OWgRFNCE • - pV[H Rf3 PRO.ERtt OAMEfiE ONLY ? pFSUl1F0 ?Vf?iCt' E OB1KT SrRLCSINANFOf 09JKT3tRU[F.WDOWNfR'SNMIF) fSf O v ?/ _ . PMAGE is N SRlCUI COgNG 1.6E 9.3isz? ; - i UNIT NO. i UNITN fRS NNAf: YSt R ? VEHICLE ? PEDESTRIAN ? PED ALCYCLIST ¢ I I S MI •r? yJ //?5 A G?121'i ?rs /N? ?? T S AME E: Og1vE4 51 FIRSI «.Lc?ur?m A???- ?z C - '- -- E S . , Sfgff MDRF sl.if ZIPCODE HON NO D f P ^ R N -r IFfe2s' c H ER•SpRN ND. 2 CViN SIAIE A! H ( 5 t n• A 1v ' U E NO. IE % A BIRTN 750 f? Ct? Il°,. ! Y, ?W LUA W CtNATIpN FIRM NAVEe PHONF NO. ETFS wEIGHI HEIGHt E rKW FIRM NANFA PtgNE NO Z S.AI E " R . FTES WFKRgI GH KIT// LJ I .. ? CHECK (v) YEw IEA AH waY AHOrHEV. CODES 7 R . 3 fJK.M.W ° w ? CHECK (,? EH CLEAS AN VAROTFFOf ANOTHIN CODES ®? 3 a.v V . s'v Stn 6 'i ° P Z IN .t5 '°pN t ro ? AMR u N , ? <zs vfH TfAR ,f IDODGt.CNfV ) ? <o 1. ? „..N ? ?D1 u MO0El 0A t Dr ? M ? u Kt ? zo ? s?[t erq j1? ? r= ' SR . . NOVA) STYI(11 DR-c-) 1 s o? E M ( N .) MDIXl1UART. .f . VAi V.) I n?? H. surf rRUUR aATENO. stArt H vfH Ca ¢ EN FFw t'FTF71 r ? t . r ,o VFHKRIDFNRiKAtION NO. L .3 :. I 7 j E ¢LGSRREO OMIfR: IAti NRSi M1DDlF' P VEH N CIE IDEN fUr1 n 5 G.?IL tZ? I ! i -NO O 0.4 S d E¢ O WNtx: NSt A 1145! MIOIXf L ,}? JG 6 , IS ADDgt150EOWT1l4 W p WN ER 51 Z N E AMet AOORessa mwRANaeo. aRAUNr ,iu N T---'- i R G- W v wMAra Ntu ' 5 Oowi CHARD( L CNA4G! OMfAt It lOr D 5 tSr. pAMAOE ^RSVI tN R[AWNfD vEN lSrVOM1AGt 1 .IOP IU i0Il0? WAY ?RtMNNfO ??OI Cii 5 ? lOwlO 1 !0 IOW[0 3 AY er ? A- .1, S QE' DIAGRAM OF COLLISION iH[Et M YG- INDC e r DESCRIPTIONOF COLLISION IIRI SU.R( INTAL SHftt IE NLCESSS¢Y) f .- A9. [ Y 1/6 - /R= I L ? ' VC D( CS ? , _ . J r ` -- r- _ • A U..Y1 .GI.T 7 5. .[. OUrv . O• ?J lZ__ r!.-: !_'?. `.1 ? ._ L.___._ !.I ? ?GLU.= S?YCOLF .(?,? VG1l•.L lt!!, !t/.df 7xilUytti.!G . ._ ... ' ' ?l ! I .Yw vJ Co /l ? I? ? ° . t, _ ..+ ULN .Z.__.Hnv?i•d..._.?lbwrw? I• ? ! jL • t I ?E-O ?AwKIaG Lr6Nr DIU UEH °?b.._ S(OG • . .. .. • ... - r .. ' . 1 ?L-4AE.5+. ?'LWKENG L/GNr. UrtJ .VFN R?v.Sr?7G .. ?7PAFPKSI6r?eL, _ 1. sE?=i3r ,. .. NAME. ADDRESS INJURIES OF PERSONS INVOLVED * CODES I - 2 3 4 4 S 6 OCCUPANTS /WITNESSES j-p jpplllEWAU14 NAMIS) pAt!-. woN 3r% AG( rArui °yt"" ' . . . ! RR _. r .. .. .DD¢ru NA Nuu4 a w R, ? A r.e e.. Me. ? Ew.'1'u ? Ci N5. .p ,. ... _' ' rq. ... _. ._ .In.ess -___ HAnwra . MwtDIwM 51 Nr ? AMe. ?tYARt ?o . ? :: ? is a 0 DpNRS NAruna .. . xr 1. . 1.tnr"c mSMAlxRpr 1 r5 / N. ? M ?n ? X E , e.DGt or ArHNCr ic .erofr aK/r}?>.AjlnlrD ISA6aSx u.l ..ROYtoer w `C? JeSO /`w / MT ]4]1.41 I , To' h+ f i s? H r aM ? f' y .11 k; FF h 4 2 T. ? s? a n ? j k r Ice ' PRIVATE WAY Du N -_-PAY0FC cou rvf Y ' 0 22d?O n I (usE x+ m HOUR) ?? - OX.1NO. i L. t RSCIJ /(0 ,A Rrv w. 1??/S? ?F U.. 2 a oR foWN ?N ?E ?IN FaNO.Of SIRtfi ORI4GNWAY C43 0P3 /+ mAfs, s QW ?of rmm LAM G ION- NT?1- -? IF95fRl? M:5 t?OR qAp vONINR45ERION ?? ??? pRff1X FO. MIUE qSt .. GG G ' - !l -? ` IO O OF WEFN stPFFT 6 -UT G S/ / J O C DI IN f I 4 R[ .CNOSSSt9ff 09 NFA4ls MIIF VIN:PAM MtA MRES N 3 [ W ACCIDW7 R-F FEet OE MILEAGE - CODE LIXlISpNINVOIVEG. nRllY, l IOTALNO. rvQ RPEEO?NO.INEVRfO? ?SPIIUG Ni omDN OFNrCIFS ?BRUN WIFR CLt OEOSSSR[ROP ppAp ? fA[ ® ®pRJF[91YOAM•GEdfIY ?RtLIIRD ?vFCIE '?• . ? II OBRRSrR« 1 AMEGEOe/[Cr5r9«RAND OW ERS NAMfI [St DANAGF SnCULLCOOING US v . _ " ^ ::"L•`AT.UNItN0.1 .. ":: UNIT W" ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST R DPNR Uf DR VfR3NAME: USf /A. MIME R ? WOtiSETL ? -- srnfiADDPe t_ Fi A009[53 V 2,T62 2 2 ^ 52 ,A RPCAOE RlONF NO. D. . z OAJ6 R 3 9z- 9s 2 DR lRS UCENXN . SIAI I N I IV A l [N NO R . 5 At 1 BI I'7? - - X R N / / 11,13 D V 07 it)A 14 O e «eupuror. NAMNNAeap Nelp. Ens IGNI..H, E EXSoA"i/vEi. FIRM NAMEa RIrOrvE Ng265r- NigO Ens IGNr lEIGH 2 r '` ?x _ R J 6-O ? CHECK (.? vEH • ?'L A ? CHECK I C A ANOrNFR. E (?) F FE _'HER. CODES?? 7 • i. 5 e CODES V H<lf SAN MR D a.NSRSi 4 iirtu I 5 rncl r 27 5 y ?L WAi'Rm ID :s .D ? N N Na l ? arm. ? NrNI ? ;F D ? MrmNXf a9! ?ri ? ?ra„ KY r. W . nN. YtA4 E(DpOGf{NfV.) fI ID .NOVAI STYIE IxD . CONV) AP R ( nEV ) MODfI NOV ° n r . I .! . A) I °f Ev E Lc) oR O R WHT UCE ptA SiAf IRNEER pUlE NO. SIAIf H vEH CIXO R n ° Al I ( I - 8y3 C L - N nnlcu lunnFl[Alan NO. ven clf DfNnr OiCf I Lj iZ0 918, , L z olA M: a I RfG13ttRFDOWVfR: tA3T F- MIDR! prgN[NO 4f PR DO . Wwf9 lASt 1193r MlOplf O W as Adot/c 3 ADDReu arowNER wrvfR 2 NA t E NAmtawowlssawwewNCe ro. aRAGENr 'Z ON?c, R - YI' wM.u ARU N O• NC $I/- "° xx : ^M µ fA CH Z 'IJ CHARGE Ei • o? o• U l 4??. ^r fit p•MA(,? 1 "•O [ q! ID. [O iOn r a VO Wa ?--.D ^{AWAY ?R[AWNIO. t5 .0NAK! S roD L : toWED ? ' loiorinl: s ?• ? e f AW r DIAGRAM OF COLLISION: tr reasw DESCRIPTION OF COLLISION (USFSWIEEAV rN SNEernrvee[sw I a _ ' L I ' !_ r-!! ? .,®-__ __VEN __'_?/ Puctl£o OuT FROM R STap - --- _. SZG N ZEV- FRoA/z- o . b Lcs r.? GON77ROL ? I i _' io. ? .l .. kQ' F-Q? ? ,. fjTTE/!P_.TIN(r. To . AVDZO_._ » I o - VEH•_ ------------ I _ Iv NAME, ADDRES581NJURIES O??^RSOµSINVOLVED ?' H CODES 1 - Z 3 4 5 6 ° snr OCCUPANTS /WITNESSES u rM ADDItgNAINAwSI NAmI N SfX AG[ t IUS IN A _ nSlf. TIER v Y .. _,. -- N iJ NAIU9l O %r4 eY ?AM e. ? I ? 14 . ?a: ?ii w -NAM VIC, " y ?AMn ?M-?"rm. ?a7 ?x:; '° •DO.r - NoMa.. ...... wNe Rr ?AMe ??uXI O<".?.?a: ? IrW pSl .wl . • M1AOW W .G[??N••CrQQ Sf lul ? ?/Ct•rD ?y{;R.yND D•ifa ngPf •rrRpvtD er DAtt X 3 $ ?5?y ffi2. -I'+eV4taf' er rz? -?$ Yn >,'. t 7 A R F ^ h Ii Y. tf t , I , v is taxi" u? r tl na f "a Y J. _ :xS'Wf3AI?T1Jli t l'?r dE Mti-.'. N:f N ' '14C! . ,.. k r? Yfq ,t . y p... Nlf 2' I L 1 ;I a I J E } bl A PRIVATE WAY wN Orcaus DAY OF COUTISICITj couNrr xi IUxzHOVI CAUNIY NO. CIIYNO. iU. vC E Wn RRr IuH •Iq eNn NI L. g A l? N F GTYORTOWN ON .yµffyNO.OES?EWOHIryAT GCIS /A I gWtIOR rRf ZION ? ? ?'N I A JJMIIFS ?5 ? W .?,OP f •Y.. f f CY /a+b !/ INIt43[CIIHG W1rH 51 RPOAD . NONINI..... ON PRIN. E Mllf nJSt C f 3 ?' ? 1 e'-EN 55 SfR[fr 6 StRFfi IANCE64I4 4 tR NCf CROSS SIR OR NE•RfS -xx M . t.'IFP051 ACCIDENT R P I 4AM DATA -_N?3 F W IIT OF MILEAGE CODE CIXl SIGN NVIXV W: SIVt4UY: O I SIR S RFEIO4 09 FfRENCE T WHILE NO KIIIFD_NO INIUq[D_ ? SPI 1 iqf J C45 UOSSfEEORROAp Ci V[HIGFS $1 ]J ?PROnRfY DAMAGFONIY ? MSULTI IiFD vF HlaE 11 S/Gi e70 OSA<iSrPUC%IN•ME OF DB1FR SiRIICK ANDOWNfRS NA/Af / ) - f5 D AGF 5f1CR4 CODINOIAE "'-' U ITNO, 1 3 D?rvEYS NANf. LVI IR r MI UNIT N0.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST• x? ?/? !Jr l D T,-NAME: Si S RffI ADORE (J L Cltr Sr•IE D SIREEI ADD4fS3 xIPCOpf PHONE NO. ?? + D?NtR'S tKFNSf NO Srwlf f% I Y Af 4 H I lS? I V SIIC SE NO. AIF W &RH I OCCUPAtgN M t6pEgM1E NO. ETES GU EEIGHr E ? ? F CUPAt ON FIRM-E.PHONE NO. EYES IC?II NIGH T .7 ° i/FEC R ?CHECK (.l) 'vEHKIf ASANrMao+EE Of ANOTIHE CODES ' ?CHECK (,I) EH-ANMaoYEEOAroTIER ? 7 n 4 i 5 Y r d CODES ?' 7 a A w Sex D W, ? "Ji ..-RS ro» ? .NAM 1 ? u ? Csm. ? 11V; o ram VFH. Y [w R EIDDDCf{Hfv » C) ? Yn Y.Y ? YlPo M f ? E ? zs6R 'Y C 2 ,J EI IDMINWwI SIYIF Ix D?{ONVI H fA9 MAK I V.) AlppfI lDAR y 1 ) /^ 1 C~ . H OR 4CFN1 P.INO. A) "lEGMITNO. 61ArE H vEH. cOIOR rl ... 1 Ir KHKIE IDtNNFKA1gNrq. L 3 563.3ti RI ...EDO. HR -1 FIRST VEHICLE IDfNI fI I i ! I I MIDDIt prgNfrq. O ` SL IF- f IS EREDOWNfR: LAST FIRST MIDDY p ? W I]- ADDRESS OF O.VNIR LE7 N A NFq Ill E NAMESADDRISSCAINSURANCECO. ORAGENI , D? _ y R n OAN. Omm pur HO I HON S/ nPK,kwu CHARGE Y/ CHARGE PDO AREA OMOr 3 lSr.rWAA G ' N L '? ? AWAV lEMNNEO IDP R iOf10? o ?;WIVLN ?4[MAINfD 1".. - ?• T Oer. •' ' %nvV i ? TOWtO eY $ D - DIAGRAMOF COLLIS19N lu n INDKAY NORTH DESCRIPTION OF COLLISION: (ME 5wuMIN1AI WET IF MCE53ARYl IA -. / ,SWlrn NfCESSM f eY AR ;/ J .. I `? . Y YB/d/G1:??I.LG/o•S !JG/°?I Old..?i /.rLs? __-- _ " ?f° ... . -...? ? T.^ /`ti ?./•L ??a( S/7_Er/r/fy/d SpJGe?C L?i)???. -;. _- w , , G CUi d - ^ .-7 ,... .. ?... ? _. ?. ?. / G!•ct[S:'c/ 37B aiJ ??u,;?/tlG%aE4FH_cI- w .e r. c yirc? C•a/,rC' i? / ?Etr d {/?/c?, .x n. LP°dn/t IO7.Yl. NAME, A DRESS & INJURIES OF PERSONS INVOLVED ? CODES 1 - Z S 6 ° OCCUPANTS WITNESSES ISfr.nfAflNluslAn "'.v ipN• NANIS 1N NR Y M I I wf .G ?• .4 / r /1IU?Pr??i NO y.3Y2 I'll • 7 ?' K% AGE IwtU5 ? R(SII. lllCi ?' UR . H• •DJff 35 r >u no P eY A.11, ?;' ?"N E ?: mwY .-f3 N,r• NAItq d. „ y ANTVfO IRON ? ? AAAI ? W, r ANS . f ? w.- ? n :Hr r , , 1 144 .:ells NANgf INe tlr ?AMa ?MIT w' ?tr ?n MIS A•40FK....w111•NK ' IF UY :N,f NCr I Kf 11 GpD Pp Kf FjBelytD UArl IY %FWr p FIT : ^?N 'i qE M PMTSOFVlTIICLEOAMMIFD :_•:: '+': cr..c_.__ ..x,. , PAflTSOFVENgLEdW J-. ': ..- .?,? i:..,..: (SI WA9THEREAUTOMOBILEUARUTV RANCE a LIABILITY INSURANCE INFORMATION-VEHICLE NO. I COVERAGEIN EFFECT FORTHI9 ACCRIENTON YOURCIJI,j YES ?NO ?nll NAME AND OF UABRIfY WSURANCF T'OUCYNOLOOb U I Yl h 2 :.w....: .: wsuRA cECOMPU Y,. .._ x: ;l t ?, v . is ,la's"TE ? • sr??a l a NAME ANO OFLMOEIfY E NT:r _'.: - MTe,-_ - 1( PIEt OCD, H Putt. a. yG I ISTw Y •M --,}.. C T'-. Y.., ME.- 2ND VMUiYAST ._F.'.?:il... VMUTEP?IORT aRAmtOUe 4., .?FY. ,F ME[i - NAIAE - NAME -'E,l .. ?a ADDRESS fL/V SE% - RAT Doc --- nM D;D? a I DDCIpJ U E w?,oNRr.?DTDR F9 ED a,, STATUSOFFAAAhD' WE J .,-MARK FWSIONE iHATAPPIJES .. STATUSOF-EIRID .. ?• •. _.MARHFNISTONETNATAN'L1E3 Q DRM WVENgIF DDIABINO NWrds?,Iw.nO E •.?? WVEHgLE OJ+dFVUO nOIIDLAAYM BlE •(. ?FA$ gLLEOREI NY OR f RUR DEliRAN KILLED ,yEylRET IA(I•MI I DMR4Nl I AY,ETC ?RDfSIIWW °F I•AwtTCI 0?. eIN 11 50 BQI °7? ?n EN waTf.IN ? 50 e? 70 'N -' v+OESCfl(JEBELOYV VmArINPPENED'OKTFATOWnGFSDrfRIMOEnt ?..::L'.Y•iTU? 1r 'S't SHO W NOPM BY APiIOW W GPCLE \ .- .n.1 ..,.... ........ ...?. .. .., r. ..,....... ??? MMNEE M?H6.?N+??xAAAE dam,, O \ 1? ?N.t.? {_LY ?Yt EP,/? ?lA lV 1???? E+, NRrt4(ACN Yft. AND ' CAViYY w.,.. w-. GTY.TOWN.-e.•?r MLES,w rl rtEl -.-CI Tom LJL 1 K rTsFG RR,U ?0 ®OF ul1 I?iLN Ll R v?JS?: RnADDN Gy?HAMCOF STREET,POAOOR XgMWAI - ., t -_ WTERSECTWDWITH: STREETOfi ROAq.+. I: PE EO l Ml , }W u NONIN TEflSECTIONiOCATgN OF COLL1SgN L[/?•f•,f/3O.V U/GLC? ?(: O. L, P•' p DATA' } ? ? 'y DETWEEN STREETAND S TEFTT , A .? y ? !! ?? ., RER, R Q © nowc ui[Rmronlo[iiTVr LAnwAn(. E TFJ4? ?YMlp1lf D f aR0aR0F F n S J ? q { FCfAW: .... © ® IF Saw,. ?A ? wttE : DIA ?v wCtE 60 C E ?OTnIn IWwTFI 6PEG ' Mew ve OM f ? 10 009 ? ?? LE RfOF]:RAlA ?Rw001 ?nlf m,n '• 061ECT STRUCK- .:.... .IN+LGUOaRCTaTRUCq -.?.:., Y.:. OYMER OPODIECT9 NAMEANOADDRE53 -V Y }, .A ?N© EO O d a n DAD 1 i ET LOGE LCf OflIVER3lASTMAME:'...ts,Y.:. ,. : •FW3I NAME , +. v,M00LE..' O l DRIVER9lASTNAME -.. (.FIRSi NAME... .. ..: Mgf1LE, T?; A ESL _ ' - c Dw`? DR _ , / (GS 1t41A1t? /t/ Lfu Er AMADORE59 .. ..: - .: ROUfENO:AN000%NO --. AOnE mAx TVq SRIEET ApORE53 igl :.':; ...: igUfENO.AND BO%NO. -? ? -? '- - FERSDNe WERE INUREOMA ` /? J?3 ?. flf-l CITY .?-.21P CODE ORNEP9000UPATION .:. <aD4°N CRY ?cuDE . a srnrE .•• R PArgN . aav E SO C CU p 633 ju N PEIC "- /; .{- ? j OYIY pj L-, (.0b3 -(7 ??D n ? T ? / / I 1LE:.l i vei0? MIVERSUCEMSE ,h,?_,•,;:yA STATE SEIN .; DATE OF &RTN_:: ,ACE' DRIVERS IICE ,I-DER STATE SEX ..: RITE OP wflTH •,A -ADE, -£-5W- 1 L WA E o %AY G? i ll aA-KS-? (/79Qu£ a M - i S veil YR.. MAdEI_EV.-D000E`l_ NODEL11gVA-0AflTI:=:: BODYSTYLEI]DRI'?-.: 1570 Y ?: :; MAJt VFNgIEYR E 1CHEV: WOGq .. MOOEI.INOVA-0Agi/:..: BOM ITTYLE12-)1.L'.. C 6uKEee' , y l . lrJ b / It.?? ...r•}U'b I I C?. V _ LgENSEPUTENO. •: ':uSTATE,::i„-:_tiPAILERPIATENR...:: :.,'SIATE.I '._ '.. :.. _UCENSELNAfEN0.,. '_.. STATES;:; ':.. TIWIFRPLATENO,;..:: :9TAlE:::;i{ vEHgLEgENi6qAiqH NQ•;..,:-..fl9BBMOOEL98NEWERF?I:. OOOMETFJIIMILEAOEI .. VEHgLEgfN1ilCATqNNO:_?; i,'.lty&:MOOEL9d HEWENI:_::_ ETCH (MAEAOE REG19TfFE00YMER.;':..w.lt/.4i+E14T.MOIXE.WUAQ i::.. ::;i nOPoVFASU:EH5EN0.'.;...::. -cctaTERE0. ER:;.:.DAS _IST-PLENAME7e;.,;: DRNERSUCENSEND.:I-: •:u.: ?a A t?s?B Ga-( awl cs " Fa(Uik k1 OWNEASAODRESS -n., :..:-.ISTNEET,GTYANDSTATEW. Y.%:.': I`OATEOFBWOI:: t' OYMERSAOORE59,.-r 1, ::ISTfiEET, C/fYINOSTATEI. .: ,.1 .:?'.:.I TE OFDW11f•. •,• Sam ?r ? -a. yvE a ? ,t rl E LI. VEHICLES POSITIONS BEFOI I •? VFIIgtC N S E W 0 [is ., w ?Gcl?? Yy Dl(N Pf DERTFA ? ? O ? n1. ?Y, ? N WAS USWO MADSWFK! F?tc•OYI rfwcll NEAfMCP C IP,n 6?1 QIF, f ? WET 010 ? J Q -. f1uNWp ] J Q4glWlAl } y,r & ? A ? - t ? f00 -- s ? I°svf c?Frl Y ? I ? r ??' . YASnN iCRNOf S[ ,/I.+DwWfMl. EM pu%:!R .erow frcl w, 'n __? U L..E?L L L9/- a C. C.7,1 YEM1 Yr _??? 1'f! q' ] 'n,et ?( -LcyCe c l"r' - oe ??iO 'a S ? ? ?^`?• L. N Al f? N_R•1c.cs?N,?i.J?.9 ? a?. •I I I R S COLLISION NDw IANes veNCU Wncu +FNwe°wAd wvesraATED DY p w one DNLr Anovq UAALLr PAIw[D V[HCIE OCr]Y{D ?n- aL ?:DUC[ A.. d191'REEi OR IIg11WAY NAME OR NO. CNM rl] ND •Y'Cf rl?S Jb?.. ? '.? ? ?' ? '. ?.. 01M. ?oATw E4 {. .? 1 ? ? ? ? ? ? QMR-1 ? xa . ..,. uAOwn' '.? : YR1DM DIRECTION `TO; DIRECTION, ?v I ? MOEwM% ] ? wAlllwIr" ] ? 9gULDER 4O 1..,oitnALII 50 <Rnvu"RVIK% E ? OTHER "TCON0ITION3 TRA"'CCONTROL glNCe DnLI•= rYPEoFR0M DRNERNEIRCIE KT.O", YtNOII 1NC11 IIHllil, vfKt! ICHtU dI OA IADn(I' ND I b E ] A'a'tI ND ] 1 &DAII-T ? 1 ? •JGNMs QI 1 Q ONE WAY QI 1 Q OOIMO DTI A1011T ANEAD ] ? DAWN ] Q STOF SqM ] Q TWO WAY Q 2 Q 0VERTAIQACANDPAS8iN0 fPW ] Q 1.- J Q YIELD TAGN Q J Q REEVE SKE Q J Q MIXING nIDHT TURN ROM A ? L-i3 CAIF'ET ? l ? fl-ASHWO NEO ? A Q WfCRCNANDE ( ? MAHWO LEFT TARN F, ? D R 3TRFET L%NTS OFF ? S Q FLAHO AMRER ? 5 Q IALLOLOEPY /RAMPI Q E Q MA%WO U-TURN 14 K? S ? Mfff 1. NIS ? C Q let yONAI ? E [] LEFFTT t-WAY. N ? E ? RLOAYq T Q OI.F. ? f Q OFFICERIFI.MMAN LANES 0 F Q STOPPED FOR TRAFFIC „ ? E Q OMER, oEE'" ? 1 ? ECPARATED • ? 3 Q STOMD AT ASIUIfAIL oftropl NA Y ? I f I (^ I ?'. I ?(qN -i t ?4 1' ' ?• 0 0 e0 : [3 am STM 21RO ? 3 } . 7 1 :Y1 . r n .(ti NAMY :.-.. ..,, :•:;, ,.5 ..: ,_?. ADOPEA/:•. 47 ; :1'1'A?SLa ?I3 Yt. =J'71 spG ? ? ? i ry Ty?? . - - ?.; ? 12 ? TRAFFIC) OIENT[M TRA!!q/ S I fl Y a( li 7,17F, La * l , ''Jiua,P 9 I y .. , l ? 1C? cn N >LC . E- FR San! w ?+ 9 D oc C Y c j? ? ° 9,$%70 ?. _ GIVE NAMEDR STflEET.IgAD ORHKMIWAY r: _,;.:r ENEECTIlGWITH:STREETOP ROAD PREF1% A !0 MILEP0.Ni 1,. M i`c '`,NiiP COuvT.••-/Pt?._% EA?E2 Va[[LTP D/P S / _ . J _ TI??, il.,I ' ,.ONIWEREFCTION{DCATIDNO 9}Ll N 'L[?lt /Y.l !/J%L"?-G <-.rU P?A,?MIR 04VMAM OAiA?i}., NT{"I:' { a-"'N?4?CrtAJ?tSe _ RETIVEEN STFEETAN0 STREET r ©© ' MkROiMESUros"sw¢ri?eDOSiOROUffiiwa`L,ivwiuliueEn.Y",oeE. ilr. 'NONI%AD. W liREltort AO?aw.."} IER "E, NTER OS.. TE ©® o _- :3?'ll:X'aar HJ-JCJ.t6G.+,fi'A ^ow` owuo[v[D RttEvFN[L! ?v[rKtE ecraE ?oi RrE1 ,,PEC.ODDSUB "" F" ci ?iNKtES ? ?»» ?vEMGEOBIE<t ?vERKLErRAw / ? +r?,:???'?+-i . !k- ? .c?._,? LE PECtsrRM ?wNKauvO ? .wNN ,' OBJECTSTRUCN ,. IIMNEOFIXMECTSINKAI,TER.}YAe:t:_.1--OWNEIIOFOp1ECT3NMIE MDADDHE3S. .. LOCARON .., ,. ....'i:;.?® T'?' INMADWAYFEET •Elp S- FP DETECT" • • .. IF MORE THAN ORIVER • • I-- ....?_. ... FWpT NAMES „ti-•a?.... w._.MIDOLE 'J ..- ,IfY ?E+LASi NAME .. FlRST WERE uh+%.l"- MIDDLE _RE wvOLVFO ORNERSLASTNAAIE A 715--S C JC wSWoR OI-Trs}r*?IJ?? ELso C CI .,..__..,.PWTE NO. AHOBOXNO - A SrnEETADDRES9, .„Se•..?,;... UTEHO.µDBO%NO...:, r Mlvq STREET ADDRESS EnFT°VEEA 2-?- I 53 wu "- STATE . TY - .: ;..,.STATE---s.;w.S:i. 21PCODE• DRIVFRSDCCUPAININ, ?: SEPMATE / bcot- ?,Nr ? DflWEflSLICENSENLIM ?,,;•.r,.;,-,,,:::.STATE r.u?ATEDFDRTH:.. ./DOE DRIVERS LILENSENUMBER ,.-.. STATE. SE% .. DAfEOF&PRI ;AGE, -7,-c •^ 3.1 /mL o 6a/ flKS r-* k)79'7 OE ' EM Y?AHt)+;,. SDOYSIYLEI2DRFi:. ?:? vEHICLEVR: ALMEEICMEV.-0006E1MODELINDVAOMTI:.': pOOYETYLEI;/,. VE) TR- MAKER EV.•DfjDOEI MODEL INOV • 0 o ? S L ?(Lf , I S L s7- T il. n L ENEERUtEH6:. 'n:i.3TAfE e•..:r' ..TPAAEI[PIATENO....:. ."..e3TATE.A, FF ..[1CENEEPLATENO.. :.,.rSTATE TRME-TENO., :-::STATE-.:STATELogf. LvA 1'. FrICLFO[RtTGt10NElOn.-?..,_[[9MMOOEiSEHEWEAI:.•r. 000METER(WLFX'.EI VFNICLEDFNTIFiCADOH NO.. 119Ep M00EL56NEWFJi1 DOMETER IMXEAOE /9 3Go /3N_2 7a F ?D?7? (off 9ocv ""1 RCIiIDAEDO[IM11.N.r F.A.pT7wpA?pEAVAp_.,,;, . i.:,. AIQ_ pEOpiFNEDOwr[FA..alTiEIStYOdE tIAIIEI. ...DRIVERS NEEtq'^_ 154 .?k><w eql; k 79 oE' yyjjjj /NtD .nvEdplrtN a?PwoaTlDntlE ?.. ROTYIMQlTATEi.:..,,:-: OAIEOF BIRTH ti. M ' PMIlDFVOFCIS6WA6tD,,. :ra?wr wV??! IMRdKMitIDAMAGEA.a.nv ..... roM1IA cW Area, S,//15 Y ?"' , WAE iNERE AUTOMOBXE IIAF+ITTY wluPANCE x LIABILITY INSURANCE INFORMATION•VEHICLE NO. 1• wvEPAGFtw EFFECT FOR rNISACUOEHr al roles CAR YES [I NO ' NAME MDADDRES4dlM9lRYtN5Uf1ANCE HOIDEfl.'s'v.4r .T„ ...-••.. , ..+ .? YSiy.NAMEDFLMSIUTYINSURANCEMIRANI ,;?,;,-yy: ASILITY POLICY NUMBER ..?;?6 ?:y???:?,.?;.?': ' AME MOA0011E390FllAfllUTl'NEUIINICEAOEHT-``C'-cu.l? ..?-... +'.A„a .a-H/ •••?9p 6TH 11,7 p ! WAY. A / G o -E?7 Y78 r ;1 IST WJIIIi .•^... "4u'° Ki 't4. LV}.'L""I -sfev.,. ME.-.. TRD N3E9V EREPrn FoRTm KwuNMMREm „,..m.a[n s?"2 NAME 4.0.1 ADDRESS ./e .1_.L3o(.?a?1 c.. Cf(I.FfA.L?!HrL?/?_? x aDwES?o73T_ HR?[m.clcF-ET.'.f_.%'?,?•f_ ;?c<: i;z ?tsco? t2?? cLC?ow Jko ? E.TEItC WEB[ fJPuFS?J ®=?Yn c E wlrD _?o v?ccr?a ?_?1 .. .iMSNSY E DRT ® °OC -A/ I °E' 1 Rr,coDroR. aAN, cn " ? SIATUSOFwJWEO. - -;;.Y:^,,,.. MMKFYiSf ONE THATAPPl1E5 - STATU90F WURED ,.,,, MMN FlREi CNE THAT MRIES - ' -wvaD,IMM • ? IN VEHICLE, -..: 0.a4xwo NdI OtLEt -.. e?E•-• - ,?NrfR KLLED ISEVEREI FA- I ? .SBE R KILLED 1MT31 IMlrgnlp PIE ME OFP iC ` w 1 A,N .?PFOfs[H I ? DE9 M NO' 6? G I` r ?an.En'A n_.IR ? 5[3 6 ?D ER uFlrc I El 50 - ??? SNOW NO????WINMbGFA1E -=•?p\ OEEGIIBE BELOW WHAT IIAf+PENED.IflEFER TO VEHKT.E$BY NUMBER}' _, r -???:.0 c?}\ _?Iaq?PiPocC-cF.J/?G_SLaurir o:? croui?? R.c mr' p,SON -VA M`rr"D?IIDFwlt"a`sNOw ?' i(1p,..-(ilpiSToPPGD-?Z.._.T/AE?TcPS/?n/_oN ., -?? Q?"' Sa /? ? sr.tt,OR _ -?DiPC?T-LiIJ_LL?PoAI?!/ec/s/L?dAa.-,zf?/r?ty T orJriE.._ /.TuTcAP.PL/.F?-T-?'/= __T.YI f?R16'EUi ?tj Ipyp I I I V - ' "{ COLLISION r.o "aoH'Ars YE"GIE YENa, ,m w,a nrvlsTmAreo By VEHICLES POSITIONS BEFORE ,LIrP,P+FO V IP MCWNo f I M64LY ]r,NnTKI l[D OR nRICtCN Ip K ? VM ?OMER Ei' VFNX;LP. H 9 E W W STREET OR IROHwAl NAME AO r[s W rEi II P,IME sn• %`rKF ?"a,r,oN w _ S nwarRNn ':: ?.'. ? ?. ? ALoru ?."R ECTION . TO OIRECTION,; " lot STIlANWA3UEw0 SIDE... 20 WALXWAY ]?DIfOULDER ? S ? f wNN , ,vnr.rK n IL_ - OMER F ,? •' C {IOADSW/ACE WE-eR•a.- .^; IAIf CCNpTIDN6 TMFlICCDNTPd. -• K:NEUDMI TYPl DF ROAD ', DIXKPNENICLl ACTgMp , , 1? M6.11 VlNtl! Y NK f (wt V ,N:Lt -'--" v[ ( EMI M 1 b[ 1 L M i OR UOMFI r !NURNl MIADRR?• I •.9?1 lMfi ! V oo- 1 ?OAVIIONT ? I ?.-ALl ? 1 ? ONE WAY M1 1 ? GOIND STRAKWr µIAD r t-. pt 1 Lfi•? , ??` -N,NO 2 ? DAWN ? 7 ffSfOP SIGN 0 2 p, TWO WAY E] J C] OVENTAKDKIAND PAS,,NO u 1 ;, , ? 2 ? WET ] ?SHOw+NO ] ? WSX C] ] YIELD SqN ? ] C] ROAD SIDE ? ] [I MAAPIR II%INr TURN ? ] ?rMw ? F? 1 ? OKRITS ON ET ? A ? RASNM PlO ? E ?INTEPCNANGE El ? } MAXIN[ILIFTTURN IA ? ? IC! S OINF.R S DARK 3TWIT PL ALLEY OOP/RAMrry 7 OTHER ? ISF'Ecl/YT ? Lx%{Tp On (j E • ? iLA3N:N0 AMBER ? 5 ? ? 6 C] MAXMDU.INRN T? SFl 1,Fkl r I ? 6 ? EP/CIrv So DIRK ? IT ? PR SK?IAL ? p -] ITEF TURN ? R ? LLOWIFM f'? (?? E•ASON PoN MfpEIDIgD LINES Icl-' ft 'o o' ? ? OIFICFR//l r ? STOPPFD FOR TR/JFIC I !KLwONSK,[MrR.OfKwE Afcf" r A^MAN C3 f ? E ?OTHER. SPECrv ? I ?uIMAfEO ? p ?Sro%•FDArm-.A O StdNw 1 T :" NO iRAIfIC "• ? 2 ?OMDFD ? ?STM/WO RI RRAOWAY $?'it ? ? ] ?uFalvrorD ? ID ?rn,rr rLUIE ){ wrtM11KFW.+, T?1G:."9r'x'1'L."tJ1:•du!51.'r?°:?la.S`' '..lS:IC.Pf/7'I'G39.S3A?.di ,lE,'.c AGI:.:, ? iI.Q ."^"fR 1 MIIRToR?! ETNFit /L)C. E .PT r? Bp?K SSk_?UI L'G - 3 ? 1p ? in^iiKl ltrRlnNKS F ' Y 1 71177- 5?,r.:, 5 L?,C . , . - ? "'?+' t-A'ev? y;,Z 4 ?4 a I i tw ?r ?. k?' ? y". . - V 1 f ? ? eta °' ? ° ? ? ' ,, w+• ?? k : p ? ??? i ?? T t ? f ? f d, ? , ?+?,..uk .,. ? ? Y _ ,1 , 'k e ' ?, ? 1. y } q t i` ?I ? _ 5 F ? - r ? i ?, ? F' ?'?? ; , s3 r a. ?? ?"P, d -c ti `° S- ' ., 3` rv ? d Ly ? (S. n ;? _.? ? ` ?? ? ?, r ?` 4 } ? .f ? ?. ? ? _ l L ! ?.. ? ? ? ? ?rh, , ? ? ?r° w c ? "? 7 ? ` ' * '? ` ? ? f s? z Y r ? ° i a' ,? ,? . ? l ? r ? i ,7.?,¢ .4 ? " ? ,r Fly, ?h 11 t?t:'? [? -. ' _ ? j b ?: (i:;? -? ?y 1.4 :, ?. - v r > '•' -?. ?' ? 3 ? . i ^ `_: i ? j ? f m ' j 1 ,? ;? ?, a ,? C O H ? f+1 O '. O O '.1 ' O oo ul -1 . j J . O? T O r-I 1 o ;? I Farn .i i' ' ?? ? 1 fits ti u t? ? s? :? r i ? { ? s -? ??? ? ? 4'1? ; t., •t? '?? .p ? I , b; may', 9v?' ? i a r?te? r??; ?g. u ' S R . s • _,__ 1? 9 t iI ' ,u`_. _.,,:. .:,.r;- -., ,?i1 ..}?'ft? _ a: °?,s STATE OF W SHINGTON PAGE OF ra;u.. .?? r r. ?.?,. _ iU No. ?_ - 1111" • @ ',r UNIFORM POLICE TRAFIN COLLISION REPORT 4 9 yy J oy i D DATEOFCOLUSION DAYOFCOLUSION TIME COUNTY NO. CITY NO. FHWA J` I s 7pE MO. DAY Yfl. T SUN 1 MM NES WE A IINN 5 FW p SAT (USE Y400 HOUR, >' / I PARS AN r . { CWNtt EFI°fcRSON ?STATEROUTE ?CWNTY ROAD ?CITY STREET ?OTHERISPECIFYI = O y ADMCLS. PREFI% ROUTE pppppp STREET CODE ?(•? - CTION N 'iaSA O CITY1OR1 To.. MILES ® ? ?? ®OF Crl"T'zR A WA V PREFI% EO. MILEPOST 8 I T •4 ! Y A NAME BNO.OFS IOHWAY p- ' 1? ® INTERSECTWS"TH:STREETORROAD 96 I Iyy LL O RAMP DIAGRAM DATA ! FP I O N I flSECgON BETWEEN STREET- STREET ACCIDENT MILEAGE CODE TE NON INTER %RD LIS. INTERSECTING STREET OR FlOAU OR REF ERE CR TREETOP ROAD v O ' . _ x DISTANCEANDDIRECRONFROMREFERENCEORCHO STRE ?MILES O S E W' OF ?FEET M uHIWElHS P IALCOOINGUSE 1 •.' ?HIT&RUN COLIJSION INVOLVED: ® VEHICEE-VEHICLE ?VEHICLE-BOYCLE ?OTHERIWRITEI TOTALNO. ?VEHICLE OBJECT ?VEHICLE-RRTRNN ?STOLENVEHICLE OFVEHICLES ® ?yEHICLEPEDESTNAN ?NONLOLUSION ?HAZARDOU. MATERIAL NO.KILLED VERITY NO.INJURED laPgOPEfltt DAMAGE ONLY 44 - - m+.k+ 4"fi ODIECTSTRUCH(HAMEOFOGIECTSTRUCKANDOWNERSNAME) LOCATION OFOBJECT STRNCKS E W EST.OAMAGE ? ROADWAY FEET ? ? ? ? RD EDGE $ F ' t II DRIVERS NAME-LAST FIRST MIDDLE DRIVER'. NAME--T FI-i MIOOIE IIF SICxCLl5f ON YEOESIHIAN CHECKI §?? D t V. ° C L Q_ 'A fRE TADURESS - A 6TREET p00flE55 _, V • SA v 2 o 22' RE GTY AE LP CODE. PH..... . RE CITY STATE LP CODE PHONE NO q Z ? ' N OWNERS LICE 9E NO N . .;.:. STATE SE% DATE OFBIflTII MO DAY YR N RNER. LICENSE NO STATE 6E% DATE OF SIFT. MO DAY d F . O - A- . F . . 03 27 57, 0. l pic - L - O - 'SO /V Z . O ?: CU OgrvERS OCPATION FIRM NAME .:. :. ...-... O. 2 . P EN -}• F ? OY! ? V k ° '§? cN /OWN$ CODES >1131 Cu?y IU SEATBELr ISI EJECTION c CODES >101 A? MI SEAT BELT 151 EJECTION >y gi ? ?+ w A NNAATU Cf NATURE OF R MJ ? ? EPJ IES U MOVED . FR MV DNE nY: TO `g EN RY: TO VEIL YEM MAKE IDODCELHEV.1 MOOELIDMi-NOVA, STYLE120RCONV.1' VEH. YEAR MANEIOODGECHEVI MODELIDARtlIOVA) SIVlE120RCONVI V ? PORD PT N 'z oR. V A S" 04'r V. P/U .sr. ? E VEH. LOq., U . RATE NO. STATE MRER PLATE N O. STATE E VEH.C OLOR I.C. PLATE NO. STATE TFALER PUTE N0. STATE tt!! - A N s- z W a C VEHICLE MENTIFICATI N NUMBER ........: .. ... ODOMETER C VEHICLE OENTIFICATI N N MB fl .. • .... ODOMETER .:.. . .7 " L E . E 2 8 Z .. S - REGSTERED OWNER-AST .. FBST MIDDLE flE(ySTEHED OWNER-LAS FEST MIDDLE 1M N BO VE O. E SA4 n ADDRESS OG OWNER ADDRESS OF OWNER _ .Ti 2 t NAMEANOADDRESSOFINSURANCECO.ORAGENT NAMEANDADDRESSOF WSUflJJVCECO.ORAGENT ARMERS ENFORCEMENT , CHAgOE ,., .. ; @ ?,'. , {._. ACTION U f? l ? • NJURIES OF PERSONS INVOLVED & 00°E9 J - NAME, ADDRESS I 6E% AOE BTATll9 N b'' EJECT. L. NAME: C ADDRESS: D N UREOF 'AgVEDFROM TO RY R :: L1 _ P INIURIEB' : E WE A NAME L N T ADDRESS: $ NW JLIWeS: D SC Nf. .,:FR M TO } ' W NAME: S I ADDRESS' IC I N wJ111ME' SCENF nY: TO 1 }1 ' $ NAME: 4 L ..V S AODRFw ( E $` vaAl !S b1AlU5 ITI5GAf 1.051 TqN I S HP nY: ACA' TO i iJ11NJUHYCIAU. IAISEAT UEL IpI EJECfK1N ?" I L I r 1t ?Y I I OT ?D ] O l1EY 1 L -' _ C' O J PETK1 LUN % 1 ]_0 AE DATBCENE B. NON-A&JUN F. N IN USE OTHEIIPO0;6 SOEADONA-m. 1ENOENi, I!I1VRY DUS[D BICYCLIST P0.M1MBLE IWURY A UNIWOWN CICLE A OIED PIHO.PITAL T M O T ,T PJECTEO O.PMnALLY EJ[CTED T A UN%NO'MIIF 1 _ I?"y i l I . - 0 E / p OTHER p POUTS- tl. WITNESS 0 l . . . I M I 110WN p. SEAT DEIT FNLURE . EJECTED ?L 1',1 , _ •f' J{i'` ^Ii ktn 7 A? dr Ir,:?,7 r . r ?s!mt+am--Sn .," ~ M" ,..??J. •_"t r !r MEIN= '1 . "S F 7 :wkg -.. i GJ Ni-Awk N 3` -:?ii ;&L °._ °dld: d ,A`&"€3-'rmrlt`i.iiuC4S"tiss"r+eG 0'° : 1LL t3'n-yEu 1:u£sk' w: YLF .... . ?. ? +.. ? v_ .+ . I VEHICLEDAMAGE TIN EACMHOK,C CIE THE NU BEROF EACH DAMAGED AREA A p ABE AREA OF SEVEREST IMPACT ` INSTRUCTIONS: . f 1 WARROWIS)TO MOW PRINCIPAL DRECIION OF FORCE. DIY y, 4 h n; n^`rVJT - a?Z F ? rte.. . DAMAGED VEHICLE NO.1 It?l" MIBSPACEFOOSKETOHINOUAMAGETOTMIIEBS,MOTORCYC TC) DAMAGED VEHICLE NO .2 ? IJ MD°B ] 1 I 3.ibon ln( R?M/'!Ia B IA. RBVI I6. Trunk I B 1 ibrr, a MI 4 Thal 6. Trunk 1 to ! I ? ° IB.UMWCVHeDN II.OrMUnI / I ? 1 LLII ? V?I rPJ e , T I n Uri BNEr T.OVMUn SEVERITYOF DAMAGE: EHICLE NO.1 I?DISABUNGOAMAGE 3QOTHERMN.DAMAE)E 2 . FUNCTIONALOAMAGE 9 NODAMAGE BEYE--OF DAMABE:IOTHERVEHICLE) rQdSABIINGDAMAOE 3QOTHERM.V.DAMAGE 2 FUNCTIONALOAMACE 4 NOD-AGE SEVERITY OFDAMAGE: VEHN;LE Nq.2 " I QOISABUNODAMAGE 3QOTHERM.V.DAMAGE 2 FUNCTICtIALOAMAGE NODAMAGE TOWED DY E ST. DAM AOE T OWEO BY EST.DAMAGE TOWED BY - EST.OAMPi TO DIAGRAM OF COLLISION. .;.RDwwr.iEAwAe! $ ( I: J f U' l T O I 2 F 9 TO " ( ( L t r i f s ?.DU DRAW ARROW SHOWING NORTH IN CIRCLE _ NB E _ 1 _? I r r-j•- fU- 2.WCA?iEPItlIBNM.EFpNTOI ' -- {_ --} I ? - \FI'? - b T - ra- F , II? I __ , :.?•.••_ I-._?„_ ];Iarr TDBdE. ,IM K? ANDZ tl LEVEAwCtEOR- I9A"rI EFCgLLVOr?E - I L `?' ( 1 r-T I i ?'?1, '??j.__ II zf I I L! I 1 ?( '.:. DESCRIPTIONOF :'. DICATE WHAT P BADLY HAPPENED BEFOR RO M E, OURINOAND AFTERTHE CRASH, INCLUDEINFORMATION Nor ON DIAGRAM, EADRIVER ?..? COLUSION,j? y.,, ? A&UTY,REWCED VISIBILITY, PEDESTRIAN C LOTHING COLOR.CONSTRUCTION OR REPAIRWORK ETC.) I..J U:I.J.?.•J/_ I,1" _ ? I,?r 1./_ K.?-{ _ ' tl.? ? _^ . r'O ! J h. /7 L ?-? _T T1,rh?lU _ ?y= N _ _?_y. ?_? J r V N "2 SLJA11r _ :9 _ ..T`3 Tr!? Z? P _??,Y I-I 'r G L+JHr ?.A {/?4r._s`;2 ,jT.I_^-fU ta..?__?-.L7Tr!2rV. _- ''-Y:vu :•.:r _.+... l.:r. rcc ll.Lir_ia'.i_•a. ...7tis^ NO.`DIH- 3 "FEE. VEHICLE IFPARK D W .? HEADED MILEPCSTdR ON STREETOR HIOHWAYNAMEORNO INONE DIRECTION i -E LEGALLY WAB VEH PARKED OCCUPIED NO. INCREASING DECREASING ' ? ?? C II?'N'?7 ??b(AI E W V J I /,o, wr r :'iC: ? t? I C 1 >U MPM Jil YES NO YES NO ==pr o M -M ? i= ?t PED. ? I 1 ^ r eEronnanw.r IN.e - -_- iROM cpa.Enro sE.epwEga lE.rowl PED/BICYCIlST WASUSW G: rl_-JgDEwALx l?Tf wALKw I...IEHWwER •1 ICnncs .ux BI. !cRiwss (?'I B( _ ,OacYNCiF?e I IDMD .-•_ -- __ I . ... ? •i :;:ROAD SURFACE- I.- I ;-,;- WEAT} ER.. DKONE 1 , CONTRIBU I TING CIRCUMSTANCES Cr¢CK ONE011MCRO •,_,, 4 :::,,aWER/veNK•IE ACm?BD E Ej 1 N0.,] YDwCLE ', OR Mdrt DNVErI DRrvE R .. -" "• I , ? I ? dTOO?4AUDMINEAO ?y }, ? ? LT ?,/ r lC? E°'E"_us °_r -1-A`cn wENDES _ 4,-1 i 2 f -1 - ?T LI 1 - 2 EDWARN? n-. Q--Q r ? /Y°?: ? vrn t ? -77 1-1 ? rrt^_ , ? r ? ?° L-1 dua_ wENCe f ?. ll ovE 1ENTIR J _ , r '1 L'l_ A Lr 4 J 1 a ? na`rONr rura . 130 BNMr ._F 3D 6110n'rro - al? EC ED ( oNAL oA J?L'_` L llD ? D4L IJ ? KE - 4 ? i00 -' --- -- 8AE SPEE REAn. DE! - r-II` 1 LJ 1 ---- CinNN4E EOI 1W. L? ° ? 4iUW?i . If^I-111 . _:..t??--__ b?__-.__.._ -' r? rr_ll _? 61.1. ??.?__ - ?-1 1 BIDP DO Nl -??M _ - _?__ r f _l..J ?1.?.--___.-.__ r 7 ; Ll ° ? savAD OrNFAISFECIirT OMLRIlElOFrI M F1 i?° PA4FRY°RFNDR -?7 ?la'I ..J B°?ONEAr°rAi}O° ___ (' I ?B? NO VifKIA°BR 0, ? T°iI1N°?EeI00 FOR LIOHiCON01710N5 KNACK ONO ,TRAFFIC, CONTROL. -YnEdl ;JYpEOF ROAD. ON M - E -__VEHICLE CONDITION L - -SOBRIETY::;. ..v CNe<K ON -E . °i--l m?aa ?o soNU I ) l ?? 1 0I ONE WA I j LrONCoE wt p q I I ?' r-?D RB1OAVN DAYlIDM 1 ?E? n r1r0 [!?° ? p°BruEE l99•° 1 J ? ,PE? ?10? Mveq LAN. - y i I.. 7._°AV-..,_.._._ .?.? -_ r'? ?''_l...J_°O. ...-. _ ..?-? xamR - FI l _-_ nrrwrwo nnM ?II? PAIBtm PpLrpN OMBK ] (J _EU WwA. ? ( ? . f-7 l RdrurOE ? . . . J , I B W r! ?j LJ' L ? Un 90V °? ?u?? it Af%KI EMtl ??.! Iw4ANIinaN r 'j ? "'? ?a.?°S-..) ?"p. . ?.. - -? _uur ? 1...!°_?. r r?_1..,1 ar!E_'"o__- ?;_ ( y ?A?? M?.-_?. -__. ?rB? DAGKND wwarwEr ° ? LIDNr]OI °? M^L 11, TAO vr 1..7°? IUrw LArrta ?°1 ??--.^^ 1 lweawNCIONTD onoLOwN CHEM.TEST KMA o I No ] '-1 f'"1 ?J L 1 ?? rt LJ--_ 7" r WrICE?, L.L'.L1 ? -- ' 1 wr-I xFAIM<c = p''ry i N T r.A - - r -TOrvEN _ n¢ RI?RFCM'rl [-] ? 0 ?B? ? I-D Ll pt D ?DEFEDr, -1 rl TEBrnEFUY•D cririAroe?+ri (?I ?ilno4i x a`rl?°, uromDED ,=-r'A,?!?o isI•eain % % TEST RESULTS 2 1 - ' wHBIKBTMDTrrC1NA NAUTAINM BADDE L' ra IcPjrY;l . !?;L, rc i 0r.P;.r Y l rRKEDwAICr?eD IY%ICl AWNED 94'I/7i7 170„2 1 12 °m°° ANDe µi4nB4V10 A Flay uPioiD 0 M 1N alnr.nnncaRlNAMALRwK uNIUND AGUCr _.?- u.eroRalTAOer, DMeoinrroRr Aw•rorTDUr o!n J!^/?-7;) OUPUCATE?L'OPY: LOCAL LAW ENFORCEMENT AGf.NCY &W-'TH'P ATE COPY:INVBSTIOATOR'SCOPY Y?CS pp 4n aT ? .i Li?'IA .. eP. PW p - _ U UATE OFCIXLISION ( 71 Al f Of ? UAY OFCOLLIStON TIME i SUN I 1 D'1 IU[5 WEU IMIN FHI SAT IUSE 2090 UU 1 COUNTY 110. CITY NO. FHYIA E ? 2 U A 5 D S OUPBAN COUnfY ?STATE ROU TE COUNTY ROAD ?CITY SIHEEI O ADMCLS. PREFI% Pgt{TE OR STPEEI CODE' 7h? O RURAL SECTION ?ORIERISFECIFYI FW L 11 S E W ?IN CITY On TOWN W l MILE ? ? ® ? ' T ?? C P',,.A EO MIL POST l S OF /] O C.VR • .... O D. ?? U•1L A NAME ANO OF STREET OR NWAY INTERSECTII.'GWITH'. SiflEET OR RORU U. ON ?? RAMP DIAGMMOATA o T I' NON WTE ECrION N/) !A??i? i O ACCIDENT )Lq NON Xfl D INTERSECTING: STREET OR fiOAD OR pEF MEN . C15 ERENCECROSSSTP T ' MILEAGE N flEM'EEN CODE STREETAND STREET } . EE OR POAD /\ 5 2 ./ DISTANCE ANDOIE N 7r ;CTA EPENCE OP CflO535TNE q ' ?MIL W / ?' NCNFI Q PECIALCOOWG USE ?FEET OF ! - COLLISION INVOLVED: ? VENICLE-VEHICLE ?VENICLE-DIC'YCLE OTHER IWRITEI ?HITE RUN SEVERITY NOLUE1 /• VENCLE-OWE ? VENICLE-RS TRAIN ?V/?VJ..CU_--, _.. ?STOLEN VEHICLE NO?IiNJUREO OFVE C E3 ? NJUR ?VEHICLE-PEDESTRIAN ?-4 COLLISION ?-ARDOUSMATERIAL OAMAGEONLY AMAGE ?PRO OWECT STRUCK INAME OF OBECT STRUCK AHDOWNERSNAME) ', _, LOCgT10N OF _ OBJ__ ECT STRUCK I MAGE OflIVEN9NAMELAST fUiSi ? ? O ? ? .. MIDDLE, ORIVEpS N .. AMEVST FIRST M10DLE r iC rCL iO RfIDt OHEAN CHLCKI<] D D A / TR E AUORESS A ':. : • , ....-'.. .. .':.. '.. : STREET ADDRESS: 1 V' E ITY STATE . ZI, CODE FHONE NO E R . A GiY STATE .. LP CODE PHONE NO. N DRNERSLIGENSIE STATE SEX DATE OF DIPTH N DRIVERS LICENSE NO.. - STATE SEX. DATE OF DIRT" 0 ... • 0. DAY YH Q.. AND MO.' DAY. YR 7 ( D _?fjJPATIOV FWM NAME ...._ .. :.-. .. ... PHONENO. 'f DRIVERS OCCUPATION FIRM NAME . P NEN . CODES > 191 cuss -d .. I+I SEAT OEIr_ )__. I'n E.IECRON -3'___. CODES > o, IIIJUpr ICI C10.R5----__ SEAT DELT 151 N EJECTgN -__. ..___._ ATURE OF NATUR '. IHIURIVS ?9? /%0 ,?E/ j?S INJURES FROM ENE VEH.YEAR BY M IGGGOE{HEVI TO MODEL DAA J `nMOVEO NF RT-NUVAI I STYLE I2 UR:LONV.I VEH YEAR MAKEIDODGE-CHEVI MODEL IOAN NgVAI STYLE I2 DRCONVI E ' VER C R PLATE AO C SATE E . .. -L.. PLATE NO. , TATS H vEN. CfAOfl M, PLATE NO. STATE TRAILER PLATE NO. STATE 1 /G t) . JLo 1 H C EN I CA ,. /HUMS R .., OOOME ER C VEHICLE IDENTIFK:ATI N NUMB R ODOMETER E' L E Rewr RED NER-UST .. FIRST.._ MIDDLE ., REGLSTEREG OWNER-LA,.T FMSi MIDDLE . ... O . d-;9 N . O ADOREW OWN P ,. .. ._ .: ,. ... AODHE5S OF OWNER GG /) , /IIF ' AMEA-0- 0 ! eC0 GEN NAME ANO ADGRESSOf WSURAnCE CO OR AGENT LRAM _ CITATZNNO. ENFO CHANGE gCCMkNT I A I N 'T/G A /f T I ION C NAME; ADDRESS & INJURIES OF PERSONS INVOLVED coDES _ 2 T A 5 ` SE% AGE STATUS IN TS? ' SS EJECT. `• NAME' ?.5 . . ?_?T n NAME ..d1 d ez i stulnb - - - _ T AOMESS Sa,^? -- _ S NA LI?LII? - / WAIrIEt (u?vEurliG:r ?Cr NT Pr W NAME I 1WWE53 D .r.FNI n. M ORE 54 _ E'"aue R' T ??ASU r•GEn •-. ,••• rAw ¢¢•• r T I C 11+1 NAY F 1 r'U A D r 5U M N J I U • lllU 1f LP1EU O TIC \,\ M [ ! LC ILL 1 1 .1151. 1(IAL r ICIIG K I ! r r I I Dsr R of n T m Al l r n'alro I 41 :;A c t- .owr n I uff v AL .n,LI l Ivor.n I r v L 1 't I t4ti? k .. ! ?rt JK a. 1 :;4iL avi A?" ?;...dP0.'R 5 ._v t j-, ?r 1 SV' A ? ` i ? ?Yl IT r WYp I ; L i. I ? i w I iS ? c.t 1i r 1 TT % LS e _ I t Sys s ` I - 1 t?p ?ST? ? I 7 WnrG?.IItAlu r _ f y2. F t`»' VEHICLE DAMAGE 1. IN EACH BOX, CIRCLE THE NUMBER OF EACH DAMAGED AREA. E%AMPLc T LG' DEAREAOF SEVEREST IMPACT. •O/?L/IL-.,;• l INSTRUCTIONS: AwannowlSITOSHOWPRINCIPALDIRECTIONOFFORA I y 7N _ DAMAGED VEHICLE NO. I IUSE TH s3PACE icn sKE,cH Nc DanucE TO nu LEnx MDioncrats. crc I D MAGEDEHICLE NO.2ND kt, F nITYOPDAMAGE HOTNERVE CLEI sF N'TY OF DAMAGE VEHICLE rvO] ?,},v?,, I e : [ tv O DAMAGE V[ ICLE x01 L SaDL N00Arnn0F ]pONIER M.V. DAMAGE [[I OISAOLNICDAMAGE [[77 OTNEn M. GE {-3^'+rl 5tlLING DAMAOtE OTHEII M.V MACE DAMAGE I ] E p p F O INCrOIAL p ru c?N oMwcE <?NOna[IAGF ]C]rLrr.cnonaL Da.mcE w!7 No DAUMCE ? Sxr iU1•IEO BNCTI r• ALDAM.w I 1 E i. DAMAGE kst. DAMAGE EST. DAMAGE Y /rny?FY ` TDwfDer row[D ev yy?J S S TO 1 f r C }. 0 ?ti c4' DRAW ARROW SHOWING,>,yy, %I• v. <^.u< DIAGRAM OF COLLISION //11e G%(' Of,l C1 NORTH IN CIRCLE i - -no.en,r ERbwr rL nn vw cLls r .ebural.NS oeHarsoN aFF no,oA+. ? _.I { _..... ... .... ... .' .. . F. _. :. .. '' __.... •_I L t I !. O tN?AarT uNUSU,v,su.. co,b • Rc[r.rc••.coNSrRn< o. ? yT"?•F'I ?y'?y /!d •I/ ,?dN? FG AetE rover or __ ?• .. - I 1 ] Lac+t[ra0b , M c 1 ?? 4 ? .A ,r SI TIV T ? '?! ?. -??lr/c?N/T .k %y y6"y ? ` -11?lt' DESCRIVTION OF I ocAT T ObaOL HAPPENED BEFORE, N AN AFTER T EC A INCLUDE Ni 0 NOT ON DIAGRAM. E.G. DRIVER - D T . PEDESTRIAN CLOTHING COLOR. CONSTRUCTION OR REPAIR ORK.ETC.I LITY n -.' *' COLLISION ?SABIMT .REDUCED VISIBI } ,T T u.!.a_kFr ? - M1 n. fd ..T/] e ---- !/C G?i. S! de. erd <?al? Gavs A d...r ?iF/l air.. / s r a oeL?r/ Sr?py/v:i _ f„?. mv- nix; S't<W _S? TJiE /LDd ...STrrue-lle ;0e,.? rG/j:.OdN ' , ES POSIT(ONBE ORE COLLISION u EEOS c E o IN N F t ) +•' VI.. E DED NPOO R ON STREETORNIGHwAYNAMEORNO. ONE OHRECTIO rpsr jAR EO OCCU E NO. OTECREASING 6 E C U LI I I '?j? H>Ln rES NO ES o I ., .v, r M coR I cOR? ?o rJ EIM iI' ;N /fD C OG._.. _._.._n053 ] H ' MA F 6( KEO 6 : DES GNATEO I '1S PFD/tlHCYCL TWAS USING, -)SIDEWALK WALKWAY ISNOULDEn A._ CR 3 ALK IC OSINAL. 6CVCLE ROUTE OTHER ROAD SURFACE W ATHER CONTRIBUTECK O"I on MOniIANCES RnENkL Dns ICNFCK ONfI -K-1. Cr °rR.o.i v[NSbu T?[M •YE" ,, b ORNVD[R OryIVFR , DRIVER IN— IP IvER C I,r I GO4TRAWINDNT AHEAD y 1 O.] O] L 1 '( ' U.11-BFLUENCEOF FOLLOW NG I r REGARDED RN. 1 OVERTAKING LFAN LO L 1 1 1 0 I_..I ALCGHOL w_i]I 00 C105E!•1. (. _. .-? 34NL5G -_.. AND FABBAB. K CASs ET ] B,BN UGSI FLUENCE _I.I O E C[NTE ._I S EEEHTLY i- RMAKI. 'N A .1 r __1 TURN J ,1 ]J, - - - -- .?J' .. SHOW 1 ' S OWIMG I j]y-SPFfEO DIMITST f0_ SGL GTO I r M HOFER PARKING ._}<( } LffT TURN 'N _.. __ 16L Loc..lon_ F't fzCFED NG RE 5 1 IIO 0 fR CE F 100 6r 0 F T G 6 MAKIND 05 LCT E EOUI_ UTURN' N ,... l rsAIE srE[O _ TURN 5 F r - VV ] .- 'S - S 1 Islam} TO VfOrC FAN lW W11s.. 3 EG40 G L ] I - A)e' fLOWIHO Gr,HnIY[CrrYl OrHH1IsFECH 1 r E,'- vnprrn 1,] o (G sro )/1e V Or R ECFYI cN C :] STOPPED 'On ING ( A: .I s crv1. Al ^IOLATHON I ._ I TRAFFIC PASS _ I NO r•I ;.. LIGII CONDITIONS TRAFFICCONTRO V-Ao aE TYPE OF ROAD VEHICLE CONDITION •, .. ..._ SOBRIETY _,. •.: I sroP EO A1.1-1 ICNICKONEI O] ICLE ICNFCK ONE OR -0- V[NHCLE ILIIICKON[I OR STOP SIGN ONS IIr{? O?Lt??QlR! Vf11ICLe IBI-} .r. -V y T jaxEIBUQE01 INO] I i8' I STOrPfD IN .. I- ISC V 1 HO ] ROADWAY .' t (']'' •--„ OF LL E I % I 00 OILHLY ,0 STARTING IN ' WAI 1 k —LIGHT ] j STOP 0 D A LS-. IrnlnlO .__ I TRAIFIC LANG o-:' _ ST M ] O+tVN ], .fYaLo 14N `] [ ENHRLF J I DE lGl f ] D LTY I rARKEO POSITION .,•. ?_ AA. Y LIGHTS ..1_ N01 MAflC0 ...... -K E IICDS G INIERCRANCE ?] dt [C! E ;] bD SODIIIE iY '1] 1 BINDING I[NT[RINO .V a IF.. _. LOOP VAMP r Al- '.LIGHTS U K TPAfICI - { pAHK-,rRf CT s ILAS G I AILIr . 5 0 F D DLNK NG 116 16ACKING N is+ri pr tET. S SIGN., O ZS??. -.. 5.... °,•P ?N•'rt'HUNH° IHNOIH] ,ESTC CIIE VEHM. TEST -B. I AN S DnHR Hr-rlfrl ? ) 1 u fra,•en lrcNr3 1 Drn ?LUn 1 .. SHIAn Atro ] -IAHS X -NODEFEL'TS TISTnLlu". I >M OTH[n HYICN.H q y„niniii'L X S CI r Z { {I ? INn vIn 1L 'X. TEST RESULTS S Z l ;NGUrr1CET I NA11 fNAN nAUGI 10 IN .r LI AIIHVIO CiLUP, .=L?7!?t1<3y11w"[fnF?'?- .J??+ nrr+'D19 D.SJ ?,?:" rD L??l rrH? AnRHVIA ]nro IrMfD10 a Vt7 .'.' NA, -ABN OAIE , t v , Fr ' f. v 4T4An +U4H NO LG-??! ?? NII n,I Dq?? Dt NA,L 'D DVI..' J g 4 r W?ti <r a r 1 .r.A 101. 1 ? J C ?` I T ?I 1 w? I °j GF;?. t{ ? y ? ? ''I IE'l ? /.. 4 J I I l _ } y,1 A }qqt?yy r?r '? 1 Gil '• I V b ? ?? - , C p?! 4N(tl 1 J DTI r>. 3,r ?' 7L'. ?r Tt t lK } 5. ! T !1N '7"? t I ? T. { ?fi f II ?lakJ?l;ei e? ?, ' s Y S? J>x"m W ,1? ?Y ' y 11 'f14A 47i`'°?? 6._ . _ .. .III r 1 c A?` .. 1 IU ISIS G Y=' ' ..::STATE OF WASHINGTON"=-' - - - oFFICIM.us4o L.- MOTOR VEHICLE COLLISION REPORT .- NO DAfEOF COLUSON p b DA. EM AY pFCO NEX wE USON TIME OFCOUSNJSAM w« . OpWTY ""99 G (J ?u N ? O 6 PM !Cv i Ei o r " e• CE 11I-COUENTYI?/, CRY. TOWN GTY. TOWN .. :... AOMLLS PREFIX P, srn C .. GNENAMEOFSTREET. f1OA00RHIGHWAY ,, INTERSECTING WITH: SrREET q ADS.., PREFI% EO k INLEP OST-i: y RJ. NONINTERSEC IONLOCAiONp LOLLL4'" ? DETWEEN j STREET AND ( a omeT MM ?'• ` a _. ., GAORAM DATA ?? Jt... } t r .. . . Mi nO A Esrm(EPSfcrP.csrvEEr nnww.Lr HOUSE r,uMPE, ncE. ?© POSYxO.M IEPOSt OPIDFxnfr MLMDMAPX I NO % S PfIi LAC v E FE( ® NTE a 'Tl MITER CL F'?? ?O. 9TnEETO IOM.,. r t F•.k'h? LE VI-E ?Vf-E-WICLE ? l `TOxwvGKD ? QD4 ?% 1/? 1 ? EraCIE ONECI ?vD °MERIwWtEI °fs ?vEPA;LEPEDFs(NM ?xd--N ? FIT w,N DE USE f: Y„?r3f.' r ...... rr.. _tH4.as„ OBJECT STgUCI[',r.. .....;:.:IniwE VaDIXCT3muc%I _...:'. OWrvEROFOBIECTSNAMEANDA00RE55 ...v.'.. LOCAT ION .:;, ,LI ° 0© Ol O ??? „, IN ROAD . WAY O FEET W [O e .1 E DRNERSLAST NAME _.'_-.. ., . FIgSf NAME ... ..:..: .... MIUN.E ... ' wEPEwvOLVfO IN cOLUSrorv,w3OP ORNERSIAST ...FIRST NAME . ^k?e f l,?I ?.PI SIRE AOME53'?, .:::'. :.:_ _ „..- ENO.ANODO%NO. .. LOPE inM ivO STREETADORESS .??'. ROUTE NO. AND BO%RO.,? -. .,.... .. C? . y:....... PFnsENS wEIN A O w " L CITY -,, ,, STATE _'; :LPCODE .. DRIVERS OCCUPARON,; CITY '?CUOE GINEFL4000UPATOn:; ? ?f O POPtfpw OfINeR9?EN5E Ml BER. :•_„?„L„? STS E%; I DATEC. T7 EE. I .A.E STATE 'SEX DATE AGE • 1 VEHICLEYR.: 11ICHEV1.0. LNpVA-0ART);.; BODYSTYLEI2 DRI.'-: G - VEHCL YR.. MAXEICHEV. ppOGE) MOOEL(NOVA-OARr)... BODYSTYLE120R1 I C /c I L rd _z LOENSE PLATENO-: , ST E .;. ;. TRMIEP PLATE NO. :-? STATE ..:... ATT UCEN FLATENO. STATE.' .. TRNLER {'LATE NO. ;-STATE: •/I s + vERCLEOEHTIfCATMNIHO„?, I (1980 MODELSBNEWEIR ;,:..ODOMETERIMILEAGfI VEHICLEIOENTIRCATNJNNO. ,..,.. 11988 MODELSBNE.WEF DOMETER.(MILEAGE: S -76 oZ C '- PEGISiEREDOWNER.;( - TFXI TMNJOLENMIE):...; ORNERSLICENSENO., AEG19 ERE OWNER,; , I TFI T IODs¢NjM . DPI R ENSENO OWNERS ADDRESS _„?„(ST EE ,CRYANOSTA E) .,L: '..DATEOF&RTM OWN DAE .-.(STREET TYANOSTATEI ...., DATEOF BIRTH -4 .d; Vj rL5 ,I W1, 9 PNIISOFVE CIE AM ..::::-. _ r-:.: _;•:. :•:.; •v,.;. 'ioiiviw v['«ctE PMTSOFVEHICLEO ED ' S 10PEYAwvERGE WAS THERE AUTOMOBILE LIABILITY INSURANCE f?U? ?NO LIABILITY INSURANCEINFORMATION•VEHICLENO. I. Co' BE NFfFEOT FOR THIS acaoENroN YOUR CAR NAMFAMDApGiFSSOFLJIdUTY INSURANCE fOUCY1gLDER .?, "".: '': 'i N-1 NAMEOFLIABILITYWSURANCECOMPANY ?,.-,,....; •• •. •..,-: OOPEL A lrE J , N EANDADORF59 Dom BAITY MLYURAWCEAGENT,:,,?: :' :.: , Oir _, sMr[. ....'. ,. 2r UAOIUTY PODGY NUMtlER .. r: :,._..:. .. C e D e (? T<. I - D C) 2N09UURY .: I...:..I fYMArl REPdrfoR MDrONALPUDRE9I ` ,. ?E NAMF n NAME - SEX 1-6 Da rD,.? Y ME -A-Oi WLWfD .,, MAN%iX13r 6YLE THATAPPL E 9 - TANS OF WIURF.O ' MAR%FIRST CNE THAI APPLE S ?OwK VEHCLE ?Y I 1UUED •AKn 1 N r 4 Hn wpA 40.f m ? IN V[HCLE ? No .. %R.LED ".1 N°n IiwLVlnfl rvd-LM?D "0'" i I prEDES I.- xsa ? wmre.Y D 5? 50 i 70 L OF, ,IE N ? 50 5 ? o7 -l D Sr10WNOATHIWAHROW CRLLIE I w6fiiEd rrAV ? r' IAKf (M dRw! 1 Crs- r ? \ \ OESCRISEDELO YMATHAPPENED*IHEFERTOVEHCLES BYNUMDENI '- PH Dt%Ilscvx sC( Mmrl On IwrmL pn ? A •L? _ -... _ _. / (}???z- z e MILwiR FKrr wM Ntlw ? twLF?C'r(-w p?nuNL Y , - 'A??( - • - l o 4 p f' 1 VEHICLES POSITIONS BEFORE COLLISION - rvr 3flpAr4D nr r ew 1 . 1 Irt.• ?I.. .1. ?l ? 1 E«c W mLLE N S F W ON SIN.FTp OR 1-1 rOMf: ON I,G 1 w a ... ? 1L% U9 ,I0•rL E{ ? ? 7 R? I.{1C ?_tc. `M O arr Esr, ? ? wwowl 1 x:0.0-0 D ALONG ... ,.,..... r cAn va ,n ._ fICM.: DIRECTION , TO DIRECTION T? IN Ik AfI•uL WA14AXA IDJ(kW AIM 2L_,)WALAWAr ]D-'Arf%KOfR •??.+yl,w.IX 5? rmui>,w??P R(-1_J 01rF.l1 POAOIUR;FACE,I. VRAMlR '„ • LOHTCONDTIONR- •"fRAIECCG`"-.:-X:.•-I, M1PL Ol ROAD pmIFR VEIXCLF ACrO K r ? D 'W f D ? X.N t ,y . I I F h t,! Il F F ? ?s S P F l 0 }1 3 C sYM + i NR' 'k I (?7 i ':'Q , CN w ? 1 ?CI MI Rf ' ' ? f rl f1 ? l?? ( .Mi f T . ? .?i`P. ?.,•??t tY ,?a. I l " ` ?L '?y I?yyL ? .? ? I JC 1 1 0 1 J- 1ryI I T D DATE pF COLLISION DAY OF COI SIGN THE COUNTY NO CITY NO. GHfA O DAV -, V! Z SUN 1 MDNI Z?lUCS ] WEOJA iNUN 5 FN D SPL IUSE 7a00110UN1 j / 9J'?? y k aUR E COUNTY ?CWNTY ROAD ?CITY SINELT ?STATE POLITE Z O y ? ADMCL5. PHEFM ROUTE OR STREET CODE JC4.I ON • - - ?OTNEfl15PELIFYI per' ?T A • r' ?IN. CITYORTOWN ` W PREGI% EO, MILEPOST •'' I MILES ? Q ? ? pF f'- - _ (.1 ) / I A •.: '.NAME NO.OF ST TOR IGtty/PY IM ERSELTINGy/IFiEET ORR D d O RAMP DIAGRAM DATA (/ (/ ' ( NON INTERSECTKNI ACCIDENT T NON %RD I NTENSE FIND STREET OR ROAD OR ALF. ?..?.+" MILE GE '? TER CLS, E EETOR ROAD RENCE CROSS S TR N BETVEEN STFEETAND J STREET CODE - 1 RE , J 5 DSTANCE ANDDRECION fApM WENENCE OR CROSS STREET SPECIAL COD GUSE ' ' ' ?MILES - N S E W , s 6/r 9IJ - .. QFEET ? OF .. .. ' ?VEHICIENEHICLE ?VEHICLE-BICYCLE ?OTEIERMFITE) ?Hli RUN No IUL ED SEVERITY. COLLISION INVOLVED: ?510LENVEHICLE []VEHICLE-0BIECT []VEHICLE AN TRAIN NO.INIURED _ TOTAL NO. OFVEHCLES © ?VEHICL'AEDESLRIAN ?NONCOWSION ?HAZARDOUSIAATERIAL ? PROPERTY DAMAGE ONLY OB.IECTSTRUCK(NAMEOFUDIECTSTRUCKANDO/ LR NA Ej .,. „, LOCATIDN OF Ofl1EC1 STRUCK -., ,- ,. EST. DAMAGE S E W l . ::' . .,. .. ? POA.-Y --.' FEET ? ? ? ? RD EDGE I ; : .: .. . l..' $ DRIVERS NAME-LAST... ,... ....,.:..FIRST, I;ODLE., DRIVER'S NAME,LAST FIPSi-MI DOLE I" SICYCUST Oq PEDE51gIAN..CHECK) ,...,. :. R R STREET ADDRESS .. .:..;':.. ,. :: :. __ .:: ......:_ V ! ' E STATE.::.. ZIP CODE ..PHONE NO. E STATE ZIP CODE PHONE NO CITY -. : :. .. ?. ....... R ,` - R , N DRIVERS -EN 1 ST E SE DPTE OF BIRTH IN URNLRS LICENSE NO. - - STATE SEX DAIE OF BIRTH MO DAY I YR. Q, MO. DAY YR DRIVERS OCCUPATION FIRM NAME PHONENO. 2 DRIVERS OCCUPATION FIRMNAME, ,. - F-N . 1,x AI SEAT DELT 151 EJECTION CODES CUSS - 1 CODES >(D) IE_ES (41 SEAT BELT 15) EJECTION NATURE pF NATUE F _U RES EOM- NE BY: TO oVED FROM-SCENE RY: TO 'ENYEAFi M EIDODGE-C I MODELIDART-NOVA) STYLEIZDRCONV.) VEH.YEAR, MAKEIDODGECHEVJ MODELIDART•NOVA1 STYLEI2DRCONV.). V i .'i- - .. - " G.- V E EH COLOR LK: PLATE Iq. STALE TRAILER PLATE f STATE H VEH.COLOR, UL. PLATE N0. STATE TRAILER PLATE NO STATE , H C VERI LE IMNRFICATION NUMBER _ET" C VEHICLE IOENIIFK:PTI N NUMBER _ , .. ,; - ODOMETEfl E ` E FIRST MDDLE REGISTERED OWNER-UST - REGISTERED OWNER-LAS FIRST ..MIDDLE N.. O ? N O . -? ADDRESS OF OWNER A-l- OF OWNER _ 2 NAMEANDAOTAIESS Of NNSURANCECO.OR:A NT nME ANOADOHESS OF INSURANCECO. ORAGENT - uEHi?C RnGE -- E lt CAIiON NO. -ACTI ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED Dope GE S --TATU9' SE% _ IH xls;. t i -5 EJECT. c NAME. 1 1 L C DONE,SS -- - U k JIkU(HOM N T HF OG A -Me . -??- ?-?- $ Hi IaOVIUI HOM fUf•F OF I^IaAIUNIES Sff NE RY'. TO Y 71 .-7 r d A VP f •'". yr NAME! A.AYlC55 -_ ._-_ _ TO E V -,L=1 11 S S 1 .5 E A55F? .. ._ -.... ... I - to 1 LS Z rri at JI 5 r I Ic7ION 1EC C T F t, a 4N Y Y I IY CD NOT E TCD E •. ^[ ) I '.y 1 0 I 32 UAiri? ALOV: II .C ED D (t J TNN31 I.. .I A?T/-.Y_? C ..I I. ] E IULL IC ED E I_ I ] -.t.. I • •_PR:L ER tU E I41C LCD D _. nL c4tiM i ?N E rf '? i- 77'Alx?ly •tifl? ..,t+•.„'m°.. r-1l,.u,,a ..?F.I _ I?}y pp t t ' ? ?16?y4?;?? I??M1 t VEHICLE DAMAGE CIRC EERIEIIU n ROFEACH......?...r.D'? Ek r ... ?)I ? Y DL H M INSTRUCTIONS: y"- O E Y ] ARRDVnsliosww 241. °IAECTIONOF FORCE ©?. AMAG HDIi1A EN a FOR` M - ' I ? DAMAGED VEHICLE NO.1 nss acE SA CHINGD II YcL E $. O w. c11 DAMAGED VEHICLE NO.2 A'P Fr!DrYTrl 7 S Tiwk L . 11 11 RDN (?I `11I? iS. TrwM I ` oa ; ` D. UREm[u+i+0e v? 'Y t).OvMUm YY ? , (?,1 ?f _o?--.- 4 UMrturnwGa 12 •'' 1).Overtvn SEVE WTY OAn A?.; VF`C NG.1 1QOIGABUNG DAMAGE 3QOTHERM V.D l.-? MIAGE SE DiSA OF ONAPGEIGTNCq VEHICLE) IQDISFBUNG DAMAGE ] QOLHERMV DFMPGE SE ms'.SABJUDE?VEHILLE N0.1 1?°INoOAIAAGE ]QOTHEflMV DArtAGE, 2E)FUICT10 LDAIA.A AQNO DAIAAGE 2 NNCIIONAL DU_AAGE IQNO DAMAGE 2 FUNCTIONAL DAMAGE 4 QNODA40GE iO1YED BY ???? EST. DAIAAGE TOWEDBY EST.OAAAAGE TOWEDBY ^•, ?'. EBT DAIAAGE To T KrJ DIAGRAMOFCOLLISION .. -. I Pcs s TO f To . DRAW AOW SHOWING 1 I ??- V 1 I _ I L, NORTH _ L ; I d CIRCLE _ _ _ ??• T I r I I 1 1 I I I I - - I O l ? r -11111 1 - DESCRIPTION OF ?_?' A.A E 1 PRO6 RL 'Er. DR ND NG AND AFTER THE CRASH. INCLUDE FUR TONNOTO D GRAM. EG DWAER _ COL ISSION .: h ba 9UTY.,-EDVS'3L,Y. PED_S IA CL -,H:13CO.°R,:0!15TRJCTI0I4 OR FEPFIRwo-,ETC.) r ,• / /off _ - __ -. c- • J ?L / - +w C ES L 5.'E:DS EMILL I A ?D. t - PO TIL 1 COLLISION -.--7 - n ADED ' 11, P O 9EA5'. I O.' F ETO 1F ,,N ° D `- _D cC"] P EKED O..GURIEO . N? J _• __ -Es N T -- -------------- , I I I ,. .., ? . , .ALOFT I Q v I , T k"upr fl t I > } ?k ti? ? ? ? I ILI ? 1? >:`' ji F t , 1 1 e o,- AN, a STATE U, A5RTNUTO ?.%? : [s„v,:..:.;,.5ru .v' `...,qa .. ..,,'L7i.?._ ?" ?"4I" L,•e7 L?? ?J ^'i?^z g..w:u,'?. :,. __ ` MOTOR VEHICLE COLLISION RE 2-711.11 ..... IN . PORT I NO. rv F L y T.. O ,,r1• COU /Kn R No.? ' •( fr I?? ?t I PM 1 57 ___-T d TX Y TY O` E ?? CIi OMB' EF -f % SECTION fSJ 1 I-1rJ..3 ?f,G? I LF? "?P/ /GLc.IIJf_'Ild a?LS P :Gr[°. WIT, 11? R A^ - EF M ED YJI[", OF 5 fiT RDAO Yy.? y TERS /' ( ( G(LC rr `` 1 /'I O h l ,? " N wr - - N of coLUS - - D'A. AM'DArwsT NSEC J. O \ 1' 1 t, .. ?,a, c Sir D O t?•?.a D?`'IC ? ?'1`v. ?iG:.1„C• b 1I' ' cS (;C? E .. 11 Y,rnEET-.. e t- __L?n ?E T w , orE, v?? ,: nr. er.4.r; I4[nnr. A4 a.n°...nA I•n 4et. N A RD ran, 9,< oo ( .rro,r 4 / .H;?R <L..G??:o .o,.°?N° L P c coDEusE o.. [ r ?yia a A;a D ) EJ E ;1 S?rO RU? NAN ..- .1... ER F A.E.N A "IN FE ...F.v LI L`J ° S ?. V 1 O - O 1 W ?.L'?m"-?-i 74?? ° LAST FI T -_- 11 11 M D LE-? ?: ,. .,?.r .... . _._ w... a:? DRIVERS LA NAME.; FINSi N r f P 1 .' , ? li1/l._? `!l ?•/ `??l(LV' 1 ?L Y"? 4? wo DLE oA.NO. r STitEET a 55, - ROUTE NO. D DO%:NO. T } E Z O IV U A 10 _ E . Z P CODE DR E S OCCUPATION, Ay AP{E ?tZll I a 2S3LS ? usPL i4 I? ;? • 5 L yBE ,J 0 qTE 5 % ATE O 0 GE E LICE M2ER T E 5 % -GATE .1 - , 1 v *<e'-71Y1-eT(ti-I_y7G'r S s?.3 LICENSE :.: M 1 noR El:. ST `E. IZC"I I TYLE,I . _ rl DD crL • . PLATE !4 0. 1_5 ... TR_ L ._ ... E . 1. T T .u EE P ATE E r T ..E. ATE E A ?4 NO- 1 ? EY CL (DENT FIC TO O t18 0_ _.. - N EN OLE.,IDE T CAT N O_. -1 9 0, 0.. _-ERI t ? '?f, I ? Dol •?,oav R ? RCG TEREO OW ER n °.en I -D ER LICE E O, :. .R GSTFRE ER lu[ LI EN £ -. ) I ?!.l._. N ?oP,E ..;...HIV R , G ?C"?lLpc? /IP-,tlJ - Ill /!7/7 '. r. 'y - O j,7?EN5 AOOR 5:v,-.. ?? InAK4 1.,,1 '.?2 J:DATE M OWN RS.aDDRE05,,. .•,,,,. ? ..... -.. ,. la-..,... ,,.n RAT.-F, I " "' y. (/ • r? i?vx 2s f ? ?4:1iselc? ?0. .? .?G ?? [ _??_ q( P TS q V?H C OAM ED AR-. OF C E Da MAGED_, TS V,111 ?F .G ! vlP cnu S ...? S [ LIABILITY INSURANCE INFORMATION VEHICLE NO I- co ER cE NUT...TIL LIA IL III FOR TIES ACCIDENT ON YOUR EAR ?v" s ? No ?. A DD E SO LR JNSU CEC YEY ??•,G I OF. ITY EU NC LCg HOLDE u? -N E IVIS 2 ?r? .. r !ZY :23'F /c..•tbe+nc?'..A(t,?t _.6'3 ? C rm, EA DADORESSO I?Uk LITJ'jN UR NCE AGE „?L??p c+ " / /7_ ,-, LAB/LI P ICY ER ?" -;/?j i. `? ? O ? _ ? l arCL.S .? 7`?d,?illS IGU L? 1?7• ??{t:+152.?d tr]. ?r.Z,' (:?v ?- tip. cl - C?. /•jL x_7' /:, pE 2 . t AEE` `? C k?lt(tj Piv14LL'r?i..?l r'• _/ Jj DRE t}?i(1"?1j j?7(„ j(G /? ?JC hlt'rn.0 ?14I M F E BE%. r ,? Syy •? t . In,?nlt. S'Iwt?r., ?a hcc. OG? OD 1T " N.". °" [r . P« o. roll ?.. ?fJ1 P Yri{1ec:F(.._..- .. °.o n.o[le[ x.4DIn.' -?° ®44[,°n. ' . ._ _. ___. __ .._....._... .1 A ke'r S' a A. / Er O ....... f T.O THAT AI-Il???7?I TUSO INJURED nI. MARK FIRST ONE THAT, 'APPLIES 'I MA K ED 1 EM.OL! ? EVS,I NV HELE ti !( ? 5 6 7 5 6 7 ARROW IN C RCL[ Itr?nrl lu? i yrc"ir LJ LSCn DE. BE L? HAP?PENP.D'IIR? R:TOVEHI<L?HS BY NUMOQ? Y S W R 1 .. .. ..... .. __. ! /P \ ac?y wJ easy n li .. rn d _ L[?C T z', I', I t?4v °.,.... .. nn4wM JF'1"o V6J. t.. P tc 1 .. // Q \ I L- t F . ,.Lt?? n) p, I h V! HICLES I OSITION ^61II ? LFOf7E COLLISIUIJ r n• ?• nvrs naAre D nr w 1?' JI {f i L C L L r ON HIGNw Ar N -NN' r? ? .P, ?. 1 h ,jV" y 4y. y ,,. ,MIF I? ?n p ,L ? •r° ?n.r.,?4,nnn '?, ? Y{'? IYk?! i 11 EI FJ r71II! r? ? ?l - r Y , , rP [ I y } PLO[erRlAn U u U ?I ^`D_-- -_ -• crioanlnG rnDM To ? „ , I ?'. R 41? E _ I? _ ?I 1 _ JC] A f? ..?;;:.,. B C I :' D? w ? ti t(,?;'???',L - _1, F i 1 {!I J' I wR I ry,'t ct , ,r. S :qr .oanrr ' C= cNnl f. u?nr ?r•L nn.. wqr ?` DRI ?• f •'l x-NU Llrnglcnr A...t l i / ?;??{ 1^ [?5 a 1 , 9 r 5or 1 Ck? [] nArL.GN CI () EI r??l L I E?, 3 fffjjj(((y(I 7 YS? r ' M F "L. T ! Cl,? I },? } 1 • , C ] I1Nr r,, IAI < I. f1AAN I 1 J I.? BtOP -N t, I I r O V Y I A ?I OVEIITAKIN.. AND VAR4IND l 1?+p? " py k? 1 1 t 1 l -f Ir 1l II I W,I I I NG 1 r I I I? r,_I D I-.I r I I r? Z r? MAKINO IH.Nr TU^M ,JltptyU'4 r;'B . ll N.- Ill 11 r .I LA ; r'1I A Ir?_I MAKIND LMPT TURN Y A f h 1'. '? Z { J (L( I S. O I .1 OI I .I I L I r I '.j 1 A. ";? +0.Sl .,R FI'?,_•J!Ir^. 7 r ?: 1 1 I I<f LJ E'. I _I I I .? I .I I I L r...10 l_.? MAK-G u.runn (I r Ju "'., f I r 1 { I I f uw nr. 1 I. 7 I ri z I r) 3-- FOR 1 1 i-IFI nAI l[ANAI Fl lc .I I I..1 ,i ., u r In aN _L.??_I r 1 I,. reN.rrn r,? R ?' 1 1 -1-?(j •'; 1 •Nrn IN ROAUwAY I 1 , I, + 'rl - - , 4 !' r 1 • „ ?I'I .? IMD (IwlI rrIGIN %, ++, A1r?r.RRR y . .,,y,,t•-.„, ,a,5,.,^+t .`t+-•,ryl°"". f , , :f!"' ; p• tr 'Rr ' , 41 ryd a ? ,7 is yl y. 1Nu a 1', c 1r l n I ? G S1AIt?l•.\4Aanltwl . uN _ MOTOR VEHICLE COLLISION REPORT - NO .DATE OF COLLISION. D CA USI N TIME OF COW BION .. A Fr P, V (' 1 :5: n '' IIlll1 ulrvu 5 ?` AFo P OAr rf?.1a Sun 1-m o n ODUNTY GTY, TOWN - r.a . MILES ? ?E CITY. TOWN ANMLl$ Pf1EFl%: ?WM EG Tl1EET f SE ION cF?en ( "« GF ?N [)P Lt GIVEN M OF fl AD 0 GHWAY [•1 INTERSECTING WITH: STREET OR ROAD PREFI% Ell $El'P? M EPOST iz>+3{f,,i ,,,r'y.?"f NON INTERSECTI LOCATION OF COL 10 A HPHA..$ S T [R'yA•?A?,N}?', DIAGRAM DATA ?'y*Y'"4y STREET AND STREET '•:?S ^5'?'??'??'TF`s'L?+YX?:?T ? _BETWEEN F',! NON %RD PFET GarowmA. NTl-EC- FEET ?N ?E AA Laa.o caoss rvc, u LErros Ex„Pr xG uno.AnA [1 e [ E Efl pN:LA "E E.cross IF 10 rxnre, SPyC CODE;Ip'? . COLLISI- -L- - .[.E,"CES :Z El 0 6:5, ... "=AI. OBJECT STRUCK OWNER OF OBJECTS NAME AND ADDRESS.. LOCATION ?N? p" TEOCOST y _ ,. IN qO AY. ,., - TD aFPNa owrECl L FEE: 5 W o6c $ w, 1 _ • • EuonE ,nAw • • E WOUL w+A DRIVERS LAST NAME :'- FIRST NAME :. MIDDLE - All DRIVERS LAST NAME FIRST NAME :......._...• MIDDLE oN L•a 5 E A Lot G. : f? LLS,.n.a STREET ADDRESS :... ROUTE NO. ANO BO% NO. 101E T111 two STREET ADDRESS ROUTE, NO. AN0 BO% NO. 29 1ER5orvs 1111 ^ ? Nf In,.1[D.sEA C,o2oNa- I CITY .. STATE .:._... DP CODE DRIVERS OCCUPATION coLUSron CITY . STATE:,,: :_.:... ZIP CODE. . DRIVERS OCCUPATION:.,. lEl I.l)P[- 9 1t 1.11. •2 ?n J 5 SRS 1 . 2•?"?D F} - SS><• 170 C GATE OES iR Ap :AGE, .... DRIVERS LICENSE NUMBER..:: STATE SEX DATE O.YBIR`E a AGE DRIVERS LICENSE NUMBER::: `_,?;, STATE IT ;L I -EG - <LNl (uR S? 2 >/L QSON?I u7R f 1. a !S77 Z?I 2/ VEHICLE YR MAKE (THEN: DOME) MODEL (NOVA-DART) DODY STYLE R DR1. VEHICLE YR, MAKE (CHEV DODGE MODEL (NOVA DART):500)/.'STYLE (2 DR)" } I, If 75/ n z G7 Imo I6c- LICENSE PLATE O.. STATE TRAILER PLA E NO. STATE LICENSE PLATE NO STATE TRAILER PLATE NO STATE, - x zyg 222 WA • ?ZS' 2 Lu,4 „ VEHICLE IDENTIFICATION NO. _:_1185E MODELS E NEWER). _ ODOUETER IMILEAGD VEHICLE IDENTIFICATION NO„ (TIM MODELS I NEWEIa_.;e; ODGMETFA IMILFAGL) ot_7ND 1 /(os y9s'GS.v 2q: 1 77/2 ;?116- 7 ' REGISTERED OWNER RAST.FI-.-NAME DRIVERS LICENSE NO, REGISTERED OWNER.. (LAST¢IRST-MI DLE NAME ;:,. DRIVERS LICENSE NO ;: &v n1 -RU. UIl2 i - - D'E?7 5+741J OrVc/L l?5 ?IL>< ?,:- 'OAT pF Bfl1EHq• .rYN 1 OWNERS ADDRESS, : lo- „..: TpEET, GTY AND STATE ,:, DAT OF.BIgTH OWNERS' ADDRESS '.tw:,:,'...(STREET. CRYAND STATE /I I NJ; 'un 212 i{To? AND ??+ 3y7 Co 3E PD ED)( 1 PARTSOFVEHICLE AMAGED h?soi .? -C PARTS OF VE k K: E DAMAGED 1.:..?s.. ._.. -. 1011 WH 1 E ?, ++A«° pr A'Eo s; off: _..s 4 WAB THERE s T. la YcoST C-4f- TZ-A [ -VEH .- NAME AND AADDRE55OFU ABILITY INSURANCE CYICLE 1- COVERAGE EFFECT MOBILEFOR vNT ON NYOUR CAR YES 0 AME OF UABILRY;INSURANCE C®PANYOd Aa U ?` L ^' ? D z z - r ?L NAME ADDRESS OF LIABILITY INBURAN EAGENT Gn:, v 51ME BP;;.. LIABIUTY.F000Y NUMDEfI ??`-,_"•.;,,Aj. Lilw_.w- r -.325 < Ao ra// 0 Me) 25- r R$3'y ClE) 1ST INJURY AGE 2ND INJURY: ... . AGE F? ..In/,, ? ? 2 /., A ?l n 2 ITTOAL NAME NAME Sa, M I- Q ADDRES) SE%rC?- T? ADDRESS SE% f?l[ra .JN? StF.C3!s?. S?_Ix"_GK_[Y\SA.S-Ld.LS .IJZ 1ZLf/YP?15 M F / E ,1a E51q G.1F ooc,o ,k 'Nyw.r as x.,, n ,o [?' Eol FR .. V Au,i,Ar ox nr M AuE • STATUS?OF MARK FIRST ONE THAT APPLIES STATUS OF IN UVE R D MARK FIRST ONE THAT APPUE$ l k Y PRNCR IN VEHICLE n?Sw,vnv O PASSE GEa IN HICLE KILLED A? norm 111" [vf E0 xom [ rA,w'?Mn E1G t o ?S [] PASSENGER KILLED ND I 1 ,u I NO . Y1 'C PEDESTaMN ? CPEDESTPIAN ? 50 6[:] FF, WHAT CIRCLE 50 6? 7 nLOW WHAT 0 OTHER 7? NORTH BY +• SHOW GCATE ON TH11RD1 GI- .MAPPE''RE TO VEN?RLU-'I w?? DESCRIBE HAPPENED O \ ???G 4 ?WLL ua R 11.6)D? --L- LD IG-f-t 5+0 I LJf11'4-i.a R, °:.x........ ..?r? "?' ur ?', a:.....fx 1[,f .AP .a. P+ug?J QAJ soul-h .u S ? ?a D 511I.T.anG»w.Y a co• s tea- 4?c IZGCrI • 171t,;il ne.ti? (A ,?? ?? ?? .+ ? 2 i L.l F '11-/ lJ1ps ,?,ltOW f'JAT i /J t!.lTi ? . 'Ykik;?T41 ?1 - 1 ."an --""c 7 T?d-_ +L rJ .7 &L i?t=Gt?? U k? y (?? J'n u eh ! ry VEHICLES POSITIONS BEFORE COLLISION aY LAw .wcu vr„IGF .AA m u INVESTIGATED BY T Efl VEHICLE N S fpE W ON STREET OR HIGHWAY NAME M NO (wl LL r ,A- E LI lNO HNKA, DA! ?? .11 Y?EJSt ! D Y!S ND Y!9 110 S T'n.L 1?''gnK{ N]LK[ .A.ION "? pT eRI ? ? ? ®a' ?a J.L? ! fA rf(?? M _ f J +i' I'CO[St.WR ? ? ? ? ALOIIO rf .:..' r -. e1C. FTOm DIRECTION :`1170' 'DIRECTION J((( PEDESTRIAN WAS USING 1 MDE WAIL f WA-Al ) 1. DER • D S M'wiD. S OTHER r,C ROAD YIWAC!'- WGMD1 ^. LIGHT fANpT10NS. TRArFTCCONI110L µ-fi TYPE OF ROAO., ?:;:. - DRIVERIEHICIE ACTIONS "1`'p: j ENEfa Onp HmG? [ vlnKl f RM[? IMI MIHHItI [ IcH[CF DNI OA MDAD ) "1. w~ U! E 1?11?. I ®DAYLIGHT ? 1 ? 616NA15 ?1 I ? ONE WAY ® 1 ? GOING STRAIGHT AHEAD t +? Ty 'I ®1 DRY 2? RAINING 2 ? DAWN E] ! C STOP 61ON [ TWO WAY ? 7 ? OVERTAKING AND PASSING E3 7 LJ Wn 1 ? 6NOWINO ] ? GLSK ? 7 ? Y[fLD SIGN ? E ? REVEA SIDLE ? ! ? MAKING RIGHT TURN I f L ?, Y Y ? S ? 6NOW • ? F00 A ? LIGHTS OH ET ? • C] FLASHING RED E] • C] (LOOWCIIAM?PIC ? ! YA.M. LEFT TURN I ?If ) ? ! ? ITC { ? OiNfp S ? ?pHT4 TOf?T ? 1 ? fIASHING AMBER ? S ? ALLEY ? 6 MAKING U TURN irorl, ?P[Ti ,w O1HCR ISI.ECIft7 DARK NO O VIAY• I TW ? { ? 6PEG/`f { ? SAR[ET LIGHTS ? 1 ? RA MGNAL ? E ? LEFT TURN ? 1 1:1 SLOWING 7 T ?I RUEON FOR NOT {EEINO DANGER 1 El EEC%Y ? I ? Off ICENFLAGMAN LANES ? 1 ? ITOPPCD FOR TMFFIC ) '? y IOI4CUA10 VIfKM. T.I-o-IIGI STOPPED AT SIGNAL } 4S ? '_ C. ? 1 ? OTHER, SPECIFY ? 1 ? SEPARATED ? S ? / }i.JN UC,.hICLG 1 ? ? ? 0 ? {MOPPED IN ROADWAY 1(J 7 DIVIDED p'A}??' 11An71NG IN Y IVIDERYD l?A{TOP BANI i t I l t! : yl i ,,? 1 );III"(? E YI= 5 • r"Y 9 NO,P F 0... - n S n I n ID n 1 , 777 FVFT T,, 71 § F.i B I a F. I I L P ?'' M n {? T 1. D DATE OF COWSION DAYOFCOLLISION TIME COUNTY NO. CITY NO. HWA ?L l MO/? O;j ?YIi. C Cr T SUN 1,IAOx Z N'S D WEO A n1Ux 3 I'. D SAi 52y"j1'lO0URl ' / j . ( l J L193µ E COUNTY /A - J T Z ue. c ??11CWNTY ROAD ? ? STATE ROUTE ytI CITY STREET _ll C) ADM C L3 . PREFI% RD 11 STREET CODE SECTION ?OTIIERISPECIFYT y y??,7 Q CIfYORTOW N ' PREFIX E O MILEPOST 1 O o Fq /1? - .I ?I 9 J ? . /3 " \ ? CeH e L M1LE5 N? ? ? M., q M ' LL . A A E 6 O.OFSTREETOfl HIGHWAY INTERSECTING VI M: STREETOR ROAD RAMP DIAGRAM DATA I i ON 8 CENT?-i4 OA bb0 b O NONINTERSECT%yL? O ACCIDENT I NTER NON %-RD INTER CLS INTERSECTING STREE R ROAD OR REF. N DETWEEN STREETAND S'TREE MILEAGE CODE . ERENCECR03S,lST/RE?T?OR ROAD 3 d- DISTANCE D DIHECTION FflOMREFERENCE OR CROW STREET N S IM SPECIAL COOING USE yJ ?/ I MILES N S E W OF DA ?1 6. b X 2r ?FEET ? d1 , COLLISION INVOLVED: ? VEHICLENEHICLE ?VEHICLE-DICYCLE gOT11€P(WRITE) ?MIT6RUN F SEVEWTY Y.I ?a .I . TOTAL NO. © ? VEHICLE•EIET ?VEWCLE RRTRAIN \ c ?STOLENVEH1ClE 'URE IWURED EJ 0 OFVEHICLES yFHICLE PEOESTTEµ ?NONCOLLISION ?HAZARDOUSMATERIAL PER I`DAMAGEONLY O- . OBJECTSTRUCKINAMEOFONECTSTHUCKµDOWNER NAMEI LCCATIONOF OBIEC[SiRN CK EST.DAMAGE S E W ? ROApWAY FEET ? ? ? ? RU. EDGE 5 O HERS NAMELAIT FIRST MIDDLE GRIEF'S NAMEtA3T FIRST MIDDLE 11F 6K:YCLIST OR PEDESIWAN CMECKI R We?Amot ?este ? R STREET ADDRESS STREET ADDRESS VV c, 3 G at u, I E CITY STATE ZIP CODE PHONE NO. EE CITY STATE LP CODE PHONE NO. R ? A N LICENSE NO. STATE S SE% DATE OF FIFTH N DRIVERS LICENSE NO. BiATE SEX! DATE OF 811TH 0. ?, Z- 0 0 0 ,y IFT. Z 2 Sb Cl O, MO. OAY YR R NERSOCCUPATION FIRMNAME PHONENO, 2 URIVERSOCCUPATION F,RMNAME P N N . CODES >101 cuss MI SEAT BELT 151 EJECTION - CODES > IDI Cus s 141 SEATEELT 151 EIEGTION DLURE9 F Z 14. 1 WUHIES F M ENEDY: /. ? FROM 6CENE RV' TO VEK YEAR MAKEID0DGECHEV.1 MODEL IDARTRlOVM STYlE120R.LONV1 VEH.YEA'1 MAREIDCDGE•CHEV.i MOVEL(OARINOVAI STYLEIt DRCONVI. ' v rii e AL to 2 cl oc v E We.. C OR LKT. PLATE NO. STATE TfWLER PLATE W. STATE E VEH.COLOfl LIC. PLATE NO. ST TRAILER PLATE NO. STATE YA L3G wp, " 1 C VEH LE IDEN I I? ,ATI HUMP R ,. C VEHICLE,IDENTIFICATT NNUMBE .?•.,,.., , OWM Efl _. , „ E ? , y ? Z. `1 TG S" g 2 E . . _._ .LGIUMNED OWTEfl-LAST FIRST MIDDLE R EGISTERED ONNER-LAST FIRST MIDDLE' b E N o. orl eK t?J Ke i+CC' l ) O. AD W OF OWNER ,. A DDRESS OF WNER , ,. -. .: . Zt P ? z ? : . o I< LO[Oh SL°ho( WA o? NAM µDADDRESS I RAN CO ORAGENT N AMIAN ADOREWOFINSURANCECO.ONAGENT c-TG CI AT ENFORCEMENT HARD A ' ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODES t G 1 5 , SEx AGE STATUE IsJECr. NAME: 2H ADDRESS t3? ,max 2 3 i x / U P ""u"', REM ED FR M L INAIR:EA 1.11mV: S¢ I TO A NAME: Q W W Q IN AOp1ESR / S T iNIUN}3 4f. NFI D,FII TO ?f 7 2 / T «9A c c Ly{° Po?T_aw ]A M, "OG41 N D l N.IINIFR r Yd fiCF.NFpV ! A h. TO SA I , E S NAME ?f_ S -]- AnnaF3Da Q X -2. T? _Wk 5?3?? ? 7 2 ?_[_OLA-/.LW_1LyV! 1 :At 9 Q?yy Ank)r h\l TO 11F 111tH rUi A11 NAr Ir JI VlAU11Y ClAw IrI SLAT IRLI 1 51CJECIION C ]Pf."lilAY 4 nCT 115i ? ? ) ACFNF. jDFO UTS "AD ? S S. 1NN 013NUVNOf1V O S^rF I u U Iwt.N US[LCO I OfALtY [J[CTF'D MIT JECIEO e / S 1 ] Ka0AY1 D OO:YIHYII hI I10 IV f A D L V1 RY ].RO IL[. J 6 SFAIII f LT FAILURE A CTI JCG ?p F • ? - ? g E . . J I'?iN'' , ] `. n ,n l+fY4. ak .,.Imo... ut ;1x . A ` 'e '. .d1A 11e L T I t:. I I s r. y lhi ? ? - ? I L T r fI ? r I 4 .N } - 15 ? ? tiII1 7 F 1 1 AV?SII 1 I i ?4F?y ?'A f t _ S :;nrY J y ppm nr AIX f Iwo a- r VEHICLEDAMAGE IIN EACH RGKCRCLETHENUMBEROFEACMGAMAGEDAPEA f 2 SHAGE AREA GF 9EVERE9T PACs. wl INSTRUCTIONS: W AHHUW,9) TO SHOE W PRINCIPAL G RECTIDN OF FORCE. © G UAMA DIED VEHICLE N 0. 1 L4,^,PACEF°NSRETCHNOpAMAGETOTRAtF.H9.MOrORCYC TO..) ' I P 19 HROa DAMAGED VEHICLE NO. 2 A ' 'y ='} ° IO.flool Y?? 1G. HP°D - /??? Trunk iii' ? I6. \ Lam"-?{? ? . r• e ' ` I y A ? 15. TIVn" I ? / IB Urgere.meq 1 ? J ? IPO - i-Y? ? IB Urgarc^rn^C. 1 T. awn^R 9 EIUrYOFDAM AGE tHR p Z4 yE b : ; NO.1 9EVERRY OF DAMAOE:(OTHER VEHICLE) SEVERITYOFDAMAGE: VEHICu NO.2 '),Werlvn I q INJNODAMAGE S QOTHERACV.nAMAGE IQp19AgJN0 DAMAGE GQOTHERM.V.11"ACE IQDISABUNODAMaOE G 2 FUNCTIONAL OAMAOE 6 N O GAMAGE 2 FUNCTIONALOAMAOE A NODAMAOE AOE -AGE Q UEM m E y 9 j ? 2 FUNCTIONAL OAMAOE A I TOWEDGY,? r.2 r C K,S Oh .'. V M O , E""T•O1V•1A0E OWEGBY EGi.GAMAGE NO TOWEDBY EST DAMA .? s • .. ? R - . GE S-I t?C TO 1i Y°:.Gw c c,( NN. ?'+ rG s S , ?r OIAGRAMOF¢OLLISION LWO, I I .`- H_ - }__ __ - - - TO I I t- - 'DRAW ARROW SHOWIND - Re •R" - -I NORTHINCIRCLE D°Ea°Ee oa^RDA°w r - _ - __ - !•1 A wY°wT"""iAiaAr L. I , -? - ,-I t; eiaC6b,N°NOICRG^ -- .r - I . # ? f. .^-, • -.- {- ' t[• - A a pLs' f - _ 2 a,ENRBAE tPD. ACT. ?? I I - I - . I ? . I I . I I . i I I I I ? ? L I I r ' ' - 'o°"0alecrw"?"L1Eelrsov°e it :^' - -' - - I I __ T-' ' '. I I I ? i " ? i I .M ., I I I IF • ?.0lgw I I -aAPAD°ABLTanfzu EVD^pFOR _ oEEi,?AHIarH°Nig1e _ - 1 11 i0k DEiSCRIPTION OF'0a" ONDICATEVMATPROBABLYHAPPENED BEFORE DU R NOANppFTER - , .'COLLISION!"r,'. ,r } [•X g9AgUtY,REWCED VISIBRJTa, PEOESTRIANCLOT THE C RASHA LUDEINFORMATIONNOTONGM _...Q DRNER HIN COLOR.CONSTRUCTONORREPAIRWORKETC.I _ °' Vehicle 'r1 was headed SB on C.R. 18. driver stated that a white animal ran out in front, f hi o s vehicle_ Ha swerved to the right and started sliding and went dOMII lAtO 1219 - d itch and vehiclo rolled over. ----- -- -- - t ";:CNi,7wv.> BE L .. ,?W,,, x.,.v: ti.•: .y., 4'': R.wL 5 t _ NO OF LINES PEE H. .r453?5.:5bhuE'?c "' VE NEAGEp-- POST qR MILE - ON STRE N OS V N 1 PARR , Er OR HIONWAY IN AME OR NO ONE OWEC110N rtD NO. NOREAyNp DECREASIlq °O° P Ji1(EO V 11EU 1011K 0- / 0 2- PED. n n n D H , L YES ND YES No __- r - - aw ('1 l PED/BIC1'CU9T WASUSWO• n&°Ew n w l-1 &IOIIWE^ ;t.. Dross I Iclgv - FD - --- flOADSURF^CEA [:.:,,WEATHEA„3g,, r.:,;;;,,yr,3_•,:CONTRISUTINO CI RCUMSTANCES ?,L:?,y?-, , . IfAa as IW CR D^EI IcRacR O^ernYCAI ?.,ux?.y,c °"` Gt ORE f(' .. -. g rvE^ oRVEn ,.-:: lryy"jn '- Y T ?y T =On •?i INO•.( V Y ( ?(? f- f °ry I I, 1 wt'nc:.lp10Y. t i.lf.->. 7_»?!c°_'a uaNCEa. ' 'r ?l oo bscLr (1?.? l(!L-??? j r?9ly 6w?`Dwuw ? ? 1-I ' 1f °YF VwwRw Ll 1 I I ? ( ? J"V Y w[T i ^ANwD rl:l 1' IwwENC w IT (-I o?Tn ct ._- L, JJ E—__NR " - __ - _ ._ rJ 4T L-d 0 . . _ 0 _ r?1 ^uniruRr lJ ; -- ] Ci store ,_ q_L °C_ , a I- I°° n ? , C] -0 AA" ? ( 7 LJ °° II?f L J NmOM^ - I? ej? Dt FC EOUP. ',' '? ( `J ' -_-_. 4 /? 1 4 ` Q a ri WRw° ?..r UNrw . . .. w< u O L.? °rDPDOtAM ___ D,RCnISPloan -D r. laoican` ° ifJl yDww . °? Ivvu?.sowt^ r?ur-? cgwN.c?IDH °L °P ?,? (? ° vwum°,r?l _ LIGHT CONDRIONS TRAfFlC -CONTROL l TYPE OF ROAD VEHICLE CONDITION ,?' , 1Cr4O1 pi? "0.e v 'a+ a? ie w OR YDRtI 'vYVCU R:ReeR ORC a^ WI:_-SOBR?ETY.oNa1 . HD : ARwt n U I ^Igwa r J E ; a,lt LI°?°e?TD`R°r".roxPON'LL 1 f L wnmH ` .I:J t , sro , x, e ,wo - __.- EJ 1 M M t°' r J i -) Yo rv ?Aa }' n "" CJ J /LI.HND n (- a re i NOOw^ e? - too^ ` C r 1 ? l j I ? , ..-. w °_.- .. : -< ? `? [_, IN I •I' D ww^RwD .. .. ?_ te i Fl.a,e^w .. t ° , nu lucRPro _ ,.. ° I wn^ , ( j M FI° L -,AN .ruw E^ve I L^w a ,.. ocA I Utrr ° t CHEM TEST -; 1 ~ ?° q Y M1 C q I - __ f ° I J I ? IINYA ITr I A rtr°..._ I ..., ^r^[N9eD ? _ Olr^^IeRp 1 - - n rmL % TEST RESULTS 2 .?--. IwDTrcaAe? ooM1 ;??? c _ a2.,L`.?' 'eI I JKCJ U.11v %O 7, if7r e.ro t•'•,'•nn "°Y0 N ^ w ?tY// /i•?v,...???O :u AY ?/C ;'" OHU ?Y . r x ...e .?' L--- onto nuorrt w *aw^. c.rt ?l YY 53?? 'I d 9 l } y' t a. 2 `2}c aY>?s Hi T MO. % .Tq. O? I E U DAV OF CDO 1I510N Fq1 SAT T 1 Z ] 3 f AT TIM. (US 200HQURI J COUNTY fI? / CITr rvo T ? STATE flO Ugawq? / / a . y 11 N. N UTE + COUNTY ROAD ? CITY STREET ? OT.E.ISPECIFYI O W gOM<LS PREFIx ROUTED q STREET CODE 3 3 - ECT ION L / N 3 CITY OR TOWN ? N ? 5 0 E W IN ? ) r O ??JJ II[[ . ?yIILE3 ?/,,L"7 ??? PAEFIx EO. MILEPOST ` Y?l _ QOF .. NAME 6 N ypF STREET OR HI MWAY I TERSECTINO U M 4 , [ T ®IY r( ?, ON Y / , I T111-11A • MP oIAGRq G??7Cl7 .QD I NON IN TERSECTION? L?Ile ^ N ETWEEN ?? r6 $AEET DIST E .1 TOER CL9D REFERENCE Cq TS STAEET OO R04O MCODEO 3q.. ANCE AND OIq yTION ROM' REFERENCE Og CRUSSSTRE MILES E W • / ' SQ aPECIAL COON US " SIH S H ? /? _-. lr_11 /tom r ?FEET IL- ?-I ? 1 . I//'/ J J C _ I ? COLLISION INVOlVEO: L'VENICLE-VEHICLE VEHICLE-BICYCLE ?OTHER IWg I TE I ?HITbflUH SRITY FD -/-NO. KILLEVE TOTAL NO. ©VEHICIE-OBJECT g VEHICIE-AA TRAIN OF VEHICLES C? STOLEN VEHICLE ?L NO ? INJURE O VEHICLE-PEDESTRIAN ?NON-COLLISION ?H ZgRO0u5 MATERIAL ? PROPERTY DAMAGE ONLY OtlJ STquCK INAME 0, OBJECT J1 OW/1??F/}}}l RS N AME LOCATION OF OBJECT STRUC J / { ! EST OqM OE S I G =i . + A-i L .C./LJ ?J i M ?k f/ ?RDAD-35FE DRIVE N RS ?Ll?? RP 25UU ?Mf 0.4T q T O. EDGE S (DOLE ^ D JI / /1 Jf ./•T `r'. ll: L-?/BCC D D .VERB NAME-LAST FIRST A ST NF --IAN CHECKIO R Si BEET qO ESS `• R STREET goDRE55 E C ST TE R A ZIP CODE PHONE NO. / .?-i 5L. /,t1j//^ Lvc? . <J?,ul E R CITY STATE .., zlP ED- _ ,..Rno 0 t??-a,py RIVERS NyErJO. ST TE SE>1T OgiE OF E- DRIVERS LICENSE No. - TATE .. SEK -p EOF BI MO. DAY R. oRtYER3000UPgTIDN .fIAM Mfl SHONE NO. rr n ?/wJ? ? O' 2, DRIVERS OCCUPATIONn _.;F NAME ,._ ,?,,;«• --.L[HONE. 4 .C . CODES la CLASS al SEAT BELT 151 EJECTION I CODES '"' u" r INUUR G,C f J?U?J E 1]I clg ICI EAT s Se ITS I61 EJECTION OF ss NATURE IS OSVED ?CIJ E T' dLi/US / M YEAR MgKEI ODO EVI NO LIDA T-NOVAI STYLE R -CONV 1 "" E URI N ENF BY. TO E . . / : C . /I ,.YEAR DODGE-CHEV. MODElID NOVA T'Le 1: oR.-CAn 1 G . V i { EN. C G LIC PIA N^ STATE ql Lefl PLATENO. STATE E H.COLOR.C.PLATE N0. - STATE..: igA1L gvL ATfi NO STATE' J ( J H .:. 'C, L CA FNJI?CL/EJ I D^?NT(F? iIOH?NUM3? „_ 000 ?] I C VEHICLE IOFNTIFICATION NU BE - E ' REGISTERED OWNlfl-LAST FIRST MIDOLF E RFGISTE REO OWNER -LAST. ,PI T DOLE O, AOOfl Sa OF OWNER'., _ •. : O-, A DDgESSO WANE ANO AODABl9 OP N M-M. I SURwNCe CO.OR AGENT _ ,,,., CHARGE N ANEANOAOORE3s OF INSURANCE.GO.OA AOENr,_:: .. ..._ CITATION NO., ENFORCE-ENT ACTION CHARGE CITAT NO., NAME, ADDRESS & INJURIES OF PERSONS INVOLVED COOED _ O C AM.I EK AGE STATUS EJECT. C A.... : 1 oF P 1. - acirye ev -_ ro A NA- N T N wTUR DRE lO $ / HENOVflD FROM NI M • 1 R N,. n wruge OP E eMOVlD qoM S S $• uhf It I fTA N r O To C a O TUf ,PAaaSTUNIN .Of3TRIA tt 11 BE AT 1 01.1 O N 1'INNJURr c LA40 OINJ URV AT IKI aen T-ELT I1 IF EJEC110N f D CYCLET . OTnfR 6 ? I.OTNlRPOlITION j, OlAO ON wPlP V wL IVID MT •NJUOY "T a. U9DII IJUaf 1, TOTAL L - CT1 E 4 WITHlf. E ] ISUfMO POSI;=TOUHKRCYCLNo..l1 f A . 01l DIH NOaPI T AI T. 01...L. INJURY .UNKNOWN'' '-" LPARTI D L A UNKNOWNIP ..... . I , 6. 6lAT SILT F AIIU R! . O EJECT Y>1 I 1 ? l 1 f 5? uh ?1 3 yy i? IMP I ?1 ,?Prtn ? „ Cf ? ' ]Jki'?'3 AiY`i .i iF •T ylx ?,rt L W ti ?sI [? . ?s 1 J.kl;, 2 i:;' S14?F` ??^ a11] t {n v Y t( ?; / ,? 1 Jfn ,.'-7 T{ 1 I P r K I y;?;, 1 i ,? ? I t: f ddb. F ' I [" It ?1' `b ? r .YNul?lt'?h'c?, ), I_ S I 5- ?4? j r f' 1- 7 r r din r +?Sn?ll?e tt?o 1•? 1 1 i 1 IZ III I tIr 11 ? I ? 1 w>jl Pr A'l'. I. (^1 ` DAtEDFCOWSION DAYOFCOLUSIUN 1 A, - TIME U5E 2aD lL lRl } 000NTY NO / CITY NO. FH'!IA _ ?URBAM1 / A ',I TRI 111 ILES WEDA T SUN I MDM1 2 D 5 U jy Os Rl ?L/ J J ( ?kURAL r _ OUNiv 0STATEROUTE (COUNIY ROAD ?CITY STREET O ADMLL:r. YREFI% POLIJTE OR RCREETCOCE cCIIUN G?? ??? ? n ? OTHER )SPECIFY) N ? MILEPOST E L .11 CH)OWN S [ YI IN N r W FI% EO. PP C? O , iy LY ? ? ®OF CG /I ; N/ O^' A,ILES ?? U LL •? RAMP DIAGRAM DATA C _ - i ORHIGMWAINTERSECTIND WITH: S AME NO.OFSTREE IREETOPPOAD T ON a• o e.i? 131/1 R D N R _ 4 / ACCIDENT OA O EF. IN'E NON X HD rEASECtt- STREET OR ROAD T O R NCH ECPOSSSTPE E O NON W IERSE GE?Y 7r•4 . 0 / I.IILEAGE I CLR. ERENC , g / • ? ?'S L/ N BEi'NEEN STREETAND STREET r CODE 7 ' DISTAM1CE AIiD DIRECTIDN FROM NEFERENCE OR Cfl055 STREET ?? FiH3 HUrv IAICOOWG USE SPt ?MILE3 N B T-EEC? W QFEET ? ? LJ ? OF SEVERITY © VENICLENEHICLE ?VEHICLE BICYCLE ?OTHEN I-IEI ?HIT SRUII PILLED WLU SION INVOLVED: VEHICLEnR TRAIN ?VEHICLE OWECT STOLEN VEHICLE NO.IfUURE.U ? O TOTAL NO. OF VEHICLES L>77 ? VEHICLE PEDESTRIAN NON COWSION ? ? HAZARDOUSMATERIAL PROPERTY DAMAGF.ONLY OSJEGT STRUCKINAME OF OBJECT STRUCK AND OWNERS NAME) LOCATION OFOB)ECTSTRU K E W EST.OAMAGE ' I ? RD F.CGc 5 ? ROADWAY FEET ? ? [ ORnJER5 NAME-LAST FIRST MIDDLE DRIVERS NAME LAST FIRST MIDDLE FF K[tiCYCLL$TORPEDESTRIANGHECKIU ,. , R STREET ALDRESS ' ?THEETADOH v OG B 2/3 v ' pity J STATE ZIP CODE PHONE NO. E B E CITY STATE ZIP CODE PHONE NO. R R .Ar ,P%C jC?37/ 377 RTH N Dfll ERS LICENSE NO. STATE SE% All 11 11111 N DRIVERS UCENSE NO. STATE SE% DATE OF BI DAY VR. M O O• YR. OAV M0. ? 5?3 O, s ?J r ?? o 9 PNONE NO. OCCUP TA ION FIRM NAME n O 000UPATION FIRM NAME PHONE NO. `2 ORI1 E1 ?? r '. SS ; / • G?CC r IG F' C ?LT Y ?J ATM oA I!) BEAT BELT p. I`'I EJECTION CODESP> 1D1 CIlA49 / ,y? 151 1 CES > ui CLA I°I BELT EJECTOR SE AT ! ' Ste! I ?I NATURE WuR ES . NJURE . HEMNVED FR SCENE BY: N TO fEMOVEO RDM SCEN' nY: YEAR AAKEIWOGECHEV.1 VEH TD IAODELIDART-NOVA) STYLEI2DRLONVI VER.YEAF MANEICODOECHEV.1., MOOEL(DAFIT-A) SIYLE(20ROONVI . ' v e-'9' 9' - . ?v.-r Dom- C> V ?d 7 r f. r/ E c COLOR . UC. PLATE NO. VELA < STATE TM- R PLATE NO. STATE E VEH. COLOR UC. PLATE NO. STATE TRAILER PLATE 2:0. STATE . . . (•`... .: .. ION NUMBED YEMK;L ID lOFICA i ODOMETER C BER ,; ., ;.. VEH CLE IDENTIFI ATION N CDOMETEH - E / / E C? l7 C/.?? 99-7 F r?J l? REGISTERED OWNER-UST - .FIRST DOLE 1i FIRST ._ MIODIE LNE N ? ON • D . ? ADDRESS OF OWNER ..: -.:' DCRE59 OF OWNEfl - .. ... ... NMIEANDADDRES90FINSURANCE CO.Oq AGENT, NAME ANp ADDPE950FINSUPANCECO.OHADENt CH Nfc C ,? - OITATIONNo. ENFORCEMENT CHA CRATIONN ACTION CODES I _ A 5 E ADDRESS & INJURIES OF PERSONS INVOLVED EJECT NAME , . SEX AGE STATUS . ?J7/r/TNC' y NAMf.: ? ? ? ` I p A/Q l / (`-'.'•`-•,-?1JLL?IlY`!?'L?? r"%l• ? /V u P IUP O - NA VUUPif S. REMOVE FROM SCENE OY'. TO A ?? 117 ( T FDORFSS. n? yfCL!I-?/ i//L_`<_,_rr? - (=- (-- $ NIJAJIIP"S' F EMUVEDFROM (,f,Fl'F. nV: TO NAME. - -1 1 1 1 1 1 1 T AOMiF55' IdffldM A u EDr sccNEnr. TD N Iv.nm•Fs E NAME'. S ADDRESS: -- %I Tai' if??TiCi.(__-? TO 111+I ITS ICISEAC POSIiCw II. LRYGU.w9 IIISLIi IIf ISI FJEGTgN _ J JEC O NJURy D.B U RI JJRY I.OTU CALLED OC CO IY FJCIfO ECCtE n0 1E41..I F C- Ut.O 2NOtIN U.,F 1'1401 C. ;T,_ MI AiN _ 11 DfAUAI C(1 J \ T. OI ..II'ONTPN 0 u1AD (1NART I.URY ] UO alfl LL Ji.GTCD D 5 G -t. II1E-11,L I U 1131 HCVLICI A UNPIN IIDJIRTAL PO.II,LE INJUNY r ?JYM D'.VN Ir o E nNT ?.: Si '-„f„0 Z R NM. IVI:ANo", .•I SUt1 LLf FNLUNF EJtGfED ry pk t versnm• A 9 inc Ftm"._'• 4Ltitt , .., r ^Il i 1I % Gft 77 - k ); J 1; A las.: .. +c Pj r T 0 .r ' VEHICLE DAMAGE N -STAIICTIONS: - I.IN CHBO;CIflCIE THE NUMBEROFEACM OAMAGEDAflEA E%AMPIE 2.' APEAO O QI 3. ARP.OW(Sf TOEHOW F SEVEREBiIMVACPRNCTPAL.DIRECPONOF lo-E. A DAMAGED VEHICLE N * O.t IUSETHxYGPACE FORS EECF NO DAMAGE TO THAAEfL% MOTORCYCLES, ETC) / DAMAGED VEHICLE N ,n O 0.2 {u '?YC?/ C% lI ' t5. irw N f Ii. Rael 1 y SEVr'RIrY JFOAMAGE; VEH LE NO.t Y. M W° SEVERITYOFpaMAGE OtHER VEH 1T.OVMUm AE 00THERMV.DAMAGE 3 2 FUHCTIONALDAMAGE NOOAMAGE :I ICLEI t Q DISA-41 DAMAGE 3 0 OTHER M V. DAMAGE 2 -"ONAL DAMAGE NODAM G RIOF DAMAG E =ABUNGOAMAGE 1Eff TOY U A E WOBY EST.°AMAGF. TO @ FU NCPONALDAMAGE a NODAGE E BY ?^ T TO "Mr M OF COLL1510N„ ? I 1 ;DRAW AR "-NORTH :?q KW ' J a Gt cos,Rilcrnx v v 44 - } - - 1 I ? a tG O Hnw peY o a u?Eri'rcaur"wfW?c" ,_ - :?- - ??l\ _I I I QFaJ Setl /!F"?'t_? I__1I- ! !? I _ I ' " kI r--I I . I I?_I I ? I , F I I lt'rsd?dal C, I '??d?nd I.t?c arl 1 I?-1' ?I i j I--1 -?-" i qq?? p} 1kKKii y ,DESCRIPTION OF -;COLL)$IDN, IINOICAlEWHATPROBABLYHAPPENEDBEFORE DURINGANDAFTERTHECRASH, INCWDEINFORMAPON NOTON DIAGRAM, E.QDflNEfl DISAMUTY.REDUCEDVI8181UTY,PEDESiRIAN CIATHINGCOLOR,CONSTRUCPON ORREPAIH WORKEfC.1 ... .. .. ZANfT 2a ?? - .boa l//lO.d..3/f._Tif?.._J/l yNlSFG_Yioa+ _ r PO TIONB REF EC?LC$IDN VEH --ii, ADED MILE POST OIR +?.rii - ?;.;?•-n\? Np OF LA E9 SPEE0. VEHIC FPAHNED xf.AUI IN ONE OWECPON ON BTREETOR NIGMWAY NAM - NO --' INCPEASIND DEC ?Y REASING EOR NO. ro. ¢ -'. LEGALLY PMK_EO YES NO WAS VEH. OCCUPIED YES IN . -- - ? 7111, r V 7 ^ PED. C 1 l' C A SiREEi M _CR094N0, OR RicHw OR M 1 .TOwT, PED/RICYCUST Wh9 USN G 1 EW4K•" - _ _ _ q PNEO 10ESID 1Rq O?__ , I i utwAY•? L`.,9pUlpEq (_ ?CR0;w- i_ CR0.S5wult ? IocvctERglfE "?OP+ER ' . + .ROAD SURFACE IG C ONO , WEATHER •;( ,I OREI i .-,i..,a ".,CONTRIBU ' 1 TING CIRCUMSTANCES.'. bt (Iq MORI ;onrvrneYEf.nE ACtcND O'E S • D1uvER NO ,. , dwEN'. ` ER 'Y ?,,,O,E 0?., -Oq MGID [ f l ? AHFAD _ nl, CJ.--T YQ n_ _ -r, r7 I) ow fpD?E__ L S . ? ?, r?. `?:" >^ ? =PN . - - ! aoH° Po ?'C M J --- - r r0 - - ---- ? , - o :.? WU a,?;.PR - - ` ?.1/AJ - , CE ?- 1 T 1 W----_ . L r r-t r? 11 YaE (?J =_ H+WIR L l ,- ECiNEfWa 4 -+ _ ?15? uAm10 J JI -- o ` S ? ; ?.. E '- m ? ? I - _-;w OPO 6? r 1 ? I J ( - ? -?? ?e;? -ttow:ro m PE orq AII RIaxGr'» i x L] PA- _ - f- r] ?D « _- s ,yaw px ' ? r Lu] r°R .: LIGHT CONDITIONS IGrtGA O«q ;TAAFflC CONTAOL r xo u TYP OFROAD No iGlfcK Oxf on MwD r VEHICLE CONDITION E W Ox SOBRIETY p a ;a .6i o sto, CJA? d (J? maN n L? °N W RV FPI I Ho2 '" nMrrt I 2 TWO- [N rGTtrt - ^` A ', ' ) °... )a.L ,a ' ; l lP`a_ E - 1 Ip[ p. __ ? , --- 7-'It ?oPOr,9I?tIMON r h - ' J a OAA JTnEE U L I AFµr ___ ? ? r C? ? °` ocr r 1 )e ?1 I I i n ? ? ?, ?r IrN rR q+ 7 4. raoN °I 1 _ - _ _ ? ? oR fy? 1 I 1 n. IEwG Ix xD Ctat? n.cxro ' ` - s 1 TRr ar 1 r, NAL I ` -.. 1 rmIRAx ?? J ai,°io-'"we4rvwo -- ox fR CHEM.TEST r Nlt 2 ° J..` J ; J btlON ? lA6 ? J ? 1 ( °M --- , ?, iF5r 6w[N iRIY[C TI. ',. ??"-" •__._ ?' .JP7')YX'`C?? 1 1- 1 LrrtK ? J I ? ?i?f/??In rsr I I r nfful° ?? Or R lutnYl .vrtsm.nAO r ?'j ce.'.ma? RMw Ka .. !I UMWOEO .I a r n .:,..fome I cPii 1 % % TEST RESULTS 2 +sR Ff[ ?111? :? /Jiyn a r - lo. R e ? wf,cs .u wueE N.wxP D y c.?$7 Ana/s/5-'H? Swa^ a c? rfow r ° H MRf Y . ..I?p.IMD aR ? r71 { Yn+F ?F Y OVWCATE COV Y:IOCAI UWENFpNCLfAf.Yi AGENCYpCOPY+-TNPLKAfE COPY: WVESEIOAfOR'9 COPY l Y ! nNa.s k Y? "i f k a I I .? MOTOR VEHICLE COLLISION REPORT Np, r - y DATE OFO COLLISION , ' pAY OLLSION TIME OF COLLI610N COUNTY TY NO I I s•r o n u u [[ PM COU TY T T N •ou.xP[MLEB !? .CITY. T.I.Y. 0 _ AOM?CLS PREFI%,o » 4 xri x?r m[ [ } - "- •. v ld?- [[acct cco SECTION 50 1' PC?cN (L _J'J 3/s 3 a - ,c OIV NEET. ROAD OR X HW Y INTER6E T ITH. _ STREET OR ROAD PREFIX ED MLE xK» .__ ? , . », r l7c c %cN C? „CBa? LJ?: ?r.? c?. S2 u, NON INTEPSE<TION LOCAT N OF C LI$10 AMP IAGRAM ATA t'7 BETWEEN / STREET ANO 3O NDN DO w• Lwo•P [,P[. T .:L[.P.. R, IP[x,L »P ,.„PN.,, . E ex,PP[. X.RG ®O T R CLI. A w[uc[ocwP[[ ow -T I - o oLV[O u cc[ o u[w [I CODE USE »? x » ? x,.wU 4 LI _ OBE T 6Tfl UCN o uc NAME AND A 1-1 O o V -, "...- .... ....:.::. _.OWNEROFO J,C 6 DORE68 OCATI ,.. LJ I _ si INROAD WAY - Mw o. ? EE S T- I DPV R AST NAME FIfl6T NAME MIDDLE, cv[o , I. T ' '---- ?•••?•'? . DRIVERS LAST N E ,FIR T NAM tG' [P[LLP»Pw AY, 1 - 6TREET AOBRE6 .mac L_ RANO 8 X NO, Ivi?n?ou[[w? STREET ADORES OUTE NOi.AND•BO% ND. co[u[ou C [ronrraxN E .I GI n ?' - -' TYVTE ;? Z G OE RI E- OCC ATION_ GITy? :..: - 6TA E S? 1. LIE tISE !t? J I 9?3 0' ?? e fry/t e `? U q STATE fiE% GATE F q E OgIVERS LICENSE HUMBEq, STATE SE% y DATE O.- RT AOE " Si AU53S/ O ?? Al ?, j? _ a _ 7 a[ MODEL w 1 BO Y 6 E _ I MANE1 _ _ I _OOEL _An_,I .BODY 6T LE 12 w.l ?, - ?r IC ?E MTE - e ?T TE ,, :_ /?„ / PLATE __.... STATE.• TRAILER PLATE n.-.l 4 973 6T TE i TVEN EEICATIONNO ETER - ..REDRIVERS•LICESE-NO.Y RED 61 OW ER ODRES6 n u RT E 6 A RE58 OA _ [[, O - ,, •, -__.._- ____ _ TAT 1., _DATE. F BIfliN A /D 9? ?''r<ur w.t r an .. PARTS O VEHIGL O AGED ,_ ._ . _ ro w[rn:n vm:c[[ ART6 E ICLE O E ILLIABI T I LIABILITY INSURANCE INFORMATION VEHICLE NO 1 EH EAE FE 6 R H AC DENTONYOURC R 1.1' YES ? No (T9 "' A Nw? AODPES6 OF LIAOILITY CE PO Y HOLDER __ ;,.. - -, ', N E p L ILITY.INBNRANCE COM ANY 7?: 5A ;5J2 D i?1 - lJG ?yL ?_ U 'i( l- 1aL i ?tEriC?fiC. ?Corio' AND A1ORE45 OF L - TY U A E_AG T ," n r[ LIABILI P LILY UM _ ?' .Y? D ?(? d75, .. ru LcY.9 n _ rn .. .. 1ST H R _ : 1. .'.. _.... .-?.e•+ ..., u.. ...:..., -.. AG 2ND N U Y u[[ AGE N? :-!ZL ,... ME??. - E \ -, L?IAA• .lX _ N ?.1 Y~'-. _ _ Gam ' ODREB .F _-.Bax l 3? -F ---- ADDRESS E y NAT ? . [ eiA U8 0 NJU EO R FIRST ONE _, .HAT PLIE STATUS OF INJURED MAR FIRST ONE T PLIE ///???({[pp,?{{{? VLHI LE KILLED Iu,uwY u,u,rU FIX An N EN LC I?• ?I'? J KILLED L-T UU NO. __ Is[v[w[I Iuluewl'»a c vF-i`V p O J,- 1 1 1 u I _ ,ux LL11 u ',. - S Ic N El 5? e? IIO.7 Px' ? IS? 6??' - OW q YA O I C CLC ,L0. ?, I DEHC O[ BELOW WHAT, HAPPENCD IPEFER'T VENICLC6 OY NUMGERI ' 7tl s e PI,[[,:Px %.1 -- AN : ?- ai• : _ . r L " a ? '- - - cL- ?.? C ( rt0? 4 . S GLt ?j ? l To CA, - `^?-??\^i l t ?l c c?JZ? c c tsw4 rot-p ---- ov. VEHICLES POSITIONS BEFORE COLLISION I (`&' [NICE[ N A [CD [ INVESTIGATED BY tut • w ON ITR[[T OR NION A NA E Oq NO » r NO. IIYOURI ??.? • Y[SLY IRO L OIOL C[ "? ,I 13 El El El Ej EJ (?(L n -"..: ....uv.. .....•.- 1?1L..'TOyf.? t. :.)•no 1 is a /n?oM 1 uaga 1 ? e - IN ronr w L :o[[w.?w •y - , PRWOLU IACL l.ll?[?? ALO 110NT CO DITI NO.? 11 IIC; O} ? OLC 1 G -?. [nl•-•--.-+ ..-.- -. _...- T,'PL OectO D DR Y[RJV NIC GTI N 4 .- 1 •[ ._- 1 ) 1 } "t!w k •o i 'V »ICEf IEx[C, Out oA ?wll`" 1PK.[ } 1 ? w::u? • I IJHIDAYLIGHT 1 SIGNAIt 1 ? ON[ WAY w[ ?}DOING STRAIGHT AHEAD "1I I ? 1 ? DNY )? ANN. NIhD )/? GAWN 1:1 ) El LTOP i1GN _ } ? fwU WAY ? }•? OVERTAKING AND PAe SIH6 I 1 } 1 l v M1 y. El ) 1:1 W[f f W.N. {HOf E] UUSK ? } C] YI[LO SIaN ?) ? R[OAOge OL[ ? Z E:] MAKING RIGHT TURN [ ) ? Lwow )? roa K ? Lmii ow [T ?) E] FLASH- RLD T[ G ANDS .• 9 - ?) ? :LOOP, RAMPI ? K E] MAKING LEFT TURN I 1 yn A El IC[ L? fP[LII YI e ? ?==21,111, C) L ? FLASHING AMIIf.N ? p ? ALL[I ? L ? MAKING U•TURN r i e ?{P[LII? e ? {TNL[TL FONT{ RR SIGNAL { TWOWAY { 1 UAL El { ? SV I - OTN[ ? ? LLIT TURN ? { ? SLOWING .6A.- FGw HOTS[[ ING DANGLq T?SP[CIIY ?T?OIIIC[q/ILAGMAII LAN[{ ?T? STOPPED FOR TRAFFIC IJ1 't lo,[[vn[n r•New. M[I,.c NP,[Y,C1 OTN[w ? L ? {Pl CITY ? L E] OGTOPPtO AT SON SEPARATED IGNAL 1 *TO' C] ? ? • ? LTOPPED IN ROADWAY NO T AFFIC GIYI DlD ?10 ^ tTAwiINO 1N 1 r J II 'l n -1 } n YIGLD K IoM nri A? '.rT TAI, ,?• .,1; l''?, •, 'Q,:ti + Y1 ?,,,..? „!+X'"°V '.r'i••-,cr,? r 4' 777 7 ?'.-?`r','E? 1??.,;C?',?:? npN. ?•a? ;3?-?C?d?.<?s>ltl?r ?;°rr -? 7 , '?'4gkps? ^WF??.+P???' `? ?^ ' Y t STATE OF WASHINGTON PAGE OF NO J POLICE CDMrU NTlx.MBEP UNIFORM POLICE TRAFFIC COLLISION REPORT T1C ? .r I D ?-OAiF OT CCW:.OII U YOF CCLLLtiION TIM1IE. COUNTY IIO. CIfY 110. FH 'N MO U)r--1?T ? ?t ! :Un f tU tr Fil Ai IUSE 3A00 HOIIRI 7- J? 'yfSU PAN ` CULN? F THE ADMCLG. PREFI% RUII rE ORSTRGEf CODE SECTION ?S1ATFf UI C?,,(fUNTY nOAU ?LLY S E! O ?????\S(•I Y\ ?DIHEN IS E I YI W J CIrYOIIiOIYN VREtI% ED IAILEI.O:ir O (SIN ?y{ ?MILFS I ? ? ? Q` OF .Cc V\ Il.? U LL ?O./Q C y AME 6N0 OFSTpEET Gn HIG11'NAY 1.VO WITH: SrPEEi Oq HORD INFEflSEC1 L L, R AMi DIAGRAM DATA T I O 1 _ ?1 Li. T R _IL.S•?o•=,_C? .-cc-?_.i R L K o " %RD w(EPSECPr;G 9iq Op pO+D Oq REF O NON M E SE4l Acciow MLEAGE INTEfl :r ER CLS ERENCE CROSSn'? D N .MIEEN STHEETAND _...-;.STREET CWE EENCE OR LROSSSTRE?- pISi.WCE CR NN FgOM E EF III S PECIKCOD NUUSE .. I OMLED r JrGL300 - L r ? C ?FEEr ? ? OF _ . COLLISIONINVULVcO: ?VEHCLE•VEHICLE ?VEHCLE"BICYCLE llTIIERIWRITF1 ?HITARUN ?VEHICLEOBJECT ?vEM CIEPH TRAIN -t CO ?SIOLEN VEHICLE C O NILL SEVERITY tIO.EO ?Y , C.J_ L,i. I TOTAL NO E I ICLE rvO INJURED yE?NONCOLLISION IIAZAROOUSMATERIAL PROPERTY OHMAGE ONLY ? I JECT STPUCNINAME OF OBJECTSTRUC.-YINER-El .. ,(. LOCATION OF OBJECT STRUCK EST.OAMAGE. 01-N-c L.\N I(1\Cw' ROADIVAV FEET ? ? El ? RD EDGE 5 A•A CL3LO DflNERSNAMEHAST FIgST :MIDDLE DRIVER'..NAMELASTFIRSTMIDDLE IIFBr YCUSIOHPEDESTMA.VCNECNICJ:::. ,..._ 'R: ?O v t ??-JF C LLA ' I STREET AOME33 -..... : • .__. _. • _.. ., : __ - ... ? )i P ' I STREET AIDDHE .:. v , T 1 /Vor \oeh f c\,, l t7 v E CRY'.: '., ':.. STATE. 21P ...... .: PtlONO. E CRY .. . .::. ..,...STATE .. :. ZIP CODE .:: PHONE lq. yy]] N OHNERS..E-H -._ - TE 11 DA(E OF DIRiH! ST N DRNEPS LICENSE IrO. .. ... -. STA(E EE% OATE OF BIHiH e O. p F D ^ - A M; DAY ) ?' DAY YR. O I\ y GS S m yV I DRIVERS OC-DON, fWM NAME.. ..,,: .,'.. ... :.. .1•tIONE NO. 'j ; DR,VERS OCCUPATION .. AME ....:-??.-...' ._ ........ ::. .._ P N .' LA l CODES > 131 cU Rye,_ IAI SEATBEIT._ _ 1!'I UEC71ON CODES > IJI CLJ_ , I41 SEATDELT____ I':1 EeCTION __ NATURE OF INJUPoE. NATURE F INJURIES REMOVED FROM NE BY TO REMOVED FROM SCENE By, T V-EAR 7-7 MANEIDODGE"LNEV.1 . DL???:? MODELIOARTNOVAI:. SIYLEIt ORCONV.I sw, VEN,YEAH• MA%EIDOOGECHEV.1 MODEL IDART•NOVAI. STYLEMDFLCONV.1 ;. E '. V H. OC. PUi -0::. E STATE TRNLER PLATE NO. STATE E VEH.CULOfl .. - PLATE NO., STATE TMIL H PULE NO:' STATE .. I v,?, IL ylq Y wit C. V I NTIFICA ?:..:. -"C VEHICLE IDENTIFICATSNNM9i:R?.;. •r .-... ... DOMETEP .....:...•::-:..::. L - H S-'C E E . - flEG45TERED flEG15TEflED OWNEfl- .....MIDDLE UL6F CI o. t\ o. ' ADORE390F OWNEq '_.• , .__:.._.... .v .: .; e:.:_. 7 M e,Y1 , Na dull 1 .. z', ADDRESS OF OWNER'.: .......... .,::.•:?. w I—. I NAMDOR . E AGEN „- •. NAMEANDA...EESOFIN-CECO.ORAGEI .. ..,.. v ?wA I w 1 n5 L.t ra CC 6 " " AO?K?A ;. CHNq .. CITATI NO •.. ENF ORCEME NT HAR E .. .. .. A N Yl o N CJ N e- ACTIDH ADDRESS& INJURIES OF PERSONS INVOLVED , """ ' NAME CODES z A s C , NAME' SE% ACE STAIUB N EJECT. C AD 11- _ U p NATURE OF IH'VO ED FfIUM PUUPoFS SCNIT Iir TO A NAME N T AMVIES S SOF OV; ; FIIOM TO Nl11- W N ' AME' A ge, T N N A Ura!uT-?- -- TUInlM- -- ----- RCT •,1' nY To S N AMC . 5 A .?_?__._.?? LUwess M -T To ?._ . I I S Ib 3l Al PgSrt%rv :, IV •• I HrGf AI DOLT ILL LJLLrILM1 C ^ PA ;FNGETI -- A 1 I OINJURY !. NCAll1INf.IrIJVIIY ' 1 NOT UISGLLf.O I NOT r1FCl rn '• O . rt1?UT'tNrw, I[IISf ) ONICIiPO•JT[W AO ? Z nI fI•F ; DF AD O•I 'IINAL .UAItII•JJ U nN IrvINt'NTII'MVRr I )NUrIIIU :C f0(ALLY EJEriED D U:.(n ,l nnnnM.LrEnCrCn (J SONrCN - / LID'. M•]I(lt'CvLICI DNUIr;IrO.•IYIAL F J 'O+::ILLE rNIUIIY AV••rr1OY.:I U1?NOY/N Ir ) [ ?r 5 x? `t F r g . A? P" - f 7 i r l "..III, a?} a,NL i ? -SILL ?. nji - E% C11°O%, CIRCLE THE NUMSIIA OF EACH DAMAGED AREA. I NE AMPLE 0C IVEHICLEDAMAGE ]. SHADE AREA OF SEVEREST IMPACT. P < • ' • O ! INSI•RUCTIDI?J S: V E y S. DRAW ARRDWISI TO SHOW PRINCIPAL DIRECTION OF FORCE. GN SKETnI NC DAMACe TO TNAILEII ;, MDroncvc[fs. Erc.r DAMAGED VENICE[NO'2 I DAM AGED vEHICLENO.i T, 11 I newun ? 17. x wIV " S N? SPACE F TII .? 1. nmm VEN CLE 110 AMAGE 1 OG DAMAGE V FIN E rv0 1 E[I VENITY DAMAGE ] El OTIIERMV DAMAGE OF DAMAGE: POTHER VECLEI IECI DDAMAGE )E3 OTHER M,C -A'S . NY OF D TE QDUr1CxOIIAO D+MO GE . LI NOIDwMAOC AMgGE S ?i I T U fUA'CTIONAL CPU_ < ? N SE V EST.DAMACe D .AL A.A.E ] GuN < E3 NO M ST OAMA E TOWE06Y CT k TOWED OY E .OwMAGE Ss O WE R To t S TO - TO , DRAW ARROW SHOWING DIAGRAM OF COLLISION I IoLNI?rY noAaY+rFaowv.«w - , I -. NORTH IN CIRCLE I wY ncrsonorr AO+ow I ol .... ur.uwwur[N.. wnomoNS Du •ArcN.coxsrnucr oN wNEwiLrc. I 1 _ _.;. - _.. I i . I I ) L«Are .noe+eLL •owr r ? ? I- 1 ' ' - F--• 1 - rR .. INOw Y[N C.[ rEOfsrNl, y Il I I - I - -' I I _ J ?? ! ? + oeMCr wsronswrl <. sNOwrNOe+eLP V[N CLE rn wrwrn[eerow - I I ._ 4 _., ?i I r ?_,r I .- .r _.._ I } I ._? -- i 1 .1 J• ti 1 -1- - -- - rmfs +gDA•r[n[DLLI] DESCRIPTION OF INC ANI LITY EPEOE TRIAN CLOTH NG COLOR,[O SrRUCT10N ORLPCUDE ETC INOT Ox DwGRAM, E.G.ORIYFR _ DICATE?REAOTUCE OV LIVIAII OI]Ae1LITY -. COLLISION , . 4: \ i } ( In1 Ii.. ty'I,. n l1 1 1 t'L .J\ L )r . ! .. J t L "- I lc ..,. _ •- 7- SPEE --- - AR 1 DS _ POSITION - BEFORE OLLISION EET ORNGNwAV NAME OR NO. 11j0 f LANES IN ONDRCCTION r s[u s.r[ LEGALLY AgKEO WA OCCUPIED HEADED HEN. G. ..1. POST DIR INCREA31N6 DECRE ASING ONSfR r I I_ I r ,... i._ + I` I c, Imo, ?• V - F YEe ND 1 . 1 i YES NO ? ?J " D r - F o To II J r '""- T LONG, . _ • ) < E°]sl c.. _I c "I MA FO 6?" "I A ? MARK E bI 1DE56 TEO ]OT C C E OUTS m HE _ R UST WASUS 1 I SDEWA r I I611DMLDffl IC O W I 1 '..- 1 0 YEN n[ ACE WEATHER ICH E OIER IIIVER E _ LLII_._I 601N0 TNAIONT wHEAD CL 0 ORI FR "O'? OF UNDfN INFLUENt[ ] p, ] A. OED ] SG ?? R 0 ENTAKIND FNB NO AND F D l YFtl L1, -• 44LLV]EJ.7 <[ TE _ ' F Tl u I ONTi URN TID A TO I RK n6 PO gI AK Na M S UWNG JEEDLMT ? SO _. OL ION..___. _ LEFTTURN MAKING CE .A ; I S R .Al 0 ) T N E 110. DE FIC lEDUIP__;_ I U-TURN - - I 1 1 1 OD TGRANT IVI -1 I 111 I DS lGARaD Q4G 1 T9 I r !"':J _ ----- - EI I 6LOWIND _ I ECIf Y1 S • S - DTMfn ar[CI ??,- TO 1_ . OP[N STO ? T F E SI f 1 CIGYI 1 9 I xOV OL TO I STOPPED FOR I , T E -r I TRAFFIC L. r[R Otr :e D 1T Grvw GN S J N ITI O ND C O VEHICLE 1-._ ... N ?K ` - _ I J cnoiioi AT SIGNAL I I°I _ CO- NOI fION3 [NICK ONk1 TTUH RA F FIG CONTRO 1 N0 ] V[NICIE eM KL] TYPED ROA I NO, ICx[CK ONl OR NON! f Q v ?EC ? I VENICE[ 1{rjt:ON }I l[DI I NO ] }1?1!!11l11 ONeI V[ NCLF NO. T . -I t YN DW • SIGN Ll i 'Ir O Ew Y VE I 11 AIIILI I kOrr I ? ROA A - TART )0 iPA1rIC I?NE 1 DAILIGNI : . ] ,. SIGN WAY T 1W0 ' I. 01 q%f3 •' - . IMIAI 1?11Y - 111 -I I A 1I G . ... -, rll D T.. f I F ....... T. 'I LAIC TI 1 .. ...... IRED - TTI0 P RNl 0 N T -. A G I ROAD ,.- ANO[ r < C - _ V[ ?l IGNIi DSO! I[T I , NL TERI NO Mf RDINO ICN J1]1 THAPlICI t DUSK 1 _--: DANK-SFR[Lr R[D LA G - MP A 00r 'kI Er ALL ! R I< [4 O[ 0 (OI < .IN OrTINKINO 116 !ACHING [ llcNlf on Axec _.-_ ' CHEM. TEST VI ? ' it DI+nR•SIPf[i Gniq Urr II ]?GN .6 'L . 6 ,w.r N T.I. DISPPF,IIYI 11ANU.NO F srnlll LIGNIt 1 II " FAQ 4 LF , .... GIVCN ? Ilir nfrUSlO UIN ! I ), DIV1xED •. ', _1, NO DEFECTS ; TEST IIESULT] OININ 1wkf.Nrl S 1 I'- Ill.+rlN4 u?P ?t rr++.?l wNA rCN 44I r WUrrC IAIlA 1K 1 ) v10E0 -rA ICrIt, ) 1. UII<l ui, I U -7-- IIUII [u 1 wN LICI w%Iv [? TLM AR1iV10 -1. AUl t A I UNr C[ N.AIrIC rIDw TRItl 141D1ON16 MIN FIIUVI? I1AIL 1 :1 I f • "1 t h;r y x 1 < ib h 1 ? `v4'<KT: IW n.. YAl V 'ry ' M1YI ? e'K'??I?IF ,p ? ? y? '4]7!i ? 1 1 f I'?I."" al ? I, ? L- 1 ? I-ti>1 ka , ,k y " 4?r ? ? SI I I a 1? 11 ? 1 r; Y T i 1? ti ? 1 ' ? ? y x rti ,1 '`. C?al`? I i 1>{ r , ,r ` ? i L I I'Y, {4 ;a 1 yi y a1: 1 I ?' I -?'r SIIT ,. Yivw nl 1 ,1 ? . St "6Jr' R l .ys rT?? ? a.. 1 hf} 1 Y/ A, , •?r 1 ??r? I ? 1 ` 1 1 i, I Yt, ? ry X ?,T Wf 6 '••. - Y.. W:AC,`ti. 5YY I1 STATE OF WNSFj?Ntal UIU PAGE OF NT U BER CE COMP 1 ? COLLISION REPORT • A 0 zK 171 UNIFORM POLICE TRAO -4 T CITY NO. LINTY NO. FNWA Mf ",y4 Sd ,p DA(E OF COLLISION Y DAYOFLOLLI WEd lU[5 NON +UN SION n S FRI B SAI IME IUiE?dz 1]QllFll ' j /? URBAN RURAL i MO. DPY^ * 7 l l d 2 I Z ( Z ADMtLS. PREFI% TOUTEORSTREEI a SECRON ?4 COUNTY ?STATE ROUTE CKCOUNTY ROAD ?CITYSTREE1 W C u 31 / J V L "'4' P •E-' JL• E ?OTHRISPECIFYI CITY OR 'OWN N W PREFI% EO. MILE POST /O t ? IN ry l / MILER WITH. G'PEEt ORROAD TERSECTING O VAMP OIAGRPM DATA S C /N?AMEAN,O?OF,STR?EET Ofl GNW/.Y /rcr1 / ? N C '? r IN /t?q UN NEF. RROAp TIN STSEE c E T `s+: ` •yY', ' T I ?.? G tl^Z_J / O OIY _ /T6 NON INTERSE N - --T Gq•ev?t-,t/ Gl ACCIOCNT MILEAC ITE INTEA All,. O O SIRE CR ENC R J' ?T)) O N STREET BETWEEN STREET AND pSTANCE ANODIRECTION FPOMHEFEHENCEOn CROSSS'R T / OINE CODE unWltin CMl. OOINGUSE O ?' ?Q30d k ?+ y+ F , S ? N S E VI l ? E ItItY VE (' []FEE! OF ?OIHRI R IlEI ? T RUN NO KILLED 'fl '? - 1cw ?VEInCLEdICVCLE VENICLE VEM CLE COLLISION INVOLVED: yEACLE-OSUECT ?VEHICLE RA TRAw _ RI L ?STUENVEHICLE INJURE NO INJ RED DAMAGE IV PROPER" " a p VEF CLES ® ? VEHICLE PEDESTRIAN ? NON COLLISION - ?HAZARDO SMATE "-- OAMAGE EST ?E ,? KAND OWNERS NAMEI . LOCARON OF OFLF.Cl STRUCK N B E VI J • OWECT STRUCKINAME OF OBJECT STRUC ?ROADWAY FEET ? ? ? ? ROE + i ME5N AN C _ u ' + FIflSI MIDDLE . .. ? R 1 DRIV ERS NAMEVST „;:/' STREET ADOIFESS I " , z z >? la s Ck, nom. 5 v E a ' .. -ZIP ODE PHONE NO .. CITY ? uJ? gB5d3 />-56-2 y R J' ° .STATE SEX GALE OF dIRtN A ?D pyAY I ? N 0. a p F ' L-.?S-aF- ?Om 1. ENO Z v ,? .. .J _ ....PHON . ORIVERSOCCUPARON '. FI MNA E ,. _ . (gJ ALA%,_(_-, MI SEATDELT _ EJECTION NATURE OF y T I-Es F EDNESY' TO VEKYEAR MA%EIDODfECHEV.1. MOOELD T-NOVA STYLE I2 DR. CONV.1. _ v mono. o urea A v E . A. STATE ALER PLATE NO. STATE I+UTE NO VEM U G E R L C H ? ( p 10A. 5c T99( w P FSh ? . /t OOOMEIEH C L . ... VF ICIE IDENRf.CATIONNUMBER I? O l c 6p a // o Jr'S 93 L N E ! : FIRST ..... MIDDLE : w ... REGISTERED OWNER-LAST.: .?. ... . N I PTw? O. ADDRESS OF OWNER . .-... .:,...:.. '- NAMEANDADOPEESOF WSUMNCECO.OR AGENT - ' R .R .:j cHAlw ,.... .. _. GI FO CE ACTIO NAME, ADDRESS & INJURIES OF PERSON S IN K IU' DRIVER'S NAME-LAST FIRST MIDDLE Pf dICYLLISI OH VCI ES r K o YE R ' STREET OOReSS 7 52_5 /2 r? Q e N„F •."SPATE. ...:, .. LP CODE ., PHONE NO. CITY .. OI ?. I?c? gB,ot y5TE DATE 01 RIM B STATE SE% O ? . ONNER UL ENO -'-: o -Ee-R?11yK wa /K iZ /SY 9 - _, PHONE NO FIRMA AME 0FATION r R . 00 F jrM(k LL ' W4/rCK Q . Iq I 0. fJ CODES >IJ' CLASS-- --IAI SEAT BELT.- EJECTION_J_.-_ ATURE F INJURIES `1nM0 EU TO OM -NE .1 •. STYLE1200.tONV.1 NOVA ART F - .. - I VEM YEPR MAKE jDoDGE-CHEVI'. MODELIO >4h4 R / lotIoA4 ?olR. 7 ... TRRAILERPLATE NO. STATE .: ... .. COLOR C P ATE NO. STATE VEH . F{ cpA. 5b( 30 . x VEHICLE to- TFICATON NUMBER ... ... ODOMETER ..: .::. Y ?pRl3 NG oS /3 J1 FIRST C3 Sam .MIDOIE _ REGISTERED OWNER-LAST ... W/1C felt !? . .?yn9 e J ht C ADDRESS OF OVYNER L04, c e 9 / $ .G?COmII e? 9/531 / P0 , SURANCE CO. ORAGENI AODRESSO ? NAME ANO LL) A CE L Ct { ATI MENi CHA GE N '..: CODES 2 5 VOLVED SEX AGE STATUS ?• T EJECT M ?O wA P .A5` A NAME N ADORESS. S oUUMFS Ail 6- z? 111.1o VEDFN M SCENEHY. T W NAME: AOOnESS' 1 M D Ho. Y NA U1 N wl NE SCENE DY E S NUJE S ADDRESS E N R11. sLiulF dr $. xLAm'1 tK)N ' uNNA1M CUSS tU5 r OY 1215EA11 NOINJUIIy BDISAIILRJG IN11111V ' I 2 PA^YNOEII AN l JAUlIN6 DCAD AT SCENE O NON 01 AL [VIRf11TI1NlURV O Pf IKS11P ° DCYCIIST 2 ! ill[RI'USITION RUS MOIUnCYLLEI ' N.," ] OI AD IDIEDIN 110'+11lAL TPOSSIRLC INJUIIY D 50R1fR y I I'O:i1110N UNXHOWN . E A WHAk SS -- INOTINSTI.LLED 127 INOI EJEC/EO 2 NOT" UK 0 TALLY EJF.CIEO D.USCO 0 PA AI LY EJECICD II If S GE.ATIOILifAIIURP A EJECTED vvvmr., cTet.ar. t._ 1 I e L ? '°OR 1 -,q ? I E T rI 7 77" } ' 4 { FI 57 w W7 + T V11 s F ? l ME I -I 'sg YG'7. kS.NC ?cew ?mxLr.i.: gb?i?4kr ?. a P ?umz, 4a a _ G?' l NHN ?. VEHICLE DAMAGE INEACn HOK, G1nE E MBnt f EAC, UX AT ED A. "'- ' 2. SHADE RHEA OF SV NESTESTI MPACT. INSTRUCTIONS: BAK ARPDw sI TO GHOw PRINCIPAL mHECnON OF FO c ... (? UC Q?IA : r DAMAGED VEHICLE NO.1 SPACk Fun SKErn1wG DAMAGE TO TNT-S,MOTU..lc IC., DAM AGED VEMIC LE J.2 134 11-22 1) Or wrn O tun S CYEHITY OF DAMAGE. VEHICLE NO,' A ISAeLIHG DAMAGE. T?/ORIERM.V. DAMAGE CTIONAL DAMAGE , LI NO DAB E AG SEVEENTYOFOAMAGE: IU,Nf. VEH1-1 }??I ARCING DALIAGE ) O OTHER I.N. DAMAGE 1 ] LJ FUNCTIONAL DAM.C.E q O NO AGE LN. O DAIIA..: VENICLENO. 5iEVEHJTY FAMAA1wGE M.V.OAMAGE ? MAGF. ONO IIER DAMAGE ESI.OAMAGE TOWED RY OWEDDY EBt. DAMAGE r . V / wfD To SF7?000F To S s?OO o , io DIAGflAM OF COLLISION ORAW ARRO'NSHOWING '..enonr ll.ruNt, ! NORTH IN CIRCL a?oFFAD,DW,Y KON,KOL, rDH, MN ,1rALRIMP E I L. I ` 1 . _ _ .. _ IT-T rTtLH iDN .rOn .,I NEA, Ir01 LaAr[n,OBABLEPpINTDF : • 1 ' . . "ON DAH,D.,eLfYEHKt[OH ? ? A ORtDLLr,rON E _ ,.- I - DESCRIPTION OF IINDICATEWNAT PROBABLY HAPPENED DEFORE DUNINC ANO AFTER THECIIASH INCLUDE INFOPMATION NOTONDIAGRAM E O DRWEII ..COLLISION , , . . DISABILITY, REDUCED VISIBILITY, PEDESTRIAN CLOTHING COLOR, CONSTRUCTION OR HEPNR WORK, ETC., IN_. he 416 q;64-h o/ -- -( FJ U (i ` ? _ee pp / ,C b2/Ces r ? aKS n? ?:¢ Z4 1 ? / K ? ? o Ac . o- ?eh. n,l e- Slie in in ?r OR ON ><? Tf1QC / ?? C ? k `' . S ! ? ? ti Y C __ 2..1 q _..Il.e Q._r 1co ? + n7 _ . S? i _7 'k4C ' -'- t d f Z /A / ? 1 i V h e P , '. SA eo .._ o { , `p ! Kovt. _ /rf e. _F c K sn9 - o - I POSITIO VEN.-HEADED N BEFORE COLLISION --0-. R. .' ON ST ET OR HIGHWAY NAME DR NO. F, A IN. NED REC11ON sPE resreO E0 5 s,rf VEHICLE LEGALLY IF IwRKFD WAS VEN. NO. N S E IN INCREASING DECREASING /f• N r A 4 ? U (LIIM1SO/! 1.4 IE! M I ME y N 9 PARKED _ YES S NO OCCUPIED ?S NJ YES ND F r ?l 1( it + ALDNG .: e n r.rv.. ,D,f.f H .. FROM [-TOIL ?10.... __ --CR - -__?__ /D CV[LISl WAS US NG. PFD _ I NMgNKED 8? DESIGNATED 1' ,SIDEWALK )I 'C IS 0 LDEH eI 1rCROSSWOAL 5j --j L I. BICY E OUTE )! IO N ' . ROAD SURFACE. IC lCK*NEI WEATHER,... ICIIECK ON El ,,..__.;. CONTRIBU IC TING CIRCUMSTANCES VECK ONE OR MOHEI - I HWEwYNCLEACT1111 INO . DI[1 OE] ER O.} DRI EH O.} D ER - NO ]: r ?1 ISO GHf AHEAD ?x y pR - _. ''•`-.- CLEAR,GAWYr ,4 ..6GY(21GZ._. 'j U FI,UENCEOF L _AUGONOL___ ._L L?1 )i -I- FO OW N6 i OGLOSE Y - - }r 51, EG RDE WARN. L IG WERTAKIN6. NO IASSING ] W T ;RAINING _ UNDER INFLUENCE OF LLLj ORUGB I O TLR r LL I APPAR ENTLV BLEEP L I MAK INO i 1 _ }r i 5_F10 _ ) Y,OV (n--I SPEED ED N TST T = I P I , G G TO-' AL _. 11 _ C 5L I LOCAOrLARKING RIGHT TURN NU. LJ IN LEFT TURN 1, LK ,: 2. ?E 1 ...- EKCEE "CAI _ .LSAFE EE . 1111O PER URN r? ?) OPNATING DETECTIVE EOUM I '?I NAK U•NRN 5! I ? - r - OIDNOTGRANT- TOVE INCLE ? " -__-_ 1 I 55 EGARD 9 AGO LIGHT ___ r I I -I (- L IG? SLOWING OT IEIIIYECIFYI ()iH AIL`ECIFYI r O ( I. ?BI PEH wS,rNG r ICN SOiGNgISTOP _. I N O N VIOISPEC FVI LAT ON }rl STDIPEO FOR l `_I TRAFFIC IGN CONDITIONS ICIIECK ONH 110,2V CONTROL TRAFFIC NOVENICLE vfN .... TYPEOFROAD I-?N .., IC NEC, ONE OR MORE VEHICLE CONDITION., VEHICLE f{M I?Q ,v IND ) j?o 'fpjg?i .:.. .......: .: SOBRIETY.,,....-:.:.::: V'HICLE ICHECK ONEI } NO BIJ ST —SIGNAL OR STOPSION .,? SIGNALS L 11+^ ONEWAY . pl . [j ID -ED I ROADWAY' 1 eY D LIGHT T:.151GN.-_ 9??,X_ OWAV-__ I11-1 DFi[CTIVE EDAtI r,,L ruPAIHtC TY _I i--I? LI. TP?FFIC UN! ] p 1 I}? YIE LD I? ? --] R lF HEAD DLIGHTS _ ABILITY T 2.-1-2 T.IM PNREO_._.?. ?II? ARKfO1031110N 1 OUK IA_. I PLASHING I 1._[:j 11O,HALNOE 4.J l1EFECTIVE --L 1_. RE AR UGHTS l I BOtl TY H FI f TPA G.. IENTERINO I? I.LG IiS ON F .. .- FLASHING NG .-._1 A -R I.-IM1fJI ALLE _.__ J-. _.011 SMOOTH -._ HAD NO NO NNKING I 1 -? BE ?IS? BACKING q S T ABK-Si LG LS OrF ' IB. ; HR . _?.. SIGNAL L 1 r - J !B? URAgf 41FT NL Ll I1 cruntD DRIVtTI CHEM. TEST I NO.) _• J G L IK-NO l.. STREET LIG TS FC. ff A SEPA _ rl TESTG FN k LJ - OTHE R ISPE GIFYI I O Ov1U[D AA ( \ NO OEFELTS ? - 1F5 USfp , OHIEN WftiF i ,rrK y NO D L uNOW1A(p ] .- - l ",on1Ein E- Iir1 rk % TEST RESULTS 2 ' YF3,14w, I. U,FIC[IFSN A SHANK HAUOE NO. LUI DATE LPAICIAYIU.ED 'y i }KBD (( 1 OUCk All NV[L AM;ULANCE AF ClloW P/2 yi2 }fOJ A ED MPf ATOP N )eM H S I X ??VV?ES/TTIIGGA?TING?OFFICEII'SNAUESRANK BApff NO. AGENCY 1 p1 01,1.A Ok 1, NtIADIIT pAt[OL?F APPROVLp tlY LATE OUi?ICAi[ ?COPYVrLUCAI. LACY CNFONC[ML NT AGENCY'S COPY TIIIPLILATE COPYpINVE5TI0AT01i95 COPY If 1:' h 77. 777. F 31 E' ?S?yC?Y 71 Il 7j 7 rl + :.f I[ ..A ;F" ITyI i wL'vN lq,y ,41IS ? rl ?ni Tf 3 ? 1 1 1 I? y ? , ?.5 ..1 PI) k I jl? r K '? STATEMENT OF; c). 8. /0-.27 1/ 6, w bov?. ?G/97`Pr G?H. .1- .SQL r - __... --- j.,rr_.?C...._.T.__ ..__.-........... ` fI t?? r N sus - , - __.... .... .. _.. --._._... _ . _ ------- t, Y is ,.-r..l )?? .__-'__-___._.-_ _.__..-.. .._. _..._. .......__.........._ VEX 1 ..... ...... -........... ........ ....... ........... ...... ...... -- ..- ..------- _.... _...... _..._.._.__ ._.. __ _.__ ...... CQUAjrV Eo ` __._-.-TorA4..._?1?ACTnR..w?_.T_RRz"L,ER__.SF!=Q_?260__PJ'- _ ..... ------ .. --- _ - ---- ._. -_---- ` ,. ?? I --. DSSrRNas AROM _GENrrR"A1E .ro S7' r_._....---- ? _or 5racr_...Skt05 ..fAOM..jPWONr 7ZRES. u. of veN• 01 - - - - - - - - SFr 7tN. r M _....._.. - NdPE :SCUFF SKtO /f/dUORO-CA/m Akvm Rfrr. MvT• 7-499 1 ? A ' l 1 ?K , r NO I40TOR VEHICLE COLLISION REPORT _ . / O Y DATE OF COLLISION I Oa r 5 ?? -I1E/ ?_ r ELISION o a TIME OF COLLISION „ unl ra lytl rl > ?? PM "PI OWN ? COUNTY //, r _?/ CIT N 0 E*CUD •^ ? •l EGi DN COUNTY CITY TO"- ?r MILES EE CTY,T .API 1Lr F r_?" ?? J I ?,?. .'??;:. ?ll!r1J1o1' pOM.CLS PREFI% . ?J GIVE NAME OF STREET. H OR HIGHWAY INTERSECTING WITH: SIREJ;Ly OH ROAD EiOUCR ?-J t --?7' G,Uif/.r/IW PREFIX ED MILEPOST -7 NON INTERSECT] OCATION OF COI It ON BE STREET AND STREET NEEN E rDGl aA lav+D Caoss r,c.NIEaD.T On vLNL Er NV Ur.Drn+aK 1 ON RAMP DIAGRAM DATA _ NON %RD NO•U'Up? I T INTER CLS. [ [ ° Al IEEI ! OF ? vo C]"r ?, o, Ix n•.li IS C. CODE USE ' ?? ? L:/-? ve ? ° . OWNER OF OBJECTS NAME AND ADDRESS LOCA Oil, STRUCK I ME os..LOT Stc I ?I?? ee TIO JNY A uIJ Es Laua OWFCT a IN ROJ Y 5 W FEET I.-E. $ .?q yy¢ j!?{? ?jiq ?g?r.? l3i 'J I:>. [•L••a•rL ?:??qt_ LluiC _' SiL E, I _yl '?'I)? 11 N DRIVERS LAST NAME FIRBT NAME MIDDLE DR VERS UST NAME FIRST NAME MIDDLE ROUTE NO AND BOX NO . . STJi ET DDRE55 ROVTE NO. ArJO BO%NO. ERE STREET ADDRESS DoISEA5>< I S N i7.?_ r? CITY STATE ZIP CODE DRIVERSOCCUPATION CITY STATE z) DRIVERS OCCUPAT OJ_J h rfn?l`I?'• t'?c?.? EapaT.p ?yrJrl? IJiiE? `^ i i:\ ? ' _r. r; A, ? H AGE pRIVERS LICENSE NUMBED STATE M. DATE OF BIRTH GE DRIVERS LICENSE NUMBER .. STATE SEX DATE OF BIRTEO i 1 c LICENSE r S-1 .' F :2. ? i .7 ? ° ?" ' I- y E ,. E ?H HD E YR. MANE (CHEV: DOE) MODEL ;NOVA-OODY STYLE (2 DR.) EHICLE YR. MAKE CHEV: DODGE) AODEL (NOVAOAR¶YLE (2 DR.) VEHICL a r - STATE STATE TflAILER PLATE NO . _ LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE LICENSE PLATE NO. VEHICLE IDENTIFICA'NON NO. (EBBS MODELS A NEWER) OD.-ETTIM.LL...I VEtUCLE IDENTIFICATION NO. (1458 MODEL- c NEWER) . ODOMETEA ]MILEAGE) FllV2P.3I >>j - ENSE NO . FEGISTEAEO OlV ER (LAST-FST MIDDLE NAME) DRIVER-LICENSE NO.REGISTERED OWNER (LAST,FIRST MIDDLE NAME) DRIVERS LIC ?!a :+s- ' "• /•1 f I /v L; ?.?t : OVJNERS ADDRESS (STREET, CITY AND STATE) DATE OF B RTH OWNERS ADDRESS (STREET, CITY AND STATE) OAT . OF 8 RT ^p 1..`J(1/ (c If., t tr.-.tJ=.r?C1. •f\r?l 4' u E V I DAMAGED ° PARTS OF VEHICLE DAMAGED „ E IJe. }-I? PARTS OF EH CLE sDa avcnc V4AS THERE MOBILE LIABILITY INSURANCE El YES y 1. NO LIABILITY INSURANCE INFO' L' TI0N-VEHICLE NO. 1- COVERAGE IAUN ETOFFECT FOR THIS ACCIDENT oN YOUR CAR ....... NAME AND AODRE55 OF LIABILITY INSURANCE POLICY HOLDER t L[ z a NAME OF LIABIUTY.IN-URANCE COMPANY VE -ESS utr s , NAME AND ADDRESS OF LIABILITY INSUFpNCE AGENT _rEr T•TL LIABILITY POLICY NUMBER k-- DI'JJURY: "r.`•""I ". "'. r'....vnr, vV•IS' AGE t-T INJURY GE 2rJ NAME "-. --- ?plaE rALE ... .. ._ ._ _ r O DDRESS SE% DDREAS M F _ ?]7 ? 11 -u- J?? r . - L nEr _' _ - RST OI E THAT APPL ES. HK MARK I IRST ONE i AT APPLIES STATUS OF 1 J EO I • v X05: a l STATUS OF cp AIL LH I VEHICLE - D- c O+ a L IGLE KILLED y'?'rr,", v'vpa N U E GE KILLED •?v?n?, xi.D'o Gr p'G ?', EiC i n NO L a o -_? +EP P 7? r7 n oEe ., ;,,E In ? 5? 6? EDLS R:' D 5? "cl 60 ? - OVJ NORTH BY ARHOVJ C RCL[ DESCRIBE BELOW 1IH T HAPPENED: (REFER TO EHICLE- BY NUMBER) !.. I l' !4_^' .. 1; Y. C<lG o'i s CIAGIA Dc / J L' \ _ q n T PE ED f ??/ ' - O n D ,- . D a .. r.:Y ? r% Y,i-__ 17-'"'•, 3':?7 GT?J.4ii; A.i 1C'.. ' . Y tYY i ^ _ - ,. J F. rr N - Ir . F f [ ITV arC r D (Y - ;li 1 I T i i HIL,LGS ilJ li L i kl h rl D D E [s o ? I ?J D s ? „ . .;., C f 5 E K a' l7 (J . 7 ? ] ? I I ] I ] I ] 1.7 ? ? CJ.D, E C ] :°Ira? •TI -I [A CTI . :.`1 IFCTION O DI ON I ? ? O I i ? .,? I 1 ? I .N I 1 1 ,? I I IN 7 J. ,, I.] L CLE ALTO I I ..L ':• I 'AD Z,1 .. s•r . . . - •a . 'r,E Y.:': ,I r,L1T ll.. ,I .I t (:'] t I J E "'( I I '] t l] ., I J I J E T I? 1 1] GC D 5TF r T 4HEAD ? ' J ] N I..I 1 I J ,N i] J I] T FJ Y vi J I] OVE] '. AI DPA:'.IND ' ::rI I] '(r S I I I 1 . II I I.]Y.ET 81..1 ..,.r: 11 ]n K I I J I N I ] T I I t/.ID IE IJ T 1.7 IJA.NG r.•.I,t TURN L AK NIi LtFI TURN ] I ] " I.• ITT :.,r y AI A I I 1 t (II F IlIU AA11, I ] F I ] •' rU I MAKING UTURN Ill I.] ?'? Y I 1 t 1 I)FT 1/J S FI .r LH I...? '' I AI 1 s I `'E I 1 I (I4 Y ) 7 .O JAY I I51 ?,r lY AI 1 O•ir,t3 1 1 A I L I A I ]lfll it RN I ] ° IJ Y.LO!!JD ' 1Al/10 I ,,L. 'I ': r:..t .'.rl? it 1 EI I J I,,.,. LAMS I"? i } C10FI F - . h". I ) " I "It for IN (? a I) r I ] E I) I.IIAnD 1 1ccrp 11 T (j slrrrrn NAOJ,Ar I I • 1 '. I I I I .r 1.. 11 III r I II , •C ?J. >t O X ?xvar? t . t I?l',?}' y { IG.' Y "s } -°'. .. 1 •r I,:. 'Ir +-A? , .4./' 4A r p V,?t F, . s t t I (h 1 ; ? 4? l ? , .4 to l h ?4J t 1 T? Y Sr ??{{yy71 a h i r { 4 yy}TT f t 4S r a L 4f? fh\ SYI n :'4?j _ J a ti47 ? r?f? I ? f •, r{ I MOTOR VEHICLE COLLISION REPORT u0?•DAlJLOL b?[1•y-1•T[, ...i.;y: DAY L [ " " It EI OYPTN•iy:. j MC.OF COLLiSIOHR ..L vi a -s n [s M C +1 r 1 ? l T .3CI PM ? t n AL ...y000!(TY.: :y""'.:LI _•_+•_O.W:,,.Lp,.. .°rrar°. MILEi,:., N E •-: ?. LITY OW".w."...L... - 7 n aif fi q4% ' ECT10" ,n O B 3 So GIVE NAME OFiSTREET?Li OAD OPN GH Y Va Up I A:. v SECT IHO WITX?B T?OIyROA ?E - MILEPOST 4 " 1•,n 2[3 z:. 1 N INTERSECTION LOLATI N OL s N --w fs -V •c f".j !' (:• • BETWEEN STREET AN. STREET •F.{"04,4 ;.'. i LEI LE OF ,. •na.o cnoaNna, uA[roai on Io[n, nlHO v.wow.,K. [, enroc[. I T I O LSO _.fJ n? n[n Iw,rr lar.- CO voLV [q?A MI H „ , . or v[nK[[a nNL[.I[o[a,nl. arsro Ii.nun .' . OBJECT_ETRUCK c or oaJ[cr Hoot-fs,y? ,Y,;.•?-' O_ N. FNOBJCLj6, Nj1ME,,{.!{D (IDOfi E561 LOCATION .?.???? - • N :E, M- TW.- t.f MIDOLE .•* [,[InvoLV[o •. - xJ: _: _:FIR NAMC DRI4Eq LAS?IPME '•FIRB AM ^'_?5 I O ;i '-VIl "•: ; ,,. . Ij L, Ev? ,y .+ ?yy •?Y:L_?:;...i.. RVER L AB.4 W1Lf! JAN[ F l?c?i l;-. 6 EET?yADORE58' T:t ,L. '' 'flGUTE?O. ANO BOX 0 yla V213, ET.AD_ORER6='•':?ti'?-. gOUTE NO: ANO BO%NO' 'y _ 3 7S \*krl 10, CI .•.•. "'+': 6TAT •v°J. ": PCODE DRIVERS OGCLIPfjILO•(1?( L=.:4•sS?A?E M;r?+-i,?IP.CQOF pg?yfBB.OGSIfEQj1p z6a" o-eu v a M":DRiVER6 LICENSfi?H??,•UMB-ER'=": " 8TA E %, Vj'. ?-Aj `OF B flT,H. AG s ? OflIVEr R6 LICE?]E HUMBE •.. STATE 6 ?DA C O -BIHTSI AO W 26 1 " 8 X1051 MAKE -'. a[v; oooa ODEL-''IH.w?- GORY BT?EE..: 13oW1 y K [ vR A1tE":.IcH m [I LAO-p4 "^' Hov uHTI BOO 'S E•J2 eIE aa , IQbI? RULi- igii C4LacaA 2deer loapedp:Ia. LICENSE?LATE HO. L STATE • :- RAILER FLA, -1 NO. •.. / 6T-.E_ T : LICEN•6E.PLATE NO. 6TAJE. -- RAI ER'PLATE NO";:Q STATE^•'• EHiCLE 1pFaNTIFIGTON NO"..:1 9EB? ooKL[ A -11 ODO E ENI`ua z h? VEHICLE 10? E-"TIFIC+1TION NO ::%11964`oa? 8 O ETERfuIL[ o f.h ?3 t" REGISTERED-OWNER + usT; ?[,!.i?uio_urlMUtl'. :`'. :., (VERB LICENSE?O.::. •.':y - - _ , ?,...?L FIELD TERED OWNERS CRIVERS'LiCCNSf N o CtLr •r t•Ifi ick, Ltd ?,••-x„•,^,••??(!?„uTV ,/;!,e nA ;1.;.i .,?.,: ,LOATE OF BIRTX OWHERS ADDRE RSA D E66_ T- C-*- Z[I: ,:+I;i•Tl;_.: OATEO BR N - ° 450 Lo[c !, ed9wv r PART6 OF VENICLFa,OA'A/;OEO -;y;?y,+,.?? 'yr: -' V""•u.'uu Ta w.,[° c°ai - PI?RT6 OF VEIJICLE EOy;A.?, yµ - - [a HERE NUT B E I S URANC LIABILITY INSURANCE INFORMATION •VEH ICL NO 1- co EFFECT THIS ACCIDENT ON URCAR YES ? NO NAME AN?•wADOREbw? aOFL1ABuL,TY SUR C _-ICYN LD R ?(}.. ?S'• k y, yy NS• '?P + .'. NAMME AF IABILITY,lN6UR HA CE.C M A T"•'v "?Yi Akk IA NAM_[AN_DfODR6950F.L1 BILJT„•f[?BUP NCY AG T °[-i?L>:,dire_.S:f-.C>`T_?_s3t.ca:eLl'-' -ZISIAB LITY.PoLIC +NU BER `?"'" -+.' .16 1 UITY'"JrN.. :W. .w.j;J,'1' [eF,., ..:-. S.k: .. ,AGE .. 2ND INJU Y ??h. eKa K' P[[el. -:V ' RE S_ ??.L.ua, .i1r71.(yM.L..r•?s'7. kL?W:-..-' I-af.+•-+. .... rw.?..v +4s! NAME M E SIX '- ADDRESS AODRE.S " a .n, o. n,ue.a -- Fol - -- -- -- aIen In,aM[a ,tab ? ° ?? MY mz. STAT SOF NJU CD ,. ? ' MARK FIR6T ONE THAT. PPL E6 -. eTATU OF IHJ R D I(.t'IR_9L0,[IO JN^:aP L' BY: • ?"/, Hy la -[. "on.o veproLemm?r N }}I1--?,{I [D In, In I KILLED x.71 O K NO Iv noel .. _ 15 1n,„o,l o.7.,n I L[N [,[ L {.! ? S ? J L?Lffff El 6[] 0 r SHOW ROW CIRCLE \ DE6 N C E OW WI T HAPPENEP?MEFFt TO VEIICLEES- BY'NU BEfl • : Ff h VeVt'1? St ttGiLY ui{ _/ r d__4c Lo _4_ e D Q _c- S tc'Q.. 1 lO V a?t.5_ ? : ,h Y ..w : - ?:. } hscured b??_sl l 6? eaa-Ve at-Ld- jull. ?4? tc(z.l_krtik[? SS I, ?_Picc* 41ld-s -vat, Utz ' • l 7b Ilikaa - - = vehic e- a_kar ? ? &.4 ,re i l ic4e - -•--• - To OlurrtrCUkl- E w i nr ofima3e_ _ ?tlCrlc 2 _-,--- , ` r t -- _ _ - ----------- ?ln IHVCeTIGATCD VEHICLES POSITIONS BEFORE COLLISION [°?.+[ [H ?u BY occl - HLAp[D MO Y m IV ? ?wu'c[ M fM aL V[ CE[ ON [T ..... O AT AM It BBD q, ??910 a o tly?-. r a? o ? [ ?Ha [n [.. a a O OT fR ? ? C t ? El ? ? I L :ti...Ga'li?[Y- ,LgLIS?NO LTU ??D??] wLOra."brTlrse..wZ:?; _.jl ? !?lA ?Iy r ?o.. O O , w . . P[D[{TRIAN WA{UfINO 1?a' L-J B LJ [. Iwaol, a ' a• T ?IfLCO ?T114.` ONpTI Sw>. ?OI rgO.LD?Wttr p`[I[M?J? n n AO Uq1 \Y[ TN[R?Lq l 1 uM, owa 1 El a 1 _ DAYLIGHT 11 ?){IGNALB ? 1 rn?o1HI wNL[ [ ? av f c,[, 2DN'E WA1'n[I 1O 11 C3 OOINU STRAIGHT AIILAD ' % I ? ] ? STOP fIGM .[ ] TWO Al WM ? OVERTAKING AND PASSING . y CCS?---AAA pRY f NING [ DAWN kp IL - [ 1?f W[T {MOWING ] ? DUSK ? ] ? YIILO 61GN [_J) ? ROAORSIBL[ [ ] ? MAKING BIGHT TURN p 1 ? ILOOP a {jSI MAKING L[IT TURN SHOW A ? 100 . ? LIGHT[ ON [T ? A E] '-IN. RCD ? [ ? LJ IHG AM—[R ? (3 A L LT ? S ? ILA{ E] M f L LY S ? MAKING U•TURN ? [ ? IC[ f? I{ LCIIYI f ? LID—01 F ? [ OTH[R { ? aTR[[T?IGNT{ El f E] RR SIGNAL El • El LLITaIURH ? { SLOWING L f I[CIIT '' W, T OT [R ( SON IPK`Is OARO[1,.. T ? O.P"'._ ,JT E] OIIIC[R/ILAGMAN ? 1 {TOPP[D FOR TNAIIIC ? wNU,au rN?ow. t.ar,ac NO wa. [ic.l ? f ? f?[CNY ? S OR {f OP LION IGNkL El 1 ? SCPAR TCD l I / I.1 ,e. Slra} K. Y[s c r?IrU (,V/ „• i D VIOCO S STOPPED IN ROADWAY J T T E -? ? n O {T gTINO I (gyp ' I L W p?B[,'^ ry?y ' 1"?R'l rIAt nCt'!5'^ 1 ?•Ptmr' T, ' N ?' bW1161K5 .in?TM 1n9'j?f1`7l 1 r ._,..LRtdLY?Y5?1 `?I k Y I F' 1y 3 ? a ># a 1 sit, rr _ y ? ,lrsi i ; ? t ? l V O ,L 41a ? 1 t q, n ? -a Inge ? ? ( r ??.. r4; '^ ?. POLICE TRAFFIC COLOWN REPORT 125TRAFFICwAY FKKKfc ?NrrvuwNR PRIVATE WAY Lc.?oyws . -o'S O I$8 »D I;9 . n .: IMw sf d U courvrr J r`.GGo? / carol arY NO. A O RDRA 'Fi Qt ? N CI"D"WN arvo slafNO9f.cnw.r MHI O, Ow o.?/a/PCA?? Otd NCaGl?.2 ei cls nafif o9 t $0?70 9YCI//JJNG Vn In. 519ff1 OR 90.D1? NON INIf 11- I i0//i/ ?/G % FJ BtM'ttN SIRf[r f 519[!1 IO MK[9Mi Qo DISlANCf tDi9EM1 ONE M9fiFef .CROSS SIafF Nt Aaf3 •i Mllf Si I fS S f HFi w OF ACCIDENT MILEAGE CODE a AM p.1A -I N N-ID' 111L%,6 NO. rvIURID? O S.IIUG[ ?nli{RUN rvO K x I.E. CIS ey D 51HE1 R90AO04ISifftNCE c."mc FLTOR _21 - (?I _ 101N NO OFVfnKLf3 LJ O ROe vDAMAGE OrvIV a NRI ?vE EN / . OeIFf,15NUCK INNFf OR ODI[C151aI1CK AND OVmF9'S FU.MfI [S10.MA(i{p SHCW COD?NO IAF ? SfT. S/?'EG. G yi E' f ?CiO - UNIT NO. I UNIT NO.2 O VEHICLE O PEDESTRIAN O PEDALCYCLIST S DRNI9'S rvNAF 1 !1951 Mi -vim s? /3?2i Z__ vNfv'S N.Mf: VLSI ?? ? SI9IFI AppRf53 3?Zly !E ?TiY/ 1RfFl .?DRfSS II. COOL D I r -1 .+ -+ DRNtR'$uCfrvSt SIAIt A a I V I NSf AIE 01 SiRN MD i D. _ OCCW.rKN t{.nONt NO. IGN1 .(iGNI E O CCU.w11(w MNIMF•N.a[rq. fvFS IONi HMA.I •?' q O CHECK (r7 v[NKlF.S?N IMAVIr OR.NOrNFV'u ? CHECK (.? vFNKN ASAN Dnf Or ANO .o.. CODES ? 7 s ! a s".°N1On ' CODES ? ] a Sue - Oi m"ll- 0.-1, O !: '[' O m'm. ? ? 1 4N1 O A, O W, ? P m ? =." fro. vln rlwe MAKF IDODOeCnfV.l MCOFl IDA91.rvOVAI SITN IID r 1 1 MOIXI, .NOVA) 1 .) SIAIE Ar NO. 5i H v Encaoe ll[F T37 C NNKL[IIXrvil UfpN ND. 7/?4R21/ 3- I v L tnl IIXrvlF I I I N. I I I I vewsrt9eoowrvlR usr rmsr Mloae .wNt rvo O w Isrtno w..ta: lwr nRSi lJ siaT? /?.aQ is 2? 3?? iRo .ooReu Er owwR ow*a9 7/,Sp e. e.ra [.!.?p --..,..,...ANC, DO .-IN, ?? R ? ? D.M.OFD MtA wS.?wO U..<NSxM ' Cn.R ^ CNA9Oe ?? OM ?c ?J AefA ? S ??EsL•j !S O 4 ?yN ? R[MNNID ? DRIVtN pD l1E D _ S ^ J L3Sco IOWDEY Oa?.`?l? A iOVAO s ? DIAG RAM OF COLLISION _ NSI .r fn le ni[ FS .n NDK rn DESCRIPTION OF COLLISION: IISeSVnIM[NrAI WHRNe(I McYI _. IE ? _F_r T r T 1. , 6 , ?'?/I/ ?/ 4/!?$_-1_R?Si ??..s'ZS? ?..?C V1 7 /G ? Fl IF NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES I - T 3 4 5 6 OCCUPANTS/WITNESSES ?p pN1fO?NN FNi.i»Ii i 177 1 r MIF-Vey- ?!;- M esu (ACT NwF ro .oaFn O A Me ? O" . O - ? 07 a.,. N.MF w 1 ?• .DlWt1 NIIUI EY._. -- OAMe ?[?. ? .rl. O r. ?nxV MMY ._?-._-__________._. _ .l9rFn _.-..__________.___._.__._.....-__ 'q A -L L GAM! O"K'Q[wom 41 ?=Rra •? • X .nl?__yc?Z..ME l..n. ^?'"'T'?/Jl lol.? T .gou?oo?R .u NC. OdY 2?S/? }(n Q 3i ??,?EysylD fricm.%cxn/ rg;cyn Nti? ?? yf?f O? ?'! Ar..wioE I n I x? arv. ''? y n li. . ? r ? Yne+ ' ? f+ . ?aPfet L? r RI r ? itlxY R' S , ? b I ^?Y TM?1. f ' 4 POLICE TRAFFIC COLLI ON REPORT Id TRAFFICWAY I °V. I I I Q y FVIIEE CMNUMBfR PRIVATE Al W ?I n• r Q.ES911?. courv,r muNr7ra. rrMD. ? r u NwA ND f3. (.? w.?+o,iw? wln jwn. s.r rusE]:ooifouRl 4 / . m I f1SDfJ 7 ci , l u c n D9 ,owN ? ON N FQ ?N NN°[6 NO Of SiPEF109n GNWAY 43 90U,f Oft SIRE SFCIION S M 5 g W 115 ? OF LOc L ON L 517 . RS[Ci NO m IH.S t[,OR ROAD NONINIERUCTION ] ?? { MIIf POSt ww Cc- 'E,9O B[imfN SiP[FI I 319[Fl R trlY ? I r . DISI.NCF{IT tMi `ON ERpM, Rff RENCt. CR055519FEr gNtARfSt Miff P05 ACCIDENT R DIAGRAM tN1A IIIIIIII 3 N 3 [ PEFI W E F CODE O <OII SIONINV4VE0. v[PllrCODE IO,AI NO. 09111[DNO. N]U9ED? ?SNIIAGf ?-F-UN wv9° 9D 11N0 SIRE gINADOq iREf9fNCF Mlls }S r' IMF9 Cl3 CROS SSIRfFi00R I]] . OAO CP VFn CI[s PROPER11'OAMPGf ONtY ?FRESULN IR O ?$1IX[iE o91[CIS,PUCP INAMtb DBIfC, -- AND OWNtR S; AMfI f51 DAMAGE SfFCW COgNG Ibf - E ! UNIT NO. I 9w(R'sNMA UNIT N0.7 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 21 F: NS, N Mi MF L DPN[R'sNNAI: "Sr J °z sIREFIADp9t5, SSO NOITI1 ? UI? 41 ADDRESS U PHONE NO 4 c.a,?l?,, c:?a ]?PDGDE `t3?-4Y3Y P R I r ,AR E CITY N. 3EC-H stAlf n UCtN NO 1 T-L 303K ?? 11 ?S I V AR ARIDTECFN. "b I IrR r_ OC(IIPAi:ON E f6PHWIt NO W MIGNi E OCCUPAI ON M NAM[ a Prlove No CI1.IlAw?. g?0 R Ens mleNl ra: en , ? CHECK I?) 'vlN Cil AS:H EMrior EA ANOINfR °1 ? CHECK I,j ' O O a r.DN ? P 5 ? COD 3 1 ro.. a „° I P -C.-- I rRaAN rNf CODES ? ' 7 . ^ ! u A "s'O N vDr 5 rp `S7 F ° , ? ,MN .N t ? u n Y'.. MA°EIDODCi.Cnfv.l 1 O iq:R ? „ K9 AppttlDA l.,wAl srv e l]DR CONVI p AN N{r ? u I ? Fb:R. ? r Z7 ?;°t n rEAe M.u d° cs"'. N S PP 'u E 1 nE V.I MOD[t1 I 10 v u4 O OV 71 S,AIf MltRlu4r+0 SrArt ?? C vENC R A A ' A N T NnI I -NIDKA,WN NO. n I cu.N A p I L I ?lUl e1G2RRtDOwNIP -T 11951 A 32 L I I I (y?.lp ? I S AS RWV PHON(NO. O R I D WNIR. lMr Ngil MiDDtt ?]1 ADOPTS! W 1 N wNE9 N,MI{ DITTIMOIINSUrADCIC Oa AGl NI E IoJ?£rcS R D DAMAGED MlA f,M?.o Zfl gAMAG(D M[A D N CNM? 7 MMGI P].iu ] M C -aa S ISI D,NAGE VI^v ?REMAINED ?AW?v ? Ncr AMAG! gIMMNiD fl M Iliierio? E+Sr?_p17 ICT-D VV ?AWw'v°BY: E ° DIAGRAM Of COLLISION: IU AED s??oe ,N DESCRIPTION OF COLLISION: ME SUPPLEMENTAL SNEn nraceSSAer1 EDnn ° 2 IY - yLl?_I EaAS N B o 1 _?jlM (LL ? To yiyo M6 - 49 1 -.-cv(v6 LOS1 -f _ _INI;a? .9cncsd .kd6 LA16 ?}iA.. i I. Y Sn ? . . P --- I .f 11 (?r I B 8 ?'? U 7 „ ? eth 6 k .. { __ G -?- y- ? _, __Sf iS t !f(r ?fGE U ?., Gu1 u6 - s _ K' '- --R > F trf i No ' NAME, ADDRESS INJURIES OF PERSO S INVOLVED CODES 1 ? 3 4 5 6 OCCUPANTS /WITNESSES ,?;,'"?u'owNUrM. 11 N.NE MSt9 f„Ct CM_los IAS .MO N .LPr ,?. O? ?n:? w 3 A4M0 U q .nuof ADEVrytS vwv u ?. .. __. ._.. HAf{9r Or .I.' 1 nn{..r.. L.EQ 9. LIIG: NC`fF ntR(W 0- of ?KI? n N.M o ax p Y D L8.3zi n - 2 n D D? N _, :P;„534 'S2 WEA 16p : iAFDr r a ?wka ds nom M { IFI,^, ?.MA ? ?r»,I _ ? „, +?(PSVAVEa ,.. aA D; 9 ,GE •l • r ~ D . , D:SMgvl4 I?.? I ND I?`? DAR b 61 g r pvIDN DAR ?Sw?EP ' k ??I s L I ] si IU? ' IJ° __ Y e d is ,s t 1 .E ? r r 1;?1 J ,III . r ? I ? I", No k(?SYw ? TEL b r l i I [r?, t (l POLICE TRAFFIC COLLISION REPORT I TRAFFICWAY ' RDllclcan4lAlNl-31a. _ ll PRIVATE WAY rL_ N fIMF COUNTY i IUS[] »?u41 w. Iu9 un.hio. ;W', J ,eSorc? l y, COUNT Np. Np, ,NyA ////--J Ciry R>,RA, / ur. oa lowN o o vp eroR».o»wer ON 01 M4fs OS ?w Ooi ON ?`IOCr L?'iv `j`n?s u - p flour oast .,.?IJrZOD a NI-11iNOw,1» 34ffr OR RO•D NONiNrl RSICNON tllrwtFN ?? SIPF(t t V 519ff1 ix Mllf 4o5r `//'' •./ Lp OIS ANCl RDie i .CVOSSSIVFE Nf•9f SIMILE 5 M9FS 4 ° ! w ACCIOENT MI EAGE P 11- RA DATA D n of c( a L CO DE 1 fv t0TA <IXli vIXVID' f4'Ir: »n4 R1nV ?IAO: ? tD- ?Y Or•l NO D ?x' m oeD" ".. 90 iMFR CU iNr 95f II 1 fFl 9ROM04 Nit LANCE CvOI55R Sra Q P 4p P tRTYI-AGEOMY a vEwtta ? o'iwl FD ? v[N?ie - -???i? 17 .? oaiFCl slRlx:x lN.Mfaoenelsrouen u9oowNeas N•M!I esr. D.AIACE sncAl eoD?NC UU - UNIT NO.i UNIT NO.Y VEHICLE 0PEDESTRIAN 0PEDALCYCLIST i' S oa w[eS N.W.t: t i?a Ovrvf9'SNNAr US U ?nb c s ,9,e srNFr•DDRF er AOO4fu '2 s e? / Q3 GU?Ee S7 SrAn DD PNDN! ND Y 0.2 Gtd S? ?/? ?? S' D R 02 A 1!/i4 /`uirSt? ?? Z526 Z SIaN .. e x N n » ° ^ L / GvR F % .sq V ?? ?? R•r :, Z «eu.•rxsrl 1 GEC ,:;I P»oNF NO. fns .e»r Ka»r 7 E R cu.Ar?o4 m N tA No. (ns e»I NIO» r .MEN /o a CHECK( e» IFA :N •NOI»[oM ? CHECKI? »ttlASAN Mriorrea. o{»loAl . CODES ?' D n . ' s r o» / e ;° °"'C-- r CODES ? ' s n . ; s u e "O ? ?Nx!"arts O/V y? r 2-1 F K:;,a ? .M.. ? R 1' ? m- ? :: 3 Ku 0--, 0'% nr ? Fdm. ? :: . w rp 'CU MeP M F IfxX106C»lv.l /729, MAAeeo fl IDA9LNOV• a"V.I /77?irW O H v » vl NODEI IOM .NOVA! T - .I SU?/I¢U -- 3p s1A .aArENO N» Oa A " U !//LPL !tip -' h.?e OA/u4 1 n»x:u ?aNrnlurKAI NO v »? e?aN? A I NeNn4mowNEr wr sr ?oae ffm - ?S f..71d rwNe NO mB W ? wNee: wr ?Nvsr n9E mA L ve- S,11 11- •DDnss o. , 5 N E 'L AMfRAfwnssormwR•l,cf co aAC(Nr 1 A - SE 977Cc? R GE oAMAU Mu ' /S 7/S •MAWDN A 'ow C E»•.IX CwA.Gf/ _ Or r .".or D 3 ?SioriS+ A s ISr f ?RtMUNEn :w.." ?ww ?REAUINm eS o ? S S? ovnoRY A-1 Aw.Y RY: = vcr, ' DIAGRAM OF COllIS10N: ut Isui•iYI "0 ?•or" DESCRIPIIONOF COLLISION: IlN13UrnfwNlu Hahn Mee SSMYI . -.. 3 .. 77F TPLn4peE . F rG(?? ?.?.?d Z Sa !>i bcv.r c? o q V Khody .C??/vt • . Vch?c%. / .C I/7?. _ 7Fi/iJ Q._...... s Eaveh c% / e ge . ..v_._, c rR , NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ODES 1 - Z J 4 S 0 sa OCCUPANTS WITNESSES Ivu=-llw•1"r•4N•w rd ADprgN lr Sl . •cl t six r vd L•r '? r :' evR t,fa Wtr ., I. ».w a /00 ..... ilo Aiia6 Iy7 Z / -- N.I na 4r o Mll;- X1 41 [] 3 A 4 , M 6 •pon31 r ?410i U:SJD 4 0•MR n r l ?'"r' , O H a w ( !V IS ? N S IM ?. ?•MR for ? +,rlflyi •,O p„K"Sr.•M, 4,•N4 •OW C, •Ot•rCr p1i 4011 p ?5!•rC?ID •IX KI •4arID 10 1.041 ID4 D n P79 I ? d AhAR, IL II - F?'br?E: ` I r' I ' ?,? , ?;I 4 ! a` • r I f n , y ? aY v J ?x £N I POLICE TRAFFIC COLLISION REPORT IlJ TRAFFICWAY FOL,CEC iNTN MOER• 3 If Z C] PRIVATE WAY i _R?'FIQ. SDIU • . 1I x.10 w., -. [USE]NOURI COUNEY cDUNrcJ?° clrr NO, -A el ? S l FF?RsoN C? RA 2 rRtEE09 nGNWAV ? ! ZN 0910wN eN0 S ? "" E PCl 5 gg RO", I E 52 0- evlf5 ?3 ?W ?or inA[?cau.ti oN NOO 17 l? 00 Q /JE NiE 95[Cr NGw11n 51Rfft OV ROAD NlnrfR5FC1?ON fN% f MRE POSE rp ' SN1 ?` O BFTVttN SIRIIE 6 ,f IT c /^? 5. r'V 0?51ANCf 04 MrlON iROimR E .<R05551RfEr Oa NfARf51MILf 5 3 s f if Fr W DP A ID MIL AGE CODE D RAM DAEA ,. CCLLISgN NVt%Vfp: vt9r nre RUN IOEAl nO NO LLIfD-NO.INlURFO- ?SR IUGf ? weoaDM %R INIFR Cls IN R Crl Rffi OR ROADOR NIERfNCf CR0355ER[[TOR ROAD (?5 ..- CFVINICLES 9FROK-DAMAGE ONLY ?ARE ?v-EN LH. S 091EC1 SIRUCAINA.ME OF 06-F STRUCK AND OWNEa'S NAMf) [Sf.OAMAGE SPFCW CODWGIA( _ UNITNO. 1 UNIT NO. 2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 1 S 5 3 E. Wr ii95r if DRIrfRN o?. c MM M1 f. USE --1- DIX SNt fVT4-S IJ.LVZ ot_ aw n 31v[frADDRESS ^^11 IP`') aT 3s ?'n~ t ftADDUfSS I' W pr-?RC w 35 ?. Aif IIPCODE vnONE NO. D nO '37-'2 C' R BRE. ME. B 2 cwntrSUUNSl SA1f D,. "• A1L % D EFaeR MD RAr •. SN EL 2 G WA M 02 z w 5 NS i ? ' OCCUV•rION IIRM NAMFt NKNF NO. a nFlGnt 7 E oCCURA J N-Ie1-l NO6g2_-/••1S3 EYES WEIGHT nE Gnr Z ZUDE lV r 140 S-1 R u ? CHECK (.O 'vEnKIE ASI-R YEtA.PMiolnf4 ? CHECK IV) VEn cif.s AN iMPiovffa Ar olnta?L ? Q CODES Si 7 5 E .c. 6 i °e°r • CODES ?' 3 % s; 5 En e u y • 5 "lE 2 aR3 4 - ? .MN N l ? W, ? zsm. ? <,1 ? °? ~ ? McMA E ? u,<E ? n,;- ? H.Z ? :. vt vE.a M..l IDODOf CMfv.l S C r?V tI IDARr.NOV•1 STYLE 12OR..C-I E • 1 nfv.l nTEA IDARrNOVAI R O ACCORD 1 V.I sRe I v n.C a Pu um ARER PIAIF NO. Serf H vfn,caoR ' - - ?u 0-122kL- wol, C c r- E 1-1 & 4 . KLF ICtNE IUEWN rq. 2 5 S 0 0 1 a 1 I -7 v L E FNKIF DfNii i I 131s 'O' c S REGiSR VEDOWNfe. LASt FIRST MIDDY V,i2 PWMNO. W 4fD wrvfR: IAS1 11RSE Mi IXf aMk CFO pk ED 2 p0RE53p OwNlR A ( M(? S FLAY c-_ N r 'OWN! NweR•DDRns(a lNwv,wnco. OR •cINE 4S2- Blt / R C - 00- 53 - 2Z2? : ALS-rN- Ipbxr e.IC LAJ DAM.ctO.er ? ? N '- ' " Pv PL-1-4 T .-\S, C401 ', AceDARu ` r " CaARGI ' '0•"'0 1 .0. R wE rn?N crRwee M a L lSr. DAM.G?I ?Aw? i ?RfnwNf .wAGt D ?pW,pf'R ?R(MNN[D fSf O Y y tow A eDer, ? TOMD S DIAGRAM OFCORISION: u ? "' sY p'o 1n DESCRIPTION OF COLLISION; IInf SUOnfvn............. fsv.RYl RE.C OTC S??Ql.fc?a?.t?CS'P'ft`t E _ ?T FL _ ._ __ NAME. ADDRESS 8 INJURIES OF PERSONS I NVOLVED F CODES I 2 4 S 6 ' vsurnfMlNru sla OCCUPANTS WITNESSES Id .ODitIONN NWl n SE - - -- -H% ?Gt AIUS ;yeiN ---- wi -- ulcr I'm , NAMt wr?fS?PORo, Al??t cD Z8z-4G?B"l I F- . __ _ .DMI\ . uvl Of lMY.r ?AM e?i'V' 11 . ?.?t ??l- ? N,M MAST ason> _LDHALZOl?1 A._ ___.--__. .. -- v" e 3A5-S1F32__ W; 16 1 1 .3 (.,gn 641 .4 ' N•E?Rf . . p .... va eDf.oM?Me ? ri , ? nre. ?nrw ? r?iyv p M1Ml _ HaaLocK wA, asa3 , . m3 til it fiver ?.4e ?"::' ?- . ?.I ? x ' ?ti4f fD ?f4 4' 4os g It _ SS 2 r ?YwAN w :.ill ... "? ?..?.?si?. _,? z? „ ..._- ..r ^rs.` `W 1s`r. .L.. ..i4,?. _.._ W;.?2; • s?Yi ??'+ - 1%, , ?`'"`.?,.? ' `T9't. ???3=,^* STATE OF WASHINGTON SUPPLEM ARY POLICE TRAFFIC COLLI N IREnORT ;3 PA4 7 OF ' FATALITY IDENTIFICATION OF COLLISION TY DAMAGE ONLY { I CASE NO INJURY r of COLLISION OF A?x^ CIIY® STREET, ROAD NUMBER OR NAME "- " f-FER COUNTY30N]I PROPERTY MO. DAY YR,E OCAnorr (? /? _oulslorv .Ql.{ Trc. CiV.1LM'A CU / -../Oy /S g: .E NAME - ._ - 1 NAME Wk Ilk ODlj ?. ? L.. I,4t M?{g CkAIl-)..\Q___. DRIVERS SN`{D6 Q 'UAGAFS T. vS FUrt,NZ'E-S VZ.VY.`AN +' (USE FOR ACOITION AL INFORMATION WHEN SPACE IS NOT ADEOUATEDESOCRNP REPOON OF COLLLSNONINFATIONSHEEi TO CORRECT DRIVER'S NAME, OCCUPANT - qgl ,,y I S }!' AS A E+? - LOCATION OR ANY DATA NOT KNOWN AT THE TIME THE ORIGINAL REPORT WAS COMPLETED.) *'R __V64!•..?.1.-\cScN ER?l?HS_SO,B??D,_aN..?NoDY DA, AND MADE A 66AT-7-VI-IJ 4lLJ-FR0urof I VF-H. iz (FLAENTES), IA)HO LOPS NO, t - oN 5604V6;? VAL ty RD., EANTLSq LNG 7NE "LNTEP- Y 5 " {j.EGTZON. THE RLCrNT_FRONT... or-_ VEH•'F•;, SrRuc,K THE.. P-LGN'r RERR,.. OF VEN•_ ___ '? <rn , FU:E.TJTES STATED S4E. WAS PROC.4ls.DS,NG SYRALGHT- THRou GH rNC Z),,rERS6cTYaN, WHEN $UDOE.NLL-I ,S'N4oE,Q,S_VE,H-_W!>,S_ ZN_FROM'.. C(, HE.R._ S?i E. SAm SHc TRIED To_,SI/.F6Rvc no A l?. TH6 GOU.LSSAN, D4T ZT WAJ TOO ANO THERE WPS ONGOMiNG 7RAFPZG 5)Lff- WOU(dS ` If FIaUE. TILT ZF_ $?16 c mosSEo THE _ CE Nt 4 RLxnlE -SHE,-", !gTEp_ SHE. was _ Go G gBOUT 35 M?N (,THE PooSCCO Ca.Ewtc)-.-- .. j;l ,. '?? Tg,» n -SN4oER. ? TTEA__E{E. WRS-e -rTLniC,_THE_CARpaER-_U1HEN_MRKtfaCr-tFZS 71!u 13 -1Lc lE- . i Fks.r HF. WAs CC.EA2 OF FUENrF.s LANE WHEN S`NE kA r "T-IA. NE. ALSO TOLD ME FIE. ?•' -..,! u:. {:.. f.STYM4TE.O.HEASPEE-D-?O OE...A?PROX-._WMPW,. BuY.-WHEnI „Z.ASkE.D...HYM. WHY H6_.W6AJ Rf{,;Rt? Wr-TH THE Tun& I<NOW?NG A' VEH. WAS coMSNG Ar HTm FFgs'T"V HE THEN SAr4> ?LFHE. MAY NK?v_E_,on,c t..BEfN_GoE)6._APPR?K,_4SMPH. _ +' w.E. Ta TH0 \rEAVV RAr.Ev -- - - - - --- )THERE. WERE. No TSRESK IS -vLo ENT, 4.Iow6v6R, THE DEEt•¢L5 '? ¢. Y+ gE - ON 1E- R.o EaOwtiL-(_SN OZG0.TE..p_T"HE. _POLNT o ?MPAc.'-r_.. IA)4S_. Z). FT"-0R NoRE... INTO ?Uk-ns?E3_- LANEf1oF TRP.VEC.. Wx.TNb.sS, - 1„(gs?-4,R;XrN CoNFtRME.O TH&S WHON SyE S WWU.o PAf ' F-.. F?PPf37X. _?.Ot;,gT=onD As. &e Saw Z.r. _ { ?F WZTNE?S. HvKm&NGfo20 Slm-r"O HE- r>= NOT JEE l'F1E ZNPF?CT? $LAT SAWSTJRDE.RS-?? ?" LJIADLX Nt_`(." SPLfI AibwNO. NE IBM SEE. TAP.T TFtE. F-PpN-r Of SM4DCRS VEk1. WAS A SHOFtr.QLSTPNGE. FQONA-T'AE CRASSW 0.t-^tC WuIEAll &T _.S? P.L7ouNO, T'6k*- C126'SY>,T.1GE, FROM THE CAOSTWOLK" PN SMq A ! r. FOCr?.LNf- ON FI.LCTSTFS C,ySNE Wqs gpPRcSt. l-1 FT.-,Y?a4DeRJ VEM• WAS ISLrn" Law, ENFORCEMENT ACTION ' SOBRIETY • HAD BEEN DRINKING (CIEtlL). DRIVER /PEDESTRIAN NAME - " w^?r `+ %OF UOOO - eBFLYFY _ ry? CHARGE CITATION NO. j ".yi ..-. I lD ALCOHOL , ? ? % , • % DIAGRAM PROPERLY OF IDENTIFY COLLISION AAND'HIGHWAYS, SHOW SKID MARKS AND ,. .. _ 5 _ DRAW DIAGRAM OF COLLISION SCENE IN REASONABLE PROPORTION I •r 11 -1 1 '1 RMCTO` • +, .... _. I -...:._ I ... !_.._ wl IO _.I ,_ I I ...?_ ;-...r I. _., OTHER MEASUREMENTS, I DID t{ T }I~ i I ? ¢ 1 G ': ___ Q ?-SmP -'to'm ?KN L ER T'Pt1D ?...-n -1 - .. ? I ? t WL= E?5 ? I ? ??.+ rECt.NC.,FoR.c I- -?_I^_?_ I ? _I._..f ? ? i?Rw`T^IV . L i '. ! I J ? '. C iN C.CUM'RgAO' ? ¢ s , i. I wia?vES (y) ,.: L+.? ''I_:.t -i--t-.. ,' ? •-r.._ i ??Gg II ?I ;.... i __k .i. ._._ I_...r----? .. - .,. ,. "+i /ra ? K n tti;+P i4 ' 1 ?N C '1 ,, r t 1 ? 1 1 1 4 r; I I 1 1 Y? w y WSP•159(REM 505 - ryT : uL 3p !t,5e i l STATE OF W .SHINGTON PAGE OF 1 ./% /J? w?? 10. . 's UNIFORM POLICE TR C COLLISION REPORT E I COMPLAWTNUMSER a? I ? . I A L i 1 t { ?X. Tl ? qq?,V? rn}Jc GATE OF Co"S MO D DAY Oi COILISN)N 11ME COUMYNO. CRY NO FN AY T SUN 1 MD1) IUES ] WE + -A 5 FRI B SAi IUSE A00 MOUfll 7. J . WA COUNTY ?STATEROUTE KCOUNTY ROAD ?Crtr SrPEET O ADMCLS. PREFN ROUTE OR STREET CODE _ SECTION E E ?OTHER ISPEGfYI L O ? CITY Ofl TOWN N S E W pI1N LM ` Z C? ® ? ? ? W PREFIX EO MXE POST C MnES (i(• '?, ? ICLOF..__. LAM.. .. . .. V E UG T NAME A NO. Cf STREET OR HIGHWAY INTERSECT WG WITH: STREETORROAD ON LL RAMP "A""'DATA//? Q VON VV N BETWEEN ACCIDENT MLLAGE TNT R X 0 xRERS TING STREET OR AD ORflEF. LATER B15. ERENCE CflO553TREETOR ROAD STREET AND STREET gSTANCE ANO DmECTION FROM REFEflENCE Ofl CR055 STREE CODE ?MILES N S E W (? ? wxbnElNiry PECIAL COOING USE ®FEEi 90 OF. t'CNOO`i U - COLLISION INVOLVED: VEHICLENEHICLE VEHICLE SEVERnY ® ? BICYCLE ?OTNERIWRITEI ?HIi'RUN NO. MILL ED TOTALNO ® ? VEHICLE ?VEHICLE-RR TRAIN ?STOLENVENICIE 1 N OF VE OBJ C _ O IWURED P TRIAN E HICLES ? ?NON COLLISION ? HAZARDOUS MATERIAL ?PROPERTYDAMAGEONLY 06JECTSTRUCMINMIEDFOBJECTSTRUCMANDOWNERSNMIEI LOCATION OF OSIECT SiR CM N S F W 1-AMAX RD EDGE 1. ORNERS NAME-LVST FAST ? ROADWAY FEET ? ? ? ? - MDDL E DflIVEflb NAMEIAST f10.Ri MIDDLE 11 pCYCLISI OH PLOE SIHIAN CHLLNI? D D 7 9 . R. 6TPE T AM__ R STN- ADDRESS V Q ?? • V •' !aS O OM S E T LIfY S ATE ZW CODE NONE NO. E R R CRY STATE LP CODE P1I O 8 N DRNER S' 17 L S ICE NSE TAFE SEX GATE F BIRTN N -WENS LICENSE NO STATE SEX DATE OF &,& D • MO DAY YR 0• MO. DAY Yfl _ 22 DRNERSOCCWAT" FpA1 NAME NO. 'j OZRNEERS OCwM WN wMHAM _ ? D CODES > ?I n.°ASSY _ LI SEATBELT Dn RY ? CO __ EJECN0H __ . _- DES > IJI l.? TAI SEAT BELT 151 NATURE OF CUSS -- EJECTION IWUNES 1.1 P. w L 11 FR SCENE -YEAR By MAN E fD 00 0E .1 TO rAODELNARTNOVN STYLE I)ORCONV.1 Y FROM SCE NE BY A. YEAR wME1DODGECNEV.1 M LmMi?NOVAI S YIElI D11.CONV.1 V ? L ? - _ 7 M V E VEM. PLATE LAO AIE 1RA E 00.0 v P_ ST III . AER -E NO. STATE VEN.CwOR UC. pLwIE NO. STATE ifWL ER PLATE NO. S TATE I LGP, N I t G V 1 L1 c LE 1111 R D . . VEwCIE DENTI ICA I fl M1MB ODOM TER E 2 Q •"1 F L E O G I N REGLSFERED - T .. iHST MIDDLE - Z REGSiERED OWNER- .. Fwbi MIDDLE 0. f " O sAME S VE ' . . . AOOfIE6S OF R NAM 2 ArJ ECO.OAAdW STPTF. RM NAMEANOADOSESBOFINSURANCE 0 ADENY CS0 P FARMERS 2tI CO. O LHAR 2 e IN) Poe T MONI 54Emo WA - - , GIATION FNFORCLMEM -'& F ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES - ) ] 5 SEX AM STATUS EJECT. E. •ME C ADDRESS U NAAHJR Of [ R E S RLMOVEUfi1OM SC[Nr RY A N NAME O T $ ADDRESS R L W U If b SCf Nl RVD R PA TO M[ T ADOn[ss N E Ranmfa scrrlr Nl II O AM[ S . _r SS 5, vAR r U scr N Tp IS •rUS I)1514FbYrIW I] NAIN C 2 o[Di [Sm[•N 1 I r LLASb 1.N0 wJURV 5 g5.OLIHfiIWUnv )pC•0.1 SC[NE S Iq rS1 AlwSIWAI gi ALLED PILx Li XJR NOTEJECTED D NCYCL191 N IR - T I OIHCn POSITIGI NOH gS•OUNG ] DEAppI ARH AL IF VID[NIIINNORV G )NOrnI USE ] USlO )tOtALLYLJf.CTED PAObML 11 Cl[D E ^ m ? r ISS - ? j mUS MOTORCYCLII A POSIigNUNXIlOVM . pKDw HOSp L / POSYOLE-I . NOW., _ .1 UNMNOWII I! i l? Y IT ETL1 '... :. l.ulLYWR 1 w -0a, T? L L 1 ?.r. ...,.._o. ....?..__._.. -- - L u. [53TR IYO.1" Q S 1) 7 l r 1 AFFICWAY PO LICE TRAFFIC COLLISION REPORT PRIVATE WAY igIKF COWMImrvuMete g' wrt D A. nme coDrvrr c/ ouNl• I" - "Tr:.. Nrw• ° p1rv Crrv OV lOwrv ?t?^ O 31v[tr OV wONWAV I lt3 5 ow Di L1 mk0au? ON h10 v? ION K CIS ?. 4E!50 r v5lCNNG wrrn SlvtFr OVV NOrvINrl95ECrgN._. -_ [N SrR[Fr { sref[I evtn% f AIL- 12- 1 OISr.Ntt aDlvFMgNiPoMVE v fCRO 55rvfFrOV N[ARf51MIlF .S N t -yr 1 rtfr Or -+rV ACCIDENI MI Cox ODE vAMJ AM pAIA I COIIrSgNINVIXVlD [Rlrv. 10'AI NO W[ALID?Np INIURfD ?YRi•of ?"Ire RUN p rPonvrV OrMAU ONLY ? pj}jArfD l v[NICEES ?vF?iCi ? wl rr E Roo oe arfnNu IM(e C eD IS C.RSf 51HR?.0AD?? 4 jS y WIICr S? I?KINTyOr Oel[CI gyC%_/ND OW.I[Y'S wuAtl s FSr? F/'\'%l t lLN `• r' 'fy 3nCI%I COgNO IEE UNIT NN O l UNIT NO.1 VEMIUE ? PEDESTRIAN ? PEDALCYCLIST ,9 Ovrv[R3nwf: ;cGl?s iYo?zc?c INeSN?a o 3rnfr•DD i/.3/?-/G? OL lY? nfr.DDna lol ?/J?/? ,?_??} Z rv serf lIV COOP WgNf NO a z D 11sAE " 76 732 N[v'S <lrv5F ri0 I?? LUYL? 3a/O/ slA F F% 2z:?- 1MD dg ( l NO. D c 8 Cr f % M N i I?' S i Z «cwA I'll ??' fL?Lylf? 3 '!D r<gr.r ?o 14s- R c/Ln??/ _ r wwe? .C ?6d 10 / pCHECK (?) •N ?CHECK(V) NNIC11 A3 wN wwott[or ANOr1.. S r e i° CODES- - 13 1 1. _ CODES ? 7 n . w 5 u 6 y'°I( N - Z ODES / _ r?::•D. p... r ?n" ?28:.. ? pA.e. 1 ?::' ?Efie. ?". a .. M Nn vF?g,? AN t199q?' Cntvl Q`C %7`r7.F1?!) M00[IIDAVr. Al ra0v3rvl?l))-?.[(,'rIVI 7?XC `f9 E 1 1 -1 AI 7S T 14 n I I ? _ ' q- =w //.4D sure n•m•nAle NO. Ar H C NN Or26 R r.. o J vtnKtf KAIgN NO. ZALB Zi81 S11 2:0 L NIL 2;0$ l 12 S 128 I I ncn ow*.. fur sl OpF ?Hz LLl?S ,?IC!/!G GC. vroNFw w I oWxe Iwsr inr M (•GtiatE Z •DDnssoowNe. // 3l5L- /L7 /?G Uc E ?.?Qd Z «AWea AD alriw.ANn eoeo oI'AClrvr ?S- c?.llova A R L?tS7UtK??2/•Pf9Z8 wMACID MU ' rU iorioii• e Vµ D,rA,u a... AMIM ?O.MG ? D 'T 1 en•eu IOWfO ? Ia9lAwrltD iwiv !''?` ? Aw•r ev. _ orw.r o.nA r up E r5 0 RAMOF COLLISION- rv •.'N .l -All I- P!SCRIPTIONOFCOLLISIO VW t I 1 . , , ;_ 7a Oy?.it?ity_ - _ _?_I .. ? -i _ _ I??I 1 i I? I I ?e r?lfld- LNeL__ ?Eff7 aLE'?ZroSsl -- *.d? •?'n?rt9 "1.I,.?'ON_ NAME. ADDRESS 8 INJURIES OF PERSONS I OCCUPANTS /WITNESSES jq,Irp '?ryuy'I NVO V fl + CODES v •w I i Ar - Z -V'r J ?f- 5 6 llsn fed"'n- r• NA.w E ? PJ???J .DDn S, .rwa reerp1°OM?.AU ?"AA'? ,.?0%r NAw •• .NVfH ..... Na ?d. _. _ - IM.r ?•M{ ?"`."?•(o:r.. :? ?r.M"_ +. IS/r/G)./rE,aO p?r<Ip(+.•?A?•?a/....nw. T ? X /W!/N G?VfJ(rGYQ/ ebUO. r NO KArS. ./i { r Rj' 1 C'IJD?.S?frS•NMC /:4rDK.? rOIIUJ.(.L'J(NO ?MM' D.rl n e Alrn)MD. D?•5np p , Q XI 'I s ?11 U l l h y? '( h Y I r I 7 1 , x ? kflM• MA , -44 5 M q '' a? ?x -T , . .? rD 7 I pj l i ?. i'. POLICE TRAFFIC COLLISION REPORT ?67RAFFICWAY rol¢F COMM Hurnua . ' PRIVATE WAY D• t0r IXlr rMf COUNtY r , ' I ... i - - 1 ,00 NOU41 H . N, EY C NO. fNW4 p pry pF pIN Crivp9 TOwN AMf{NO d3i4flTORrRDNWAr N 40uTt OR Has $Es pw or ON R rNTEeftCTiNG. 1. 3,9E[T OV gpAD NON iNitRXC,rON .-N 319ffi { 3..E1 t MrIE,N)St !{D?ef rF f .CROS33T V(lt NtARE11 Mn 3 Mn[3 5 t Rti Or ACCIDENT MIEEAGE CODE RAMR Dil -A , C 11- NVMVED vfRnr TOTwI NO NO RrIIFD NO. NEU4[D ? SRRIAG[ ? N 13 RUN w R?" W D rM[R CL3 Hff RROAD09 R[ff4FNCi TEE CROSS3,R[ OR ?F tlVEN CI[s RRORlRiv DAMAO(ONIr ?H:f T ?yfaCl ?? `O V 2 U? [ OBEtCI1T9UCVINAMed OBEECT StvUCR •NDOwryfR'S NAMFI C E [3TD AD[ 3rFDUl COpNG Ibt s UNIT NO I D9Wfes NNAf rws, .9u Mr UNIT 0." ? VEHICLE ? PEDESTRIAN ? PEDALCYCUST vn9 sN•M(. usT ri r , _ STRIfTADDV(3 ' ^ tp(r ADDH53 ? 'j RZ r r vrt n ryoe No D r. STATE CON R rvlR'S IrC[NRN AT[ O R•r rt I V t fN NO Af 1 11 • H IMV n _ .-AT.- r M NAME t No. eves wNtr ' E «cDRAnoN r RM NNAE a 1-1 No F EaN;Hr R 71 p CHECK (.1 snNrci[A : N CODES ? • 3 1 cTw.. n a's".°°K c M. wfO ? CHECK (.? v[H Cl[AS AN USnon fa•NOTNUr'M •ii gac.c CODES 10, t D n A°in :"' S EA e 3. , 1 NEUCns D -7 3f .. ° p M .Mr ? u r p p 5„K;7 ? ". NN M [ r(A9 R IpppO(.eNfvl IDARI NOVAI sale JpR ONV M4: p N ? p p w ? :.» H 'ROu .I l ? No So,J apR E 1 Hvl MODfID A 5 uA AnER nA,F NO su H veN R l D I S 02. - - I C nNn;lfruM?NCAT no RfasrtrtoowNeR IAST sr MrDOU hqM ND v r r N erD mnA r wwt R S - 0 wT 1143, Ff s T? ADOnss d ow„Ef HJ[xxx. N M N 9 u•t a•Da[udI swANC co INI Q ELI D•.MAC(DARE• -- g•AIADeD,wu roiarlor > IStppAMAGI eNARU W^: ?gMAENfD eNARU ' ?AWDbvtAVN ?RIAWNlD D =, f t •tDR ? 3 Or IOWtD{r WYD•v? { DIAGRAM OFCOLIISION' N ?Nrau3iAii ro?c• NwTN I'll DESCRIPTION OF COI ISION: Ilnf slsruwMAlSMnn NInS5AR.1 _ . . P $3 *-j _Veiw-l w A Nk 1w, VeN*I Fwltetu ti 7vaDS .. _ _ T AR-- Sib(?-Src?.J Qh8oe f Catlei RID rLJ 1 ?.Sirr f T-lq-5ey cr1 T)JR IL co- C )I 3?6 _ .. .SI 0 o/Sir m OF R Vate ?alwaup p / ? ARRl t._ _ Crrtea ?? . __. NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - Z 3 ? S 6 4 OCCUPANTS / WITNESSES Iw:m^EO"'1„•M„M, 3,u,V'R 1. uR •a uru3 M 41 . 1 51 A C' t'.5 wl No e. •Me iYIA A . 004E 33 H •TNf d vlD re p•N{ pruAl p- r p» ?nD O N O • fN)R,3 _ w '.?wedre 1 t Ni a{ M ? 1 ?r IM ?• Nl ? p • V?<r p !'rdn ?ii?"N ?" ' ^ X 2?P? ?g? TIC ?J5 l t ? d 31 (' rT?n Twu ?.w?s„D ryg ? ?/",'?1 ' A ?f fP ?il? •r .a z r. 1 a?a r; h k 1 ?? ? ? 3 T At' C?? 14 7 J?,?,C ? ??.? "? +"? y r r P ??r?fi t?'r _ '? r r' =?, ? 1 ? ' 1 ? ?l;f,,? r: ? ? i e Y ? h P? ?+ ? ?" a d u ? ? ?aiC @ a? t , ' ?? ? ? r 9;'? „ n ? ' ?,-?I??}`,?,?fjt? , fu h p' STATE OF W 4INGTON % No . 2 2 9 y POLICE TRAFFIC COL eA N REPORT TRAFFICWAY MNUaeu , PRIVATE WAY OF l: N II g. I i" + w••. .Oa i ? ?rw. i,i?y I }?].DD novel I °. w` .` [3S0 cou -t- p/? ,, ? rr NO. I E ? mwJ EE p. P ON ' ?I N <,r oe row N ? { tod E•NOas,eff,oe wcnwAr 0 w ? p . w,f o sl r ..clIN 05 ow Dr oN v, lvif CIINO Yn,N S,e[ OI AD NON iNrleSFC, ON ( ?? ?? IFN9 ' •.:, A$ y E _ eEnnlN smar I snlfr ? p ;,! IfM rn 11 teN .CeO553rI1f NuI[S,NI AM D•AMW N[S N 3 [ MILEAGE rtft w a 440 . ? h r CODE CdI w TAL NO [D to h; CODE O tore NO 1'{1 lttD??Np N1U9lD?? Sv IIAO[ ?nr{RUN ,w MD OVfn CIlS (_(f °q0 PIYDMU.K,f ONIY ?RSVIi[D ?S,IX[N B 3 D IM[9 Cl5 ql, 9 RNE4FN(f CRpy5 -mm.. xv ?^_ ne ,S,eV [IN- IC, SIR O SNAWN esT DAm sncw 9 moiNC USE .. n ? f _ ? 3O UNIT NO. 7 - /, n s Do v[I ^ N p Urns NAMIa []sVEHICIE ? PEDESTRIAN 0 pEDAICYCLIST s O ?H ' ^ • C •] l.fJ Sreft, !!} ee?S ADDe1S5 8 ?' Po e[f, ADDeESS y r sun lie CO ONE D A I R IN. N N r.. _ OI S?v?{L 682 ? _ OCDNA,gN ` w I N ND ? 1..?3. V n a j Y. "O , . - A f. A ?YQ ens ?-7cn, .eicn, E cu.AUON M Nrvne • enDNE No I I . R ens ?cn, .[icn , , "`' J ? CHECK(rj vfn? r v' CODES N N, CHECK (,l) • • ' c •? r .NS r E` cr,d, a vlnal AS o CODES PIt S a d A • ? k S 1• INE nDN 0 yq.cu L!L U° •, y^Ia °IDOWl.CMIV o „ .D f . 3i, 2fi: ' g ? y ? am o d D rAI niR 3 Aoo. ? E zn ? :. a - m z. l w sun r•ulle nA,f NO PAT H vE HP51 5 °° -. f ^? XvE ?' Vin ClflpM r-,CANO. C L vine l N a i A elc SRelD O i I 4 D- w,u M;, ?, . WNII (? uS, rns, MiDdl I -NI NO f I lit ? -m. IT W Z N wN I E f NNwf I ADD4155 -NSwANCI CO O. / N, E -A - R II ? :, , a . ??yy.?,??? Fd' )M1LXv II3lNAOE A•lA , ;'? o"";., ' ' o.n.DnDl aAl • 'S i±` S.? a q 5- AIU ? I 13r. 0? ? ?ol.,wN10 [nAI rC ?O,tO? DIn ? •rar • I3 ?/ N10 A .M ?IIAUiNIO IOMO AV f e U A !y ?, <" "l,+"; WAr •r f --AM Of COLLISION l , r Ir icuwn sv iip'b°w ?n DESCRIPTION OF COLLISION; IusfsvntMEMA13n[IrrMCISSMV) f t? 2rJ O /.L Y" NAME,ADDRE5581NJ INJURIES OF PERSONS INVOLVED . I r ` ' , OCCUPANTS / WIT 4 SES ,o; ?"„sow„A,NUVii CODES 1 vr. NA.u[ fl• Aol ,At Y•r 8 + 4 I _ ? • N5,1 IEICr i'i Cr+ Alv - t? {LE?.m+:.fV' i ? ' A AM1151 AT IId 1 Ir AMI ? Q ylA `., . ?w Itii,v `.` b - 1 K ? ?11 ' trx ?? •wre. Eu ADD•r55 ? .. • IU d '?rti ' oA. fIAU nA,cl n?,? r. Nr ...e? _.. J???u ,p??{g 1III ?? Or'"?ftl ? U r? Jie?1 r F I ?.+ ? O ? O F O O 4S? ? ? de 4 e ! cv .r t i 6 p ? ??+tf f f1 ? I I _ I_ d??{? ? +` ?f `r,V°ir`J4?`4l??F ,fl ?I l fl i'li:C7 fr F 1?y4? nti! k?h,?fAc h ? ! 1..? Y? 4 w' I } R Nr-R. - PRIVATE WAY D ,[OF a ,f IA N 11Mf : A p CDUN,r CWNtY N O CiY NO FH.,.A u? re? w uo. xr , ?f.l IUSF ].Op HOU41 =a / .?a? ?J sL'/? /b DURBAN I 4 H UN DE t@IN . Se C OR-1 N t6 NO O rOew GHWAY {Ci ClS Sf R I ROUT[ORS,RE N mIIEl DSTRlFsDW ?ar c ON ray ,r.•W? 9.szoo IMfR3ECDNC YAIN t ORROAD NONINTf9 tC,ION Li] RPfirx ED. MILE ROSI pf °AJ ?/ ff?£ "y E-11114 -III T 6 S REET I GIST CEa DRtM ON RUfRFN CRO--i E,ORNEARt3TmIIF 3 I F W ACCNT RAMR ERA.- DATA I IIlS rR IDE O • MILEAGE OF F[fl L E US CODE COIL LION NV OlvFO EvERUV.RD MR3FCYIN RfE10R ROADOR Rf{fRf NCE OTA(NO RAID O NO.NJURED? DuIIAGf D Hit S RUN -NT, r.w IN MF CRfESSTNEEI 4 CIS ® R ?].i ORROPD VEN CIfS O D e90RFRiv OAMAGE2 IY ? F[SVItfD ? VEafi ?•z` j l?o f OBJFCI S,9«%INAMF«OB,[Ct S"O"R1EDOWNIR S _ ' Na FI III DAmAGf EA, A, CODING AE 9 s UNITNO. I D9 vfvNAMD IASr n9s, molt U NIT NO. NO. 2 VEHICLE D PEDESTRIAN D PEDALCYCLIST DRV t u?" ? ? SW foN O TF.AN IA ? R EN F L StetF, ADDVi Sl C , I EN u I3a f I BoN.9 zft W S,ATF R[!, ADD9f53 nI ccDG/v v? 2 IIe COD[ RNDNE NO Dn1 ERsI IN. NO. 7.1 Ell. D R C All f e t D W 7? {Z 5i/ANS/v1JSL7G07 Wj} «curxnoN tarno M No F 2I / v D slcENU NO. A ev,* en 1149 0 E f W/} f% F DATE OFBITI 3 $ ?G ` 2 fns wfwNl MFrGNI r o SLfCu I ' S !/ I0001??. 6-?{ 9 13 5.,Z E R IIPN AMf a eNONf No. fns wErcnt IEICN 4tQ NRf} d- / I 1 D CHECK (? Ncu AS:N BmaorN AOr ANOrNfo Al . R 7 3 7 AT (.j o o O - ,„s,' M"' ,I r<.r r CODES a n % n s E craw a i„i9 - wIR vfN,p[ASAN FMIn r[r FAN rxEe CODES P * G cr. s. " orDx, < i:sxn "' s l%cr e i a1 .N,..--. D Sa, Z o .DV M D . N .nE1 Due°' ? bb1 D „ .r. ? . ° -11 VfN YEAS I IW-E C-I NODII IDAll.NDVAI lirlf 1]09 C1- MIRE vOWDr9 D vN ." r ?° ? p8.r1. sc D vcll D Y. ? o w r D . !Q/ _/ OL .S L`1 .? v /? v O C ENlf R A Y M D 31ATE RATTER R„F ND 3,AtE t E H lA4 / / (DODUE' ON Y.1 VrDfEI IWDART.NDYA, rl 1] . Y g Y!N C«OR UIF$[lLl?C " C P P,?- °N 2 9 M / ? ?tK/ /I '' Y/= /T?U •?CD./ I?/?'' I. T NO E A £? T6 ? w? 1 CUrDEMIFIU, IONNO. C ? I v!«rat -- -- [D! IOWNF R AN YI IEIXM3IG 4tG SR9 USt 451 Ipplf 2 31SI7 MONf NO L 06-151 1;10 I9 I I I KI I I wo; y RtG 3Tt4fD 64-I q-5 D,,rI V-X O !R IA{i $t iDG[ F yrrlt 5 ow ADDR[S30Y ()µi,[R W /i N£. •w OWNF4 ]I N A+n?ADD9usa wswANC[ co. 09 AcIM E D /L1cocK 79-3 et.+! 57 DAMACID.1. _ ?es L• I wN C,IAYG! ? CNARGI gAMAGlD ?N • G w"gNy .,.a • 4[NfD A YINfMAIN[ D rG . W SIODO IT OWED AY AWAY IV, LDIA2 RUP ISION• 1 I v Nev:>RDESCRIPTION OF COLLISION (USE ITTRAIMf UI SrKn N , ?'fIN / Se L } Ar O£R s ? R j Jlt 20 W I /N4,..F.o,e s . _.j , (_•. ..., r... .-?? I ' O/vGbrp .DC., ,CA•FF/C Tv CG FItR. DAeI?£(G oP- Uf' lCLt fT L ?- , y ? ee/clNG. RWi! F JL _7w A i a 4 { , MI T .. A, _ .. 5 I .S Xcec,e z oN If14l?r IC'EAfrC wi7ri F,evrv7'1£rT, ;.: HoDY.. Acl U.elvtc`a l' ? ' a, i}ysu/ce?el/? z//rAwIq- rNtSS_... r op7n7 P,, IV v /ncT - qLl 5A?rl r///rl V£HKt£ ??? WtS 57tip?£D I .v , I W ]eN J C cT/v j NAME, ADDRESS 8 INJURIES OF PERSONS INVOL ED ' CODES I 2 3 4 5 6 OCCUPANTS /WITNESSES ia:cuuov:i:i au» $11 •Ll lArus ",,;!' ,2, s, vtua urcE ! w z . I ? Acrr,rn. D Ave D?S<I D^ f}• A7 yEr2S '??V Av' DDR x / r / f ' - R ru o R,MOnureuv DAVe ? r D mIRA Np G. cN M1. ,9 e'S= !f7 3 ?,.RB. ? T r ••.G U r.1. mDAVe Dn 'D%"' ?:i:' .'-,. ,3 . „'ur' u, uer . 1•.AV1lRAr n.wl f r X ` ? / / ? o Al.rc, /I/w ? SDI 'Clp!.rgA.GnID K%?(I ,t? All FDr etrpvl A ,Hyy. O SoN I ,CSO ?'(?f??//III//.d /'!?N[ir ^,2n- I/Y?1/•IV(J// ].7 sl r a 4 ? + I ? ?1 a%B f r? _ F J , ? t . 1 L y J' { I. l l) .ti 5 r ? } t nG I s r L y ?••( ? IY? J 113 r }F• 'Ff; { h ?_""e7.}s-.rei?i5a + %L?: '. '{i$' _ a ,?:.ri. ., _ '; `, ?. r+." + .lea' v b.)Si' '?. E 71 f WSP ISV IRN.I.B01 Ij STATE OF WA INGTON PAGE DI/ / Brd - No. . W E ¢ ? nA F ' ??, 8 ' ? 1 s ., 7 777 ' N ,,. ?•`'` POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAV PalcfccFBPLAININUMeE. PRIVATE WAY DATt Oi COIU A O ?-R.!ru I .?.ur. 7 L $? f i.I IUSE ]vm HOVRI / COUNTY " r?r?+t 5 a.J -11- ? ? IIY NO. HWA (]fURO Ra / N OE [] HY ON lOwN AME BNO.O OR HiGHwAV 0 12 OF ON N ^ / MLES 03 Q?w RS l0 RWTf OA IR 3 95Zno CI NT[RSFCI,NG VAlH. xREEIOV ROAD NON NTFRSfC1ION E N [O. rNtE FO51 jAC. BETWEEN -TIl E -111 G D STANCE BO NFNI fN RFFFNENCF CRW 555TR[ET04 NIA-1111t FIT L S M 5 F Cj CI OF i[E1 ACCIDENT MIIEAGE CODE D RAM DAIA COUSOON NVOLV[D -1-1: TOTAINO 0 KULED_NO. INJURED- 13 SULAC( ONTB RU N wHDwOr" R.RD MFR CLS NTt Cw 5REE111 RCMDOR w11- CROSS SiN E( TOR ROAD ]] - CEVfHICLES © 0 PROPERTY-AGE ONLY 0 gF5U11F0 OIFlxi Cll / - OBJ[CT IFRUCK(NAME OF OBJECT STRUCK AND OWNER '5 NAMd) 15 T.0NAAGf s SPECW CODWGIAE UNIT NO. 1 UNITNO.2 0 VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST 5 VERSNAME wT NRST MIDDLE WtRSNAMF: UST iR l ' STR[FT ADOR[55 STRf fI ADORE55 Y 5 5TArsi r zIPCOa _.- PHONE NO D 7 rtr / sr3 I . . R 23.39 3SS•16/4 / DRNEP SUCEN NO. STATF (' aaAx 2 /c Ez A?'E f H MD /.S RIZC I V uCFNx NO. I vz3?G ' . I 'I DA iB N [Z 307 R?SB 6 lKCUPAtION NR AF-LE-NO. !Y[S IGHT HEIGHT E OCCUPATICR+ MNAMEBPMONF NO EYES WEIGHT IE GHr / I k -- d R P,,,, LGJA Sbt 7'71 e- 0 CHECK (.7 vENRIAS:NIMROV EaANG a T ?CHECK (?) -l1UASANFMROYEEOFANOIHERAL 'GM f cr a. / 6 CODES ? 3 n" 'v1 6 + s . i+inMN' S L,¢rroN 6 ^;Ery '°E CODES IF * ] aS J 1] u11URIE L - UII.F FFiId ---,T Cn OY.•u:vo..+3 / :: IH RMA ? NV ? 8,r ? .K, ? ww Mfr b74' .F . ff ? u ' Eb.n. O Y HKr1 ? 7: YEN YEAR MARf IDGDGf CHFV1 IIDANI NOVA) STrIE (]DV. CONV1 r A 1 H vI MODfI ID 1 NOVAI vl 1 DR. v.l 7 '' / Q F 4 F/E'3 T- 7 I / 2 H. Q 9 lI NFO SIAIf NI[R RATF NO. SIAIf R H vEH ROR Il A C A /k So BT ? - T„fJ C - r° Xl 8SS ]? v1.HK11- IC-OFENO. vw?R IDtMIir N ya IrcIFI Iej 1/1. 1012niz!s L 2It cI ool I I I I I 91.15RIDOWN1. -1 1'- MIDDLE PHONE1q. o ' T[R DOwMR; LAST LIG, I.- -LAI I W R . 3TS d-7 P N / .r I] AUDPtSSp OW++IR N A [ UWN u,EOOeessarNwRANR eo. oR ACwr A A R ]] A«A 4FY 4c A oTFb ND G w'CM CHAR. CHARGE rrlHCr,DNN ' ' r NET, AM.W! O pAVAG1_ ? AWAV ?REMNN[D ? AWAYN ?eENNNIO IS? IC.edA S I51. Oo ^ r IDwFD AwAY er CES tONRDBr / f.9Ln wA 10 OIAGRAMOFCOIIISION: ( uPl l wD UrtrlovlH DESCRIPTION Of COLLISION: III1 111INIAL 111111 II-11 W - : ... II IHIU-111 _EVA.S S?,t1' --?n/.....c.-i9.._._.L FT_.._.T eA?._>°eR?_. ... . _;_? ... ._. ', ody D._ ..iio..i??9rFS._rb..i.•...ivv.•+d._j4rvrd 1 ' .r- I I { I I I I I I I I NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES I - 3 4 5 6 OCCUPANTS/ WITNESSES ' x swnl»[NUlsw IoR ADDn?w,a NAM l I m -x. Ace urus v N i - -._ _ .... .51. l,<n MmY NwE ?7c??//? ?P me .._ .. Nn' ,jS$•07S/ 2 2 - .DD.ISS N d/?FE /,4 wtob a VY e. •M B O"N" O " . ?M O N ?Tan v?/one Lead- NG '°"` 3 r 9 , aEa wDr.GM RA- 0 0 1 7 Sr4.rs.r • r IA '.,1 UE a SO w IDyOape <r ?.•I=?.i: ?i-- rU ? ?R+ 05 M<fA f? ??.C?JUBV OAI ?y._I? ? /'MsE,?,?B!cE? ?1?3 22/q 22/95 72SSC r ?7 2ftY yM t I Mc -71 G Y J ? r i G' s II ?? v • 7 + I J 1 r ' I 5 Iq I 1 , ( ? 5l i( 5? S - r 1 ?',i. ?N ET I 1 ??ll. ` waos„y>v~a?l.,>P•p „r??„?,,,?` '?tF ? D..r?.aw...Ji °^''? .?. .,., A L.._5. ? ?? ;...?.._?v 4 / STATE OF WASHINGTON WSP"" ?I ril- ? . Gf ? OF d .4 O PO LICE TRAFFIC LISION REPORT ®TRAFFICWAY .QNPWNiNUMBER (R PRIVATE WAY ky '?°?. ,9q h 5'I DPif OF,eCOII Ar o?w'fN CIEY NO. HWw >s 1 S ???I r W4 ° ! I4 HI IUSE r.pO NO.- rODN.Y CDUNiYNO. A/I -pN pE p N >'?w 3 ?, i f' F x W WASOAR `• r NAAMLN0 11 mw C L$ M ?? . •d t?. OW OrSlRffr ORH z RW/JIf`ONS Rf (FS ?5F E)O pW ?Of ON/ 7r - I' r l./ 7r,JL ?? F *x, ?ffvSFCIIN f rnIH SIRR ROAD NONIN![RS[ClgN I PREFIX EO. MIIf PMi xru„y EETWEEN Si9EEr A ETRFFI / ? Y +? as sT' ac .?'rF +/ DSIAN FADV A1 A lE5f N RFSVENErf. CRWO•SS Of SIPFEl OR NfARE5l Mllf ACCIDENT RAMR DIAGRAM fMrA Z.L3G u -- 1 MILEAGE ' y( p ?COIIIIgNI V vEO. E9 rr mCODE v rfNSE I SR(r091gAD O4 Rf[RENU d • Fr .1 LN. NO RtIFD?_-INJURED r ?EPIIIAGE pHr<9UN wrvovrpr" „- ;,M^ IMFR Cl5 CROSSSflLFEOR RpAp ! tlST-KS 0 pPROPERrY DAMncf oNlr Oi19F UfD psEl°.lci Y•" ? ,r OBJf<r SIRUCRINNAF Of OB1 .-I-NAM: ECI51RUC4 ANpOWNFRS NAM(I FSI. p,vAAGF SPFCL4 CODING IAf J+ 'x 5 UNIT NO.1 UNIT NAML0.7 ?VEHICLE ?PEDESTRIAN pPEDAICYCLIST ; 3? lASr rRSr f pR VER SN USI Dlf t `??? SGu:oocEss' AFY. _ / c°G„qr Mt•Fr ! r.r J.i r,E Anal ' , 4 lNFEI App9F55 J `?' ^. .6 '? r s rf -copf PHONE NO. D air : '< • r+c .'• T. ch: R,Oi.r,N , WJ.. rSUrf I of PNONt ' D4IVE9sucENSf NO r•srn?E?, ° -p[%o R r`?`"D<.r •. v? ff$i yr` T` E MDAf°o.v r R. I cENU NO. - E ?or,rtpae4.m° r.. J. ?. VCaP'. V/,.r l;F +nl r•. A Or.. ?.. w4 Arf F Erfs A ." ° «cuPArloN HRM NUUSPHONF NO. Erfs wf G«r NEICHr E «cuPAr ( oN NwME<PHONE NO. Jr7 ?'. ;I C<,r r r?/"7T• , llr wf cnr IEgHr /? •'? K 3: Fr/=.^Scvi C-/: J[. r• &'. it;" S-f R _5 Ar;,vrP (_M S. cr/cr._ Rrr 6F, ?.r q, 4: p CHECK I?J vFHInF AS AN IMR-(t of AHoHFC AL ' CHECK (?) _? .. CODES P. 7 <I ni` < ' Cta Dte ,ua. VFnICIEn A, fMttOVFF Of AIVbrHF4p( t YaW IN, _ X M" 5 In 6 i nr 'c I CODES ?* G ci.ss a S ?" tcl N I I ' $$ j Jf -, f?r„?i?yf ilivoinor POn, p AM ®+c"A O ? Cbmv -.111-1-.111-11, 1:1 H !/[ NcY 1:5 rn fnR fIDDDGf.CNFVI SRMODtLIDARr.NpvAl SrrlE 1409..CONVy g 0.NNWANct ? °q c! ? 84.. Up v? y ••N•t 2 ? ' ` 4 AV rou CHfV l MOD IIDARr NOVAI Nl R? MA.v W.N Ury-? E /H^ 79 /nJTL. fq- I .., I A NT?< AEE .4• 'R,?? laN surf 9nfR eArF NO. surf H vn.cao :F' n + vEH¢IFIOENrnlunoN NO. ? vE? oEIDeNIa A CNQ7.? " ?? ? '? •, ? •' ?*?, REasrzREOOwN r Ff 9srrC JMIpp( E PnoNl NO f / O Rfr lsrzRFOOwNex -CASs N ]. ?_ l ° ' I 1451 MI M Nf r NtS `k' AN A _ - f,(90 W Tr..,. __ .- . y..•.. !'I,• i' i [' nD.-//C{ O •1 7 ...,T IS ADDR[SS Or -11 • r. l'• A' trr E WNt9 ':ir ?` Ell E r NNnF SADU4ESStl INSURANCECO DoAGINr o ?Ec .') ( f ° x :r. r r• Prr: TiaAnv/-r' -G. /,3r. R rr.l r rt ^ +/ Ntir DAMAGED AREA R. ''?'_ ow<o.".cNI CHARD Ncr?F cNAOCE• gAMACfo AREA .d}.?I.??, S f5r DVAAGI ? D AY ? n•t NL: OwCrOwe DP U J9 `PX RFMAINFD ?p91V(N ?p[MMN[D <51 DAMAGE ,+ I 10lOElnii s/[? f [•. ?W YO r: (^f'IAf ?OYW[D AWAY iotrOii S r f° DIAGRAM OF COLL15ION FTl?iiafrn Niasuerl f"ev ioROw rn DESCRIPTION OF COLLISION; IUSF SUPry[M[MAl3rRtru Ntt[ssA9r1 1 r <<?, //II $? IA / -4:, Irltn .rr< A L1/'1 7.RN FF;n; ?) ¢ R N ?1 / Rrrr ly r, <.. oNS7-<..p r.r,+.l,.. GY, ' 5 t. L ' E'}. 1 T/Jr ,q rt rr. Jfl.: L•S• N:JT+? GerrLf-y :i' I.?..,ig ` . I f - ?!"n= •, _-. -- 41 ? Fr,(- ?? r rJ r, .. , 77 / u•: / r . L ? L r C.I A N o '-+ o != '•_;8? u *G" 1 TI,<LY ,/ v, r.rrrr,r{ isr. ATfr..•s N+T X R+GHf / -tI _ ?:y TF.f AL /lr rEt .$+Jlf .. Ji. ?v.t f// Ll ,? 'pr IllC 41 Cpl t y"/ T,??-?? H.t•? /pr:rr Fr./. •rr 4. y / t/ ,'., ... .. ^ a??:N Y-J N+ TN/_'Ir S4?C. ?,rG r' Jtr .r.'f. s • 1s" ..,sFF '7r+r T/'r.L:.'•. i'rn7ir.Jr 6 r TNi' fnAl. .??,j! ?'' ' NAME, ADDRESS BINJURIES OF PERSONS INVOLVED A CODES 1 - Z 3 4 5 6 I - ;"SI sLr t '"` swn a OCCUPANTS/ WITNESSES a9 ADDiIIiPiu NAMfsI ur Ace rArus """ N' ,:' HsIR exer NAME EI`4 ADD,.- r !y /• u9E a /: E NI nr. AM. fl W' p "' . ? NS ? it3Ly 'r A Au I.O it }( ? G. ; `' ,I ?y ArxwEx NAIUR a R MgrEDr9 o p;°Kl p^, , rl pl:e NE AM. NWI . k ,I%vEUS AI:°i°' sFf.ne. ?AMn p^I,:n.pp".:?t, n f E f •rI51..wr N,Gfy,NINSNAMI <PANr 9ApGl p4 AGNrCr 'Im <ID S.AICNED EUKi AvPINU OAritlelPO<I UArI S b" N'y IF IY'T' I r'? a 1 rEU ,.PRS x r' :/. •Y ?r IMP F V 1 i ?}v 'r h p "^+q'rI F , ?d Y t ! ri, - 1 1 p rel. '>F 7c (? ,?' )A' a :" ' 2 s l I 'rP. ?1•? 1 a '# I P + 1 s? 7y ? P/s I 1'S%h11y'„ yT vN ':!F I y{.., f??Ir l 1y i ?' •?? ll t S(xPiRp.,3 ??i W +. rg, J t f f ?' j' u Vfr? 4, A -w. KO r; ? L 4 MIL11 7'- STATE OF WABF' GTON IRAGf POLICE TRAFFIC COLLI516A REPORT No IpI TRAFFICWAV - uM.Ix ,y,PRIVATE WAY fp 2.r rR vn R un .I ?u w IInE ].oONOUR/? ?•.. DA L 1 I IRE =7;, H- / 9n R s / / o QUP° X 1,; ¢Al QN QE U IN CIITOR tDVM NNAEONO.Of SIMFIOR MGNW.Y CL5 2 ROUT WITS s Qw QDE cc C. ,Z ON i _ ?::. ZOfl 1 IN 45ECfING KITH STRf TOAD NONINiFR5FC11DN PRfEI. MRIIpSr?l _ J$? ,1 /L BETWEEN SIREEI3 SIREEI u..'.1 S1AN 6 RFf ,CROSSSIRFfI rvFARESIMIIf N E ACCIDENT icy MlfS 5 w - ?1 - EfFI Or MILEAGE Cox - ,.bYfy COl SKIN iNVQV[D. ry0,"1lfD ?ivllUGf ?NIi69UN It. ?4e -L NO. Y?NO.INNRFD .? EHIU CIL$,; SROSSSiREf,0110M9 IJ]I ?f% (Y VENIClfS I-ERIY DAMAGE ONLY ?PfSEIA'E. ?VEM<If 3 + ' y(? 7 iil` R./.•. OBIFRSDIIK.INAME Of OBllC151RUCR ANDOWNfR's NPMEI fslD AG SR[CIMCODRIDq O r S S UNITNO.1 / g SS.... WEIrs NAWf: usr'. N s UNI7NO4•.--0 VEHICIE a 'aQ'DA ]. Q PEDALCYCLIST P "roR'??'S ? D9WfR'SNAMF: fAS ia. :'+''' m9Efr Va C. or17b - ,?s7'F'R RE. _ So tC'Fi?J Pa,N-P TzF? /6 Ir s.1E zlvcODE vNDrvfNO, V O N _ - 4a TaWNSENIo /oS R Pa.dT TivxS?Vb "-oH . "a L NEPS UCENSE VAIf v I. ND. AIE % D.if IRIN WA 3 25Y o8 v -q F y ?3 «DDRA,IDN NRM NAmE B RNDNE N0. 3 6'S'S' ii s ns cNl fxaN, E' cuvAIIDN N¢m NAMf a vNOrvE No. Frcs wEiGNI cNr 2 R?7 Z R - Q CHECK (4 4 / S 7 Y vfNiCll ASaprMxW IIANDTNfc? Q CHECK (,l) I vfwclE ASAN rmworlf ovANDTNFR? ' % R - q CODES * J onss 3 1 vri°n°Cr CODES Do- ? 3 niiiss . ° 5 fA e i nr m- lttlwN e N n/.? iR IioN rin rCU »:r ? ..M N r Q WI ? rs R. Q 2a ? a«v tt_ ? m ND Q ?s l ? zsm ? Ka ? :;? . r.y - vFN YEA4 MAEf IDOOCf{NfV.I IDAR1NOVA) SIYU 1]D¢CONV) T 7j DOpcr GoMS`J v4N E GvG?Ao yonR 'AI" n N SIA,F 19ARERMIf NO. SfAlf H N. a¢ ry ,' Nf NT 46689 lid VENK f DfN RKnt» ~ND. c' f ID N I I yRR . S E. / 3 7'% z o, L' N 0 3: 9 , o R[WRRLDOWrfR: IASt IT DDIf RrgM NO. R: WI f19it I f ??? -?rv.+. WNC M N M 0 C :x W D LIN At A'z,/ L. R° «?`DA.F¢ / v Av Col ' / o wT Ro m °RTTow ENO ; d J NVAfIADD¢t130f Drill¢AN4CO. ORAGEM m WR WID xIA m„; cNARa wD;bN? ,AMAGE'ZIA i .WAYRY•• - .RM, y > •'Sy„ I, -• Y _. .. f d?n , ?, 4111A AWAt ?0NOF COLLISI O: W Ilne slxvRMfvDAI eDIAGRAMOPCOUISION: ExE1ll NfeessA¢YI ' Idiorio?•' n It Ie NORrN DESCRIPTI ? ?? ? n',: j e , i _? , I vcH%, I?.o / ?%`AS .SlowiNG T.o T? F ?+lody .Q RA ?. I ;...CFf'T o..vTc /-/E??.Op 3TR?c^E')* FK.anR .N ? . ?? s?LyiGG ?'" N02 v4 Nr..13?vNO.eN ? ' ;` RWaa d?IV, i!F VeEH/, xp / TLARH /Nor or rl., ? ,- y ?; T1r2, D l?R4X AHD -s -k-^ v'fH, It J, CAME -r* -po ?!6r!L'..5..!h! a,. W- Pik A NAME, A D ESS 81NJURIESOF PERSONS INVOLVED * CODES 1 - 2 4 S 6 `- OCCUPANTS /WITNESSES in:m fnawr?Ee.M?iii U. AGE ?A, ' "A ,' Resin. fxa NAme: f.. w. l iil1? fi ADanss tuE ar Y. une, CAI Q-I . QH7 ?it477 HAT. °!or SI,Y_o?Y.rD r¢ nAme n..A.l»... nr_n nyDl. e "R4.dW,rk _ ,Yd#: 'd a ?? viamra uw ??45 IYU. N REPORT ? TRAjFIC\;;Y ;1 POLICE TRAFFIC COLLI TF-? --f . Kt CO.wIwIN > PRIVATE WAY ua t or co..; .. oE a roum' D ? I E? Q? 16 8 ; v •rn vn A, rw f ?e t.r IUSF goo; EFFE a cwN1r / 1 cnv w. pEVggA 9u 3 ?N pt ganr Cu0-- o scour eR Nmn«.. wnRka MCl[35 . ss pW O OF tllA(..1? ON Od ,9focR VO•o NoraNrfgkoloN rclns ROUTE ORS 9J?Oi !'l' r cT 1 g BtrwF[N STR[tr 6 STV[(1 pf ;% E of 9os m L? T / ?_ / afN D51•NCE4D9l?Il[SlRON VN f.Ceo555TVtf OR NEAefSTmbf ACCIDENT AM pAIA 4 M1P DA S f !I[r w qE MCIL CO,USpNINVgvID kvF V;;.. Y;W .i? l0 [Ill[D NO INNgfO?? ?SP;,IAGf ?NIrA VUN " i %.9D I CTI r9EF109 RJnDOR VEEIq[r.? 5 r 9 . ? IOTA, NO ff-- d VinlClfS I vWRRTVDAmAGFONIr ?9iwlrfD -lclt v` 02,1[1 SrvUC.INaf r RCT SrvUt[N;D OWNEeS NAm[I DM AGI ;Ntf9 Cf5 CgO 551v[fiOR /qO?%/Df •.'[ C SRCW COWNGUE C 5 5 UNIT NO.I UNITN0.2 Dv W19's NaM! UST NvSr mI q 41vfR'S NAmf VEHICLE ?F DESTRIAN [I PEDALCYCLIST S, 9 P' S S m/ 7-11 ?O N S mI Dlf JC T ?? 6 sERfNADDRESS Po• arm 6 ?///? d EI _ G rlP COOL noNE NO D / z /?ADt?rX 33 o E Der 'S ?C! k O TAi! E% DA Eby R R I RC D R- S7 sr/ CvA f38 P1-S& ?i ?S?D/yE F ? ? RS..... NO / S[+I art q Blarn ZR M 2 77 N mf SP»oNf No vf f WTI rAIC E 27 a P «CURA,r a ? E " Q? gS D R no"I NO t ES w (JKI U?? SG C DG Xj ?i7 D p CHECK (?) vlwc ovEf or•vo Nr te` CK(?) mm or• N u? CODES' 7. ?i N ? ? • 5 r N e CODES' a,' .;; - u- ?r> E ; IS+ r w ? . ? t:R mA[t IDOOGI:«fv s. L KK moD ? *1- 0 ? + 'S?v;l Or v ,v ? y4 ? . ? p i o 7' 4 4'77 0v , l)OR [ E v rvOVA Ga6 a+k3 t,; 13ts[? t l NE 77 s.n ,9 IR Hart NO sE•n A - - H I C - c. N a N CrJ,? 0 7095 ; E o s r 111'R 28.1 71 e WHIClf,OfNTINCArgN ND vtnlGlllq NDN EI N :? ,f?:l FIli6!9 ?i?1y 9fG;s fDOwNfR USI IIRSr MIDDI[ R NEN L F t 0 !23:XFD;zS41:-2 ;3! 9G,Sn O S Ly KJaef,r O W f0 wNER /'ASr NRST MIDt%f aj sN {.L(fCLCa C.A? ? NO. - 1? ADDMSS OEOWi.E. N E A R Eq f RT 11s-JJJ G 2 NAMf5ADD9fS5 d;N5UV.wCf CO OR AGINI 41 /VE' R iG(! ({, loYST ti P. .._r - D..macE e250 C2 y g•/aACrDM u r'iw(iOwN ICJ [. A9Gf -.?oyy CN DI / °q.w::" IvtmnmED ;" ?Rlmawr0 ! .d:'arioJ S?aO DUnAC? r6 L-I ::'... Jls WAIby ?Aw:tDB. ?:wv .1l 10 DIAGRAM OF COLl1510N E rNi[?yy ?Rxl, ICI el+ivlapW r" DESCR I PT ION OF COL L 151 ON lull suvntmfNt•?S..fN lr Nkcfss%9.1 1 ?q - ,- :... ?: .?" .SEE .S4Pjo?d'il1fN?•cc ?tHr>?T i NAME, ADDRESS & INJURIES OF PERSONS INVOLVED r 'CODES I - 2 3 4 5 6 OCCUPANTS/ WITNESSES 'ur sCw.u+rnn•I S•a! I urq,a Namrs ' ? sl. o}I qtv Inc, r mf tl?E/?PT? Ar?Y?x/.vim' G. / ! yr _ •+ ?C':ti' ? " . ?: ? -- r s ,oTSCe ?, '* ,.. - ?"T - uFanur?yvln a?,%;gs.rar' T*•• rlt lmel;rcBtO'ry?gT+al°'F' aW7'PiILI.h+,? I<` " in!} I?gl?k f I v'nl 1 'A„ ?+ Lin .y 1-? 1 ?w6?Iie w;crt - Y r }~ Ali ? II 7 ? ? { ? i I YI *Cf - { ?;? u rl 1 , ?? y t ' Y ?? y 4 ui•?? I L. 4 ? {y r, Tti•f ?E L lW ? YRMv?? ,B .n q5 L.S'e .vr hsr; '?' ?,'r } ? ? `r ?' 5fik ? ?? ?? yy E ffr pJ ???f? ? .?71d`7l ?._Y ..?@2L'kY F55' .,fBli w- .?ffi _I4i9?59N'z?'$::'- 1 ?Ax4.-:i. "AfJ.•.rtl9N4 rA /2i, ... _. =Ir r`, a '?? STATE OF WASHINGTON ePLEM TARY POLICE TRPIFM COLLI NIREPORT .') aAi3E OF 2 x; IDENTIFICATION OF COLLISION i T, _RIIY OF COLLISION ? FATALITY ? INJURY ®PROPERTY DAMAGE ONLY CASE NO. DATE OF MO DAY YR COUNTY CITY STREET, ROAD NUMBER OR NAME - COLLISION 0,o /1,,6 /&S lOCA110N •TEFFC-72SO NAME n) ?.90L0 ?/?0t?1/ 17A??11? DRIVER NAME NAME n/ f /G vs Coll dLr oA?i B ,PESCRIPTION OF COLLISION,,.;: (USE FOR ADDITIONAL INFORMATION WHEN SPICE I$ NOT ADEOUATE ON ORIGINAL REPORT OR AS A SUPPLEMENTARY/ INFORMAL ION SHEET TO CORRECT DRIVER'S NAME, 0.CUPANf LLY_'ATION OR ANY DATA NOT ItNOWN AT THE TIME. THE ORIGINAL REPORT WAS COMPLETED.I I ACCORDING TO BOTH DRIVERS, MS SMITH HAD ENTERED THE LEFT TURN LANE ON RHODY DRIVE THEN PULLED BACK INTO THE RIGHT LANE WITHOUT LOOKING. THE TRUCK (V2) THEN HIT MS SMITH'S CAR (Vl) AT THE RIGHT FRONT FENDER. r Ps d ?*DRIVER/?EBE9fRtR}1-fyyJTE - _ - _n;: ENFORCEMENi./)CTION SOBRIETY • HAD BEEN DRINKING (CH.) "CHARGE '- .`CITATION NO. ?uurr x or noon wuun.. . AICOROI Nor IE1rAluD .?n/?Tiy? SH/LAE .4.vv A/o Ua/ d a/2r c.'c. Goo6 g?f/ ? ? ? a L a } v. ti id; DIAGRAM OVICOLLISION, DRAW DIAGRAM OF COLLISION SCENE IN REASONABLE PROPORTIONS PROPERLY IDENTIFY VEHICLES AND HIGHWAYS SHOW SKID MARItS AND OTHER MEASUREMENTS, ?? 1 RNony k?Kiv? A /GnFr.l?? BADGE rNJ AiI NC Y?? UNIT pISI "' Y U# W Rt PORT 4 r , sx+•??:?:; »N-ra _ .:`._ ?_srS?.?.., .r`_. .._ akw +],?? _. F;; yy :???.lui rL4.__1 I?W? '-:- "" O vlso lRev.Lp STATE OF WANGTON RAGE GF T No x ^ f „? J?_ h ?l Rrirrif a'* POLICE TRAFFIC COLLISI NREPORT 27RAFFICWAI - (?E MNUw PRIVATE WAV +03?©O f -' - •• ?'I .PRE F.1 P _ ImE COUNrr v0 z l ,l X19 o I r i IUS[ ].DDHOURI -C r1 18 `f S SEFG ??SV N ry " :, r INNA °A". . 1 CIIYORIOWN ?du Qf o Y-T NNF6NOaSiPFFrORwG"WAY MN 95 s ?s p ON UZ u6 r rvN45tC11NG VnIH51R[FIOR PoAD NON NIfRSFCDON 3 SZOO. YRE(D! MII[?Oy7 / G V L BErw![rv SINfFi 6 S1R([I Z .SG f S OrS ANCF 6D R[?ONrPoMRNfR! 4Ga551REf10R NfARfSIMIIf PoS ACCIDENT pAA N S 5 f C rtfl p( MILEAGE CODE CIXl15gN NVIXVEO 5[veRiY uUS IOIAL NO NO Nllfp_NO1,UR(D? ?S°RLAGE ?Ht64Urv wNRH DIIFR CI.S OROSSS R 4Mp p v. c- 0 FPonR1Y -AGE -Y ?FIIRyAI[O ?Vfcrrvf (]. ORRCr StR C I.?f ?` U N INAML Of d,FCI St4UC«ANp OWrv[RSNAMF) FSI.DN.SAGf SltCVl N°ylfj - ?,FI - .._''..- -.:.:.UNIT ,N0.1 D VEHIlZE45p: ?FEDESTRIANBp.PEDALCYCl15L_ 5 dW(4'S NAM[ USr 51MI " ' ?'• p : DR fR S NAMf: IASI r k i -Fc9(e Y- a i J MG i req - L LhAl vE SIR[EI ADORED 3; RER ADOR(53 ; ? Y -U, GOOF _f IT . • . A IaE7LO Y A 96 33 -- ?? 8 oc w 3 m suu srA 7? 7 . F?rF ' wry /?1 ; IYP. 7 ?Z(o153 ry C Cp73? E A A, .,R'. mD't?Y IY 1 Q e, b:CUFA1gN RM NAMf 6FIrONE NO. EYES IGNr HIGNI ,S. DUFA rON FIRM NM1fa F1gNC NO. (Yf5 IGHI HIGH r i sCUO _A T 4 ft?c7 ET iR6 &EE fi (aDO CHECK I?) 1 nH-A A. 11 FiY?Y[F OF.NOiH[n.? .. ? CHECK (F? iAI m vfHKIE AN FMIiorna ANOiHI a iv ncrrv. 1°RCrc CODES ll " ] ar . i s ! e v f` + CODE "' R « `R i 1 . ° „ S ? . fa rDRC.w a .. °inM N s DN N Y 7 Z IN,ua«S u vF RI @f°::f DM ? AMe l 11=1 ? c" :- ? Ka ? a? x KKyor.DM f 1 en _ . - r Nn r H rxnM,Ci ? Kf ? • ?M«« ?lii H ueH raR MA[E IDOOGf{HFV.I F""ARI-NpVAi SrY,It]nR. GNV H . 1 V.I MOOfI IDM . AI / f9[?I J ? , ? C N cv -7 i u? o ?-?'D i- ' « l 1 n A A H SrA1f RAEERMifNO SIAM H YE c ?j RN u 2L WA t L,IJNnr_- ED wA C- vfHlcll roefn«rurroN NO. DFN I r A L Y !? . I I 414-11 1 1 1 1 I O O S { I nGSRR(DOWN[4 USi 41 MIDDY FNpNf NO. ?, I D VM USSi 11951 IDDIf FoR? y? „J;(_cz5: . {?iGU(i?lN x AoDRessaDww4 Pt NAMI aADDe[ssa I rNSUfANCI CO dADwr DAMAOf MlA 1 SkC..r { 07 _J fM CHARCiJ CuEI) UL? CHA4Gf Alo, ?? ;,I LAMAGI :ono'+ iww? r ? Tu "L4 S C7a._7 lRMY°ev - yuJ W f ff DIAGRAM OF COLLISION: I u r ev:of4tff DESCkIP110N OF COLLISION: If6e sIA•nEM[Nru SHENr HCeiuerl 35 OBE 1?N ! r _ - _ Est ce F .o le?_S e12rsJn?aY_._?vi. f V µ F5..4£_rW D .[I.!V.Lf Tl? . c .si /? F1CL?r(_ d??1.V.>?s_ f;;: - -- •- -_- .4_..... a. _ _. L. 11C (1 e.- I K n?E- ?}T'T?M(JA4D _ r , I ' f j -1 f ? NAME, ADDRESS 8 INJURIES OF PERSO NS INVOLVED CODE S 1 - Z 3 4 S 6 wu s OCCUPANTS/ WITNESSES rd A vnfMfNlu sH DplgffNN ,. ft f Ne AGI alas '"M" U' tl r Yl SIV InU 1 NAw .-.STk-Pd6.v /?'- DAM ... :Rp 3a:51- 3;'Ir 2 na Arp4Ea AM r r e ?m- O "' n. l" rn"v No .DDnss AMl NRUf d ?Manpr.oM ?AMe ?.. O D.R. ? ? ? :: No Af«W .... ... __. .. ._..... ._ ... Y NAI ,d [rvf aY Owe p?lr O.^.:nF OHS ?r::?,M as a l.a NAw aeAr.F eADwd A(:ErvcY /K D Er«D fart ASF? ?l?f«foFr own X C '°i° WSP ? , 1 Z l 5 k i? a awe n143/', r m yPvE ?.p r. r ,r 'STATE OF WASHINGTON a ' • O "' r "° ' ,l ,; r ? ::MOSO VEHICLE COLLISION REPOR 9 p AM s wfo H ;R ` V^ 1 IF ? ?. G .TOWN race t In IDL 11T ES. ?N ® ?': CTTY. TONN /?//{//?}- AWLL.?J na/rJRralenrRErwOS BE6TID11 1 ACDOfNfJS J O. "o ©® OF I rrMOd ?q? OfLIjYL1WAY ME7 0[NOVDTH. OR ROAD HIErEY F-0;?.• YIEPOJT .?. a N0NINTERSECTI0N-ATQNOFG]W910N '{±f?YM MDRAM PATH I'?-; , BETWEEN STREET ANO STREET - • En E,w a an%uO.ocaosEM.u.froSi oA nfNisvwauHW.w.. "` ? ®© rz?m??OR Z HaD rn9men,ar? Fr.E+% ? ' .1/? h o © F111 ® J.F N . A ,: tVF :CIE BKtC "ERIYMfE1 ,,..'.t 'ld I .t?.F aH" } .?? ? S KK J II LE .. .. ' ?r.r m °E ? OF VEw[ cuLUSaN ? wa[rEOES'w.w ? oBlCtr,IJIYICI[4 aoa4crarNwn :. ,":OMMF710TD9lHl'T8 ADDIEea _. M © :pJp i1 alMftQADlYA%v..PEEr e r ?' IXUYEP9LIST NAME' f61ST NAME IADPLE Mou ArI M4aE wWLVEO Da 5. , uuuuuu??? ® ..'.. LAST NAM ra18T ?•..? J0' mm OWVFJi3 m :.::.. , .. :':{, Iq.AItla80%TrO;.' .. Eqa vA STFtWTAa1RE9B .. 4". !!! ? 70 OCCUPATION... CRr'.`..,. ::STATE . _'L?eTAb. OCCUpATXN, f CITY ,41,, ke•':.ti.:SfATE- ,v MCODE DWVERS- ? 6 L ouJ /, rd , ?3:c5 A/ . pnryER9UCEN.9ENUYBER• - ... STATE SEX GATE OF BRRM .AGE DF!I'M CENSENUMBER .:. "- SPATE DATIE BWIW AGE ii s M?, a 70 WAM`% z 0Aipm ASR YLE MODELINOV AARTI BOGY ST?{YL,Er I?ZORI t vE/IX%E R. MAI(EIU?BODY 91 1?' e F I? V J ? ATIF Y NDa H A STATE NO.BTA ENSE PUTE HO.. ?I.; TRAAERPLATE Np..STA k Y IDLE IDENTIFDAiION ?: Ileee MOOELEa NEW'ENI ER IMa.EACEI WIOATIONNO.?.':'•. Ommc*ELSANEVIERi OODMETEP IMAEAOEI VD E j? pVIC ? 1 _? .• EDOWNER 'F41SI?ENNEEL;:T%: -:. LIRNER9UCENSE tq. :RE619?DONNEA :.:M1A9TFaWTMDOLE NAMEI OFNVFRSl1CENSE NO. ., flECJS "fDX:C::.:12T11F€L6NC.K149RATD:: ... :..?gtTbQF9IRTN.). GIYIIENB -'a OF VE) EOAMAOEp:.: farn.rzr cae WAS THERE AU LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- CO vERRAGEWE TOMOBILE UADUTY-AHCE FFECTFOR-SADGOENT(WY0WC1AR ?YES DNO NMAEOF1NPl[fYRdU ANCE COaWANY a Aro OFUASIVTY ftl CI HOLDER. ` '' I E W 13? ?,kfT" E AOMF30lY . ,.;, :.: ? . -. ...r.:SPTAR.uroM)')1ti..).•... T4?,.'I,.AlMbIIYP000Y .v ;: : 1 V?::,......: f O,T,!ti (!r9tfii?+dc .:v%i !t!5.:'„e..... :4.:.:94- ; A,IOt4DR! v,M i N1b: ... , .,P?719'aw^F9.".t: ,%nw "oE _ _ ? _ i rt. M,E YOrAL NAME \ - _ ,, eLAw[o _.. , I ^ DOR[ 4 SEX n HroA1°i[AaaEl ?? r,J m me c,w 1 NAMtSKS? ? ® ? 00C I%M ®Eu r WpaAlEO N$I •: TDST THAT MAIMcW eAn%IED ,<?y MA ?II?NTMPLtb Toru?ua ' :: F•y -$TAT u} :tY.v[n WVEHIQE w O rIWVEHICLF. ? SEHIrt IMHDaI t 'DAD I I ?. YLR ? MLLED %wP[1 iuwon a`P,`Nw [ICl ? /.SGf OrCI J? ?r<OFa .p1 E" 1 ? ? 5? e? 7 5? B? 7? w ? ?,. SIOWWRTHBr ARFXIWWCWCLE DESOFDBESELMWHAT1I0/PFVA_P;IWERT0 TENIGLE9MNUMBERI' + of /?,,,4[? 4 & + epCOwIW°rHwi11°m '< ? "C WAS oAY , /J i NEDra. !'I J 4- 1VV//?/H 0P7"#y3 `°A ? I?a?w tiL vlowly ' ' , Rortr! ?n? / I A, ? 1JRN S?.qN c TJ L a y. ? d>w.w EK. K .«E ae a ww .,V fs a v,E,v w/fh 0.2 /f a,, H G: illd, # ! -r.iy y -+D Cl+- ,.?u„h?R????<Fr7D??r ,d ?,rt?v ?s'2.#?sLtX d ire f c o D?n Y 4c Ne.v ?, ,?6 t 2, O ' "ALtal 17 oFr'? ..,,.....w.. Lv 1 w F v..c A.paow., WVC9TIGAIEDOY- .°? aNL ..ArAt u LcEeoxls..D .n s E ICLES OSITIONSBEFORECOLLISION MO ? :IaI. ? ol'cf. E N s E W ON 91 nE[T MIw:H Ar NAME 011 NO ` I ` FO L., Aw. M `? ? ? Z ?rN .Yen dI 1IC ), ? ®t D D j . , a l a1 1" /LY ' o.iDH Ak <,, 1 0 D D 0- [] 0 20 DI.AI '®Q D 1w. 3 D D ?.. a - DIRECTION. TD OMECYION '1nlou . ... , , . ... ALIy 0 nr LX zD WM.x'AY iO&l Xtn .Q a?r"w?W'a?v'ilor a oiHER Lsi1 M arwAYwUl19..0 IQ - IpKao TnE01AOAD plaKi{r)LarAE AGf1014 77 8811 Ai1411 Lla[TcONaTIOHS TIWRCCONTROL ' - ' . . . ,4.; n0AD"FAOE, ,L? HI.LII A;Ilcx oNC a.dYI KwIo- IWW .Ewa wwE ?Da?1 1 Q OOaX]9Tn/JOllr N1EA0 -?I KE, 1 , KK a I HO.nla,r O I D • 4a ?/1 V WAY ' w WAY ?g.z r] OVERTAXMAAOPASSNO ).,±. i ?alT r ?„y-q , D.WM SON E by , ? Q ] ?STOP W, f g MAXa40Re fT TUFW (,' ] ? T , ? YU,N..O ] Q fAl]X ? ] ? n[lD BIaF D..,j. Q b ASNAE ? ] ? ( ? l 1. ] ?Yqw l ?r00 [ ? ?4,r9'Ow Ft ? D ILAJMA FED Q . ? WI[11GI.NO/ Q . PAr 4ANW01.EfT TIl1UI .?+ nAMry 00PI AX . Q ICE a 0114A D.RN a1N[Er 1?]?? Il ?LASNA AAM[R ? e QNl[Y ? e QMHOUIUIIN aDlfYlf9gr [D] : D ` .. ,. .P[CNY) OTMP I ? A Q r{oW a a D MCWY a Q DART N° alta C] e? Rn a .L D a? u° *3y. -', ADON IORWTSEEWODANOfII r?Oy',1[I.", ? ) ?Olrt[n,IIAOM.N LANES ? r ? SIaTT[O rm TMrrD 1A r eLU%a wr +9e .clAwe Uc I ? e ? OT14 n. TECN'I Q 1 Q MrMA1f0 ? a C) 81 lfl on AT 91ONAL Q, 0a 0 ? e? STaMRD W ROADWAY ?wTwrD by f 1,Yn alr?rM a(? t-, _r.t, t E t? F I 77 :- i i ? ? ' ?Mlww+l r-77111 r4% w A '_`'L? ASHINGTON F W ^" ' NO B VEHICLE COLLISION REPO ` EDF COLUSN]N .rt DAY L Ny u[ sun erox LISON '.-LIME OFOOLLlS Ax?'E (OSN AY Mw+ U IH SAT . n C({W T?HO Vp? ^I Qx+uu. V s / /A/ b / PAT t .. ';?.` 1' fil- oyM COWrr na .T roui sAnr A E MLLES ..©Q - ..: o"' To" O ADL{SLO F?PE//LY/I r?WllifR'llKlr'E r ," rv M F "-MERSECTNO-STREET Ofl ROAD. GIVE NAMEOF STREET, ROADORHIGIIWAY PREFl% CQtW 27- r'C ADD NON NTEflS:CTIONLOLATgN OF COW N I S:TWEEN STREET AHO STREET h 1 7j T4'4' 'a rwr ®Q nuxo""o?cn'orsaw.rrEaniirro'"sron winirv`'r"wuww.x. n. weme nrE L •:. 0 ?i :? ?? all-LIT-LE ?vUrc l-CIE ?0RER-EI caL wn nvDLVE • 4 ID,Alx6 ?vEr.cY DwECr ?vR.cLE.IR.w D YEKLE, . la .?YExpILPE?,1R ?MNrDIINDx ??1WN M"}. f rEnEne ' ` • F ? oaEC?srmcN nmEnsrnucxl wT?En oaEC ewo Eas lti rya .. _ .,,.. tpn 1 p? ro l ©LE TMl . . a ANmeer AY• t°t ,ti a-Q1t•? C FEET EDDE P E E ; '? FNSt NAME 4pDLE RS LAST NAM f rt « /"? De A T CARS ? vavED ?D oR ORMRSIAn HAY FAST NAME ?:_.. MDOEE An/ Le s7ek ?e o ± REETADORESS ROUTEND.ANDBOI(NO.w.:, •.' '.' P, AT sort EETADDHESS _1, t ROUTE NO.AHDSO%NO. ,.' L -. ?F, ?? 7_A STATE 2A000E LnVE OCCUPATION E-AlE CRY STATE LP CODE UPATgN' I. I! ? . G . a T li vc4 / cL?v.9i3?s 1f , c tL tv?rs?l 9sa ;4? E ORR,ERs L,CE-.-SER STATE 9E% DAT[OP Srrrll :. AOE OANEIISIICEHDENUMEER STATE TEOFSRM AGE '? tL Om flA7 'S D G 4 % 3 br ie' /! A R dle M E D.Y rEM P g WE `MLEWL I. CHEY-DODDEI YO ° DEL I-OVA OOOY HfVLEa D R.I ;. VENICLEYR M,VEEICNEV: 1 I ? 3 AIO ADARn G0-STYLE12OR1 - r - A ' i rye- /97 ST ; TRNLER"TENO. STATE STATE T ERVLATE NO. LICEHSEPLATENO. • STATE LICENSED TENO. J I Z / Tta VEH IDEPI-AT 1N0. IIDSSMOOELSSNEWERI OOO4EEFA IYILEACE) ICIE IOENtIFICA ... IISSSMOOELSSNEWFAI"= ETER IM0.EAOE r,.yr r' q -: R' Cr L N2d? s9%7e7? DDS .' - REaSTE OWNER IAAST-FASTMIDDLZAL-E1 DRIVE LICENSE- REGISTE REOOWNER IASTf2aTaRODIE NAME) OR1WJM CENSEHO: - n ss?'o A2 ! sTe e ??e J f A L - 4 WMEfISADpREB$, 1ST T, CITY SfATEI GATECf ENfH , c e I ar ?Ew -ADDRESS TSRTEET.Cfry ANDSTATEI 3P21 Co ?v DATE LFDEIM MD .TER , U P T90F MICLE DAY EO ._/ ? SNR?[P nD?... PMRSOF VEHICLE OAYMEO .. .... •. .-. - roRn nDUY?iCriE ?% - a- , WAS THERE AU LARRY INSUNCE INFORMATION-VEHICLE NO. I- COVERADE N E TOMOSLE UASUTY INSURANCE FFECT FOR THIS ACCIDENT ON YOUR CAA YES C3 NO ' snT . , .:. WME OFUADRI}T NSURANCE fAMPANY. - ..;:•. .. NAMe NIDADORESS OF UA9UEY POLICr HOLDER ?, t?•<E; .. STATE <; T I Se`a't' •, :iii N - E pAOa1ESSOFUAOaRY AGENT ...aTY ',:; STATE x? I.. ;?.YABWCY PoUCYNwmn :.: D w I A- A IqB? 2NDYAAAY: y11a(7E>•.WiPRUOR,lDRAOdrOHALwA%481 'AGE ! r AAAE ? te.. A wou, D ? ®r J L " , w° G OR [aE] -TW .? APDDrOR. TAIUSOf NAAEO x ? AIAA% FAST OFIE TIIAT AFTUE _ S STATUSOFLWURED MAR%fASi ONE iHATAPRIEB :. ? { •Y? t S NVEHICIF o M, kF NVENICLE Y 1 T A pG ? pLLEO ? ,LEAix 5?I u my 5? I??DOM 7QEia 0 AyyEµ ??D,,., TOLLED ? I,EV[MI IArfr014 5? e? 7 ?ei 4 x?qq.. ?e s1owNOnrH er AnROwwcwuE I ' °e°??.'gE eEwytY^u..)'dv'P?uI[o-lrrcEERTO Vewpga47M4M?' ?',?? ?co1 1 . • YAMfHAMfM91?? . a1O? AM[a a ' r N?YIY[R IACH HrSt[ AM MrDY. ...? /?•'.. ?I - PntCrtlxdrl4H.Rr ANUW ??? ^ •f/ _?? -f!I? o? ? i ?k •,?. ,-rte QF' ?E,wI1 .r, ??U .----- ? w Kti'ln?iElt66dey ? ? ??_ w*t q Owl I VEHICLES POSITIONS BEFORE COLLISION a .E.r cr?ua vlKU RrMINDWAa PNESTIOATEDDn[ rZ f wT cal unNAY rM.eO vrKU OCCwAD R 11 YSHCLE N S E ON SIPf Lr eEGNWAY OII f10 ?PA11ML ?POUDf r - b I AAA o ®? ow rr r ,L?.,I o 0 0 o 610 DParKf ®o A. V ??, y?i W pr•xxr ? ® ? ? v ? ® ? ? ? ? ?,rxwr rYR' - nn, xWR ? ? ? ? ao D cRD.Yn NIoY DIRECTION To DIRECTIONd IE ?F, N K W'SiRAN WAS USM 1?YDEwN% 2O-WAY aEl- A A0 my 50 cwixrwi?wiav S?OTHER ROAD SIAFK[ MEMK. L,0,110a1aIICN3 11WII000MTigI IM<%WI WPC WROM wy 0111YLAlVEr1ICLP AGTgN3 pr•ICx WI NMI "ZROW ECx urE vEK.r rcC-raEwlEl r11 v1 K1E A..^A v0 r M , i I Ef??11 xOryA,,, I ? `BEM l (K DAII<.l 1 ? Nd:KS ?r 1 ? fNE WAY ?r I ? OOIHDSTR40r1TMfAO TAI I1&- P?nANN6 J?DAWN ? 2 ?ST-SON 6Q 2 ?IVIO wAv ? a ® ownTA%PIOMOPASSND ? 2 ? WE f J ? 4ADAle1f1 ] ? DU1x ? ] ? YULD S%W ? ] ? Mof ? ] ? M%NOM I URN O ? O ?1-0`O A ?Too A ? °c: rsRa LI ? A ? FLA4AYAD wD ? S A ? WIPCHANOE R1 A ? MA%R1o LEFT ILAN A ?lu E olxn DAnA RIw FI RDOPlnAMP) ? S OI1YR ? InPICVYI ? L0. 51 FF o , o RAYIM AuDln o o ALLOY ? S C) MARNGU TUM t rV.O WAV ?y l Y?r 1F r` •• 1F /- r 1 AIPyA 3 ?y dx ,. ? S ? RI'f CrIY KMOEIfORN016EEN0 DANOlR pwvCanRVl,aN ry,1RK,aM IrLr R ? SIwF? IKIrIS Or MN r o Wl Glr ? • ? NI B1611A1 E DFFICER;ILADYMI ? ? ? S ? or,4., Y`ECVY ? x ? l[Ir TURN X16 ? I ? SEPARATED ? A ? SLOVArID I SIOPPro FOR TRAFFIC ? ?Sj0 oAT SIGNAL ? E ? OR STOP SON I ±? I ''I ? } ! I ,'e Y e 110 IRNFIf ? 2 ?DMOEO - ? E ? 8r01ro[DN ROADWAY r i .II / k i " E _ , (}7 ? E 4 `SS . ? ' ?Ii f I ?IMaM)1f1 I 1 ? ID ?MAIM AHr u? 1 yy a• _ 'I,Tj;,pa-•' 'r4,C==r "gIWAx ?, II, ,,^ _ E y , p^ " ?:^:Pitr. %Ka ort. r ;I . , MGjDM.trs37177177.,-, R E II .. , POLICE TRAFFIC CO AN LION REPORT ® JRAF61CW ??? "? •? ,T ^ 7 . PRIVATE YlAY D ` 10„Cf Cnv°,,. Nr NV.ABF9• ,1> T ? • ? _?? Y ?C p300 CODNrr N? (rv NO rNr,. Ne4A.r ? t,- ,?] Q ? `, • 'r? • ?.? ] ' rp us n « c , ,ro°s au c ON F I T I N t'tl ,Tr i I cal ` y.?`/7G ' S 20 I • ? wr?]' n L? r /Itf ACf c COOL '. ?- C- .• c I. ^T I Ll ? 'IN NNns' cu ccoiisr4iirocvoo:o w•DOU UfrFUrNCi ? ?oJ r ca„t s I,.. °wc u.• s v.n•.I - _ s ,•, r 5 Y ?%R /G/ snu•r comlvu ust = > UNITNO. I _ , ,? ` .., UNITN0.2 e r VEHICLE ? ? PEDESTRIAN ? PEDAICYCLIST , acv ,e s ur r, At n°rss -? ,fesnavsl NO . a. • R un .mn ,e<aof -m NO , , c e". I ..fasvamsl ,+o sur e xc,.r.nc «NnM ..?nF o n,- .o.N, N, ?`• !S?' ! E R xal°AOw• N-1 I .oNF NO r.fs +. .rt ?cN, G CHECK (v)+?_r_ i . ? CHECK I?I NODES ?' 14 S ~ a N n CODES' xocl of ? °.... ? s.. r.v ? • •f^° Y ? < .. ? . ? H r ' E F.<?rv ot, D u, o,n .r , c N.. ?° ~'a J e (U•,e r°,A,FNC flow y? a•,F._ •,F Gc? H C v N A N , ° . A rN<. All ':3 eFN¢rr,orvl,c.r ONNO --12 ? °I@]R°tD ° L 11 . ,, aN N OVmf UY nq, MIDDtI A NO O e 15 rfvFDOVmfu l•sr rie5r v.i uorc w rro ' J ADD°F]]p O'rvNfe W • DF e pOw'NIe JI z N 3 ANI IS•p wu•°•Np CO 1A-111 E D•M:cID:° "• R INu•N a aD S , ? w.FrD e ? i.v°nr S DIAGRAM OE COUISION. s„fr?• =_ _ _ ••'IN'N ? DESCRIPTIONOFCOLU/"'ION'. us rr,fM.fN+•, swt^r fcf;s•°. r + ` ,C.OtT- C'aor?oc o Ill,, WhEA URIJnJ? L4sFT DAT'R? AIRf??J?FF?d ?Qoh --_ • -•`J D12 o )??c ?S , c aR CrEd e?3ual v£sh. -7aTd' - ???fe. lu?r-o N, baL?a, , - Po?F Rd eu 5, 5. TiPr9'i-F?c.ls?J' r Sc,ld ?h?u , ! gs q 5. ?0•j-rG evl.9 c', 00 ?? ?i77ouCdg2 AI.kL P cy ?'idr Nrh +?acc?d ou ` w ?rY u , rz NAME. ADDRESS 8 INJURIES OF PERSONS I " ' NVOLVED • CODES ' - 2 3 4 5 6 OCCUPANTS: WITNESSES ' •. s"" °!;c '' ` rf;•r I nu ? -r r nv,. e T_ C . 7 s2 7 r ° ?'?G'7? C ref,. 4??t" S rr r I ? ?' ?. mrd• ! ? ?,? a ??? e a ! T 4 ? L4 s t Ia nt r; t? "? ? ? , ?r ` ? E t 1 J ? c6 J ? ? ???u. T s I?r ?t } ?_ 1 [l 1?4 J r > F A Y ? ?jt r 1' r' + r ? I •? v ? s I, i^ r 'I t ' 7 f ?^ U M exmg,r :,:, t%A r ? nt 'p . Eli C #/ POLICE TRAFFIC COLLISION REPORT :N TRAFFICWAV I-"Cf COMRAINT NUNefR -) PRIVATE WAY ?A 7 ' 'J<II Gr CU.I SiON tVzo9 O.I UN X "' ' Sf ]"U+:.p OYro CJ', r.+• S COUNTY NO G CIrv NO. F < Nw4AN A a .? C +r pc lUwr; a El Z µ o? ° N /o?IL ON ,?/? ! 2d ICl ClS aW][04 Ia[[ 3 9sz>D ' SFC u ? Nr[Rwo LC wr» spff ,I wAD .... el, w'tdI IT411' S fnr. Eo MIII-1 ? IA.C, r[p .I <prs'. ;•af"':p NtARt;•N,r i... IS fr'I AcC'Di Ni . L CE p p.AGawM [.<,A Itl' ? 'L CODE r efv Rlr Iu01.'ID 1 p[D? C' [ ? n:C O? -4G d a o o ; ' , i nRp Mf 514E RO<O04 aIFIftNCf CRO. SSS .. IaF[T04 RpgpR ?]? < R R I e G . ? f , , ° :, ss3o O O 9 SvyCr.INe•AI Or OBiII, S, p'X. <NDO.vNfp SN<M(, tS+CAh,4G1 5 SP[CrA1 COD NG IRC UNIT NO. I UNIT N0.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ?vrpsN ^r LAS, vw,f ,•fu s Nnml v.s+ IRS M. I E ' p[f,?IIpN?z;.L ?d asFi? /?r.?l I,r ,A'f :?4<npI ?a:n+o D S,pff, ADDafsS -' .. ? /Lb2c?? .? L,IA 9835-8 R I n -1 NI NO ?.. W ,I,CINxNG 1??? LL?8 N .,.,[ G i9 h1 8A2--? / I v „Ip.,,<II?IN,r eIA,I f Dre,p,» '< - - arw<nwl .. NAmI A prwrrt ve uls m?e»+ H E s ,.,,4AI uv M NAMt . r»nr,I N . w Nf.GN] °CHECK I?I wtiE <sarisrMn'ol < "o - IAN M ?CHECK ICI CA AS<N VIE 11.1 e:•Iq-Ill A r3. Z CODES D' a ;:; '' Q S / e :' CODES D - 1r a 5 -11. Fl ' wI CM E] 0 a?, n '?•L' v" '• , :CN 'N " ? •[ II V.I LL UA r aOVa p.CU + Ui A /21 E ••,cp I W r V r a " O D Ova . H (ZO ? C ,R C >9 CII rDty, NC<]bN 10 NO 1». 77 U? 78786 L ¢LL DFNUI CA UN N ---owNI. uv Nan Mupu n.I V_ W p I—--Nfa tAS Ims, M.ppu N » _ IL L/ <DD41zSIR N Da Sq < OwNFp ql E AMI DDelf INSUpANCI CU L%<Gf NT R' ..L<'UVrc, F'%• ?f"X-a?l$(;+-cL R N u AN N WM<GID MI. E SN DAAnAC l IN _ s ulI•N m.cl LA<nnD ow:vN 0 4[MA N.D <M< u+o ? _, _?S 4r •µ< 1 0 I.,VID A_ 4 p s .. MINA. PaDC<nN » DIAGRAM OF COLLISIONS zwnlir:¢ezs<cn e.<ppowR• DE5CRIPT ION OF COLLISION I.11I`lL-l+AI-I.I1IG55<- > e' OOA?^ Q lD L.agS 6n 5L. k1K v?9 GRnc G/GryA r?n,fa<?rp/% ?u.FL? ?Id ^•?I / /C SOU '- ? SEi 1,1 r/A'Er LXL. 'il w/6 065FC<.Y,/ £n 49r LcS /.,k vGP.fIFt..? 6Ai`tt$ LoSI.?S Co.1'eoL 6n .$Gs[1T- l:cE ?r utw CtsE R? f/Q 8 ?([L.L u 4 7?0, ° / NAME, ADDRESS 8 INJURIES OF PE ONS I NVOLVED ' CODES t - 2 3 a 5 6 OCCUPANTS/WITNESSES ';a''"'141J "' s,r„i o•.A. ;' .cr 4e,,4 tna A' Mr < vl I ? ? ' n v .,,,.. 1 1... la ..< fA . ??ir_ ? r ?I ? ? J .G ..-. rl!' !.•-.4 '7 <- 1 nv POLICE TRAFFIC COLLISION REPORT LJ TRAffICWA) ,c[cornnurvr B[A' 2 E] PRIVATE WAVE Y C. f - DAEfC tI5 DA f N rIML [O S 7 y, BS O? fun up, ruD K IwvS I, of IUSE ]4w NOUR1 UN Y COUNTY CITY NO, i1w:A URBAN .? 2 L y 1707 J efferson Ru ? A ?N ?F [? N CITY ON IDWrv eNO.O 4-110RNIGHWIV l5 RGUIF 0451 [ MtES ?s ?w ?o,ChimacE ON Rhody Dr, y, zoa Q T INIFRXCiN-TH SrPE[r -AD NON NIf4XC110N Pwil% M1. P051 u Fern Way BF rWfEN SlNfii y SIR- 7?So DISTANCE 60 Rf MI`ONfPOM N[E4tN<t CR05851RtE1OR NEAREST MRf PO51 FS 5 f fFe ? W of ACCIDENT MILEAGE CODE P DIAGRAM DAIA COLT SIONINVIXVtD XVEF rY 101M NO O%IlllD?rvO. NLU4E1 4 ?SV IIAGF ?Hre RUN ruHn oi%. / I %4D Nit4 Cl5 N CIINGS REFIO4 RCVN 094VfR[NCF LROSS51wFF0RROAD ?] CEVEN CI[5 O ?PIgIYR1Y DAMAGFONIV ?!R[I1FU 0 5EO1Ci' I Y V7 c.7.a?IJZ? ?? Z OBI[CI51eUCRINAMEOi OBL(Cr514UC%ANDOwNFR'S rvAMEI t51 UNAAG[ S SwCULL COOING Ibf ? UNITNO.I UNITNO.2 ?VEHICLE ?PEDESTRIAN ?PEDALCYCLIST. , 124 ?j Dxrvf4s NAMt vsr rwsl MIOaE D4WFR's NAME wsr IR -' n SHAFFER, MONA Corrine CARLSON, Raymond Lynn s1Rf[r ADO4tss 3628 Oak Bay Rd/ P.O. Box 67 1-1 ADD- 340 NW Monterey Dr./PO Box 116 OlY SIAIF ZIPCODf PHONF NO. D IAIE IP E cm I t Hadlock, Wa 98339 437-2749 WIVte SUCENX NO R Gleneden Beach Ore 97388 ' 2 SHAFFMC721RR SIA1f Wa F D1NIH 2D 119Y 28 I V WfR S IKfiW NO. 0311352 Af ore M% D BIRn 3 20 18 IZ OCCUNAIION MNAMf ePNONf NO. EY[5 wFIGHr HEIGHT E xcu4aloN {IRM NAMFePMN[NO, FTES WFIGNi rEIGM ^ 2 R i. ? CHECK L I Hlcif Ai aN rMnovfL uANO1"{vet El CHECK(,') nlcif ASAN UworEf xw of °fv'AL v 4 CODES ?' 13 6 4 DH 1 6 ;"' - CODES ?'I 3 F s: 6 A n "' 1 5 1 1 e v '°L• 7 ]] 2 neck and backin'uries cut on nose i O? ®• QP ?T9,6 ?w ? ' R ® O ? ? P ED n 0VON x K!' " V[n ( MANf IDODGECNtv I 77A4 FORD GrL IOA41 N0 1 if I]UR-CONV,I Granada 4dr E nvEA 4 A l nfVl MOC?IIDARrNOVAI JIIY? 1 I v83 Cadillac DeVi?le 4dr ?e n. oR l FNX wA1f sluf nER r5w1[NO. AIE H Y[n caaN L 7GIiT No.- A whi/grn IUP128 Wa I ose RF 904 Ore VEHICLE Iq NNNUIgN NO. L vfH CIF IDFNIf Uif r N .gaMR(OOWN[4: U51 NR51 MIDDY -NENO. same as driver O f 151tRLDUwrvtR: lASr n4sl mIDaE N No. same asdriver 3 ADUwssofowNER W I A v r 5 E ADURE-1N?U.- CO WAGINI NAME unknown as of writing R A N -S-Cl CO Farmers Insur. Group/Lincoln City. Ore DAXZ.DAREA I I N ow,.4:: cHAeu i ' iNAAGFD'MFA cnA4ei I oy`ID°O,",c". . 4 r31 EST. OAMAG[ ?0R ?4fMAINLD 3 ro. ?AwAY" ?4f (0 fs1. DAMAGE 14etili0? 5 55500 AYB Y Bill's Gara a ®.T.Y Bill's Garage 56000. DIAGRAM OF COLLISION: IU 1N 11-11 rvovm SIRfi II N[CFS.URY) 40W DESCRIPTION OF COLLISION; IUSFSWw[M[rviAt SHFFi If rYCF55ARYl Qy Vehicle #2 was traveling N/B on Rhody Dr. Vehicl ZL,_44 t, #1 attempted to make a left turn enfront of #2 vehcile. Collison occured just inside s/b lane. #2 vehicle attempted to swerve to the left to m8 . avoid collison. No Skids were found on scene. 3 lL NAME, ADDRESS 8 INJURIESOF PERSONS INVOLVED CODES I 2 3 4 5 6 OCCUPANTS/WITNESSES X% ADl W. ;, RL 31R[ p:-'Pauline line R. Carlson me as driver #2 Lun to head v AM e Q imy Cartmel Wa Glen Rd/PO Box 67 Pt. Townsend none Q I Q l O H h Cartmel -2114 1610 e as above Jarim lac to hea AMe n AIV.Gar,clr>NAw•eANA ert Haynes Deputy (yi0 JCSO ]40UnR5 ]4U0 n43 D%n or wrwl 5-29-85 , n 5,30 H ?s x '? Y5 M ? ffi E^5 s.., Ch 4 L Y _ d n f 1.. e J? k ? , i9 ?F ??' ??l} wjay, ?4 mw rd iii A A aL; AGE E'°_--.. DO%, Cl FIG E DEN OF EACN OgMAGEO AREA E%AM L IN S`TF{UCTIONS• ' ADE RI 2. SHADE AREA OF SEVEREST IMPALi. ; QnAW AIIHOWI51 TOSIIOW IPAL IREGTIO O DAMAGEO VEHICLE NO. 1 a BZg. N NOF F0 SFAC FFDII-ETUn"C tTC DaMACF To mMLEns Moro +crL , DAMAGED VEHICLE NO .2 t) ..rvr r ,EV C] EI+ITYOF DAMAGE : VEHICLE NO.I U SCVEHITYOFDAIIAGE 10 R' +ERV[NICLD SEVFIUTY N u.r wrn OFDMIAGE VEI+I A ISaIILING nAMGE ] [] OTNER M.V.OAMAGE >U ruN.110NALDAMAGE 4 ? ryOUAMAGE IOWEDUY IS T DAMAGE I ? "AULING "AGE ] UTEIIL V OAr.1aGE x > [] 1-1-NAL.A..IA.E 4 `JNO-1E . CLE NO G OarAAG[ J OIIv. OgMAGF IER IA. ] IJlull T1'0' . (OWED BY ST.p-AGC E TOWED O ET DAM Y gGE O f O S To f DIAGRAM OF COLLISION ?I - 1-.: 1.,- DRAW ARROW SHOWING - - owr ..Arux(s - , NORTH IN CIRCLE ,I 1 fr%UDC.N0x All, _ ... O DESCRIPTION OF 1 TE WN PRODAD LY P . 15ABIL ED HA PENED SfC. DURIND AND Al T[II THE CRASH,INCLUDE INFOnMATIONNOT ON DIAGRAM, E.G. DRIVES lTY.REO COLLISION Dlsgxn COLLISION UCEDVISI0,.1Y,PEDEm-AN CLanurvc-GR C . ONSTRUCTIONORRE PAIRWORK, ETC I - i _. L z t N 5 E I PARKED OCCUPY i n I YES 0 VEE N t 11 P ALONG ON I J wr PFUI CLIST WASUS G 15 LK 0 0 ] 0 ER 1 MA-ED E' q C L O + E g E S T K ERFO ? I RO O fl ORIADE]SURFACE C EL NEI D YEEATHEfl CHELK 1 _.CONTRIB? BEING CIRCUMSTANCES C 0 EI DR ER E IHl n OT E : R I X C I NO x 1 N - T DRY ..+ `? 0> _ > hl CLEA CL OY ( UNDER IN WE C OF - fOLLO dOyEdCAS .J-_. L ALCON04 L_ IRO - t- B G R EO IAB.. I G 1 1` O I" ST T A E 0 I R s? f' f/' WET -.. t I- 1 > I 1 N E . PC E IN' Uf EO rIBi 0 ! >L ? O UG .. __ _._ ._ NTLY A _ PASS NG I NNU f I d ,: _ .' ] C- S 0`_ .., ] I f_'OW G _ . S S ff 1 I]r?_-E EE DING q E 1 S. IMIT AL FE ,- ROPE +KIN G i" I 1 I MAKING HIGHi TURN AKIN ;4[: l G CE - • - TOG -- _ I F%C[LON E E ( 0 -- OYE I SA EC EE (.., I N L . . -I 0? TO - 0 p EC I C EO - _ URN MEET T 0' J I IB J - SI J DO OI L I ' 6G . Y - UTURN C OTHER IYECIf YI CH OTNEI115PEC C f S1() G SIT. .' gI aSSOPER __- _?V OSRF STOP - G ING SI > A NG L IT ER I.P C SIB NO OL _.. A _ I gLOWINO I, '8 I T. 1ED 1011 I l + CONDI710N5 ICNECK ONR AFFIC CONTRO 1 O ypE EN0 D E OF ROAD VEHLE IC COND ITION 9 SOBRTy I E 1C T FI y ,>VO C C N . IC ECK ONE OH MORE y'No lE I$,Y? QJJ T O E WAY If CO dlh 'fHI10131 KONEI >f ICNE IENO PAT SIGNAL B ETOPPEDBICN .. H O ' I /11 YL ONT I> ? > 1 E r_ L 1 PPF 1T .: _.` L . _ ...S GN [.1 WOWY ....;.DRAKES - - I I+BO ARI 51YAIREU . -' ING IN STRAIFiA1 - .LANE i . 1, D H ..- ... ]1 D SK ]; fl0 ..-6 N i LASIIING .B , OA0.5 BLf .:...]? B UlGlf 7 f I NT Ro IA IGF _ . !] I..O IDA IFU._ "' _ "Ar+TINM1 iROM II, ARKED POSITION l .,. OA K STRE , - f ] DEF[CT E LOOPXAM _ IE ILIG T9 IT SO SCTr ^ K 1> 1 EROINf.IfNTEHINC TIIAFf I ', ET :__..L BH OH S!. _I AM ER G ? 1 ALLEY [ W 0 N fNUNKING IC IS I DECKING on Si FET 90FF IK O g -- SG I l U Cfr+ T O A -IFIr „E 0 Ilex x1 B -T'I NIT- ?kla CHEM. TEST N - .. . I ' 1., I[E 1-11 Of IYF _... ruc a r OIV IU[U V NO DC FFUTS . rc vFN TC5I 11k'i NSFD DiN [S ISP[ 1 C FYI i YI i rMC ...., OINI?I I. Fclrvl uN.-TIT, 4 % TEST RESULTS 2 POSITION BEFOR COLLISION - VfH. NEAOED ILEP iDR ONSTHfET .11 NIGNWAY'NAMEONNO. INONEDRFCT OY l[CFIIY !O. INMEASI G DECREASING AS It Mw it . ._.. >4ro , mrD X IN 1.4 Gk)F l Auf AH-1 ING 11 I.NCV IpII NI.i. PIIOVI [ 6 NL T. A1111 11( DDBLICATCCOPYOILOCAL LAWEN FUEHCEMINI AI(ANCY?SCOPrf HIF ILB:AILICOVY: NVI-SICATIN, 5 COPY t. M i ; ar .G?E r ?a 4tiR F D DATEOFCOLUSION DAYOFCOUJSKw TIME C OUNtYNO CITY NO. FHIYA ^ O{L, 6B E At6 HQVYI T SUN I MON 2 IVLS S WE A 114P ! FV A SAT IVSE Eve Y > / UPBAN COUNTY I- URAL ?STAT[ROUTE ®COIINIY ROAD ?CITYSTREET O A OM CLS. PREFI% ROUTE OR STREET CODE ECJION 3 ?OTHER ISPECIFYI # ` ?• O ' LILY OHIWN N P REFIX EO MILE F L O N S E W ?IN ,H-1I W . OSi C 2 MILES ? ? ® ?- ER OF I IACkOGK V / NAME ANO.OFS REEiO HIGHWAY INIERSECIIN6 WITH STREETORROAD ILLS. R AMP DIAGRAM OAIA T O1tl lkN -a. - /NOi.a,v /s. vcRaA' NONINTEHSECTION FLRC.,GC'.E'.?y0. Ac=- N iER NON IN XIIO CLS INTERSECTING STREET OR ROAD UgNEf N BETWEEN .. STREET AND STq ET MLEAGE CODE . ERE.CE Ts T ETONR 5 DISTANCE AND DIRECTION FROM REFERENCE OR ECROSS.ggT1g]E N S E W N TRHNGrc• T4 TNOLAN ZS (AL A ? s G HuwnEIH PEGALCOOIN6 USE ryIMILES O NFEET ? OF NAVAL ITJST4LL.A•EZON ?. COLLISIONINVOLVED: ;]VEHICLE-VEHICLE ?VEHCLE-DICYCLE ?OTHERIWRITEI ?HITLRUN SEVERITY TOJAI HO ?VEHICLE OBJECT ?VEHICIE AT TRAIN ?SIOLEN VEHICLE NO.LCD NO INUU. ED OF VEHICLES ?VEHICLE-PEDESTRIAN ?NONCOLUSION ?HAIARDOUS MATERIAL _. . "" " ® PROPERTY DAMAGE ONLY N ? ? ORJECt STRUCK (NAME OF OBJECT STRUCK MIDOWNERS NAMEI LOCATION OF OBJECT STRUCK - EST, DAMAGE S ?ROADWAY FEET ? ? ? ? RD EDGE 5 DRIVERS NAME-UST FIRST MIDDLE DRIVER'S NAME,NGT FIRST MIDDLE IF VICVLLISI DR PEDESIRIAN CHECKI U . D R D "RT C •. S REET ADDRESS - ... . .. .. •• R •.- STREET ADONE59 - _ '. V ST({ E GTr „.: ,STATE 21P CODE PHONE NO. E CITY. SiaiE ?,,.... LP CODE .... PHONE NO a 6- ?7i ) 1) N DRIVERS LICENSE NO.. GTATE EE% BALE OF OIRM-. N , DHNEfls LICENSE NO. STA1E SEX DATE OF BIRTH O, I MO OAY Y R U• MO. DAY YR r y 0 I / , 157 le ff - - U-Al ,1 1 W 12-31 z 09 E . DRYERS CUPATION FIRM NAME . .. P :. 2 - CCU PARON o flq E PHON N N N CODES > lal IIUO Y, ( _ TAI SEAT BELT.. 151 EJECRON __(.- OU55- . - T CODES > ID INJUNr CLASS- __ ___ JI SEATBELT--_ .._ 151 EJECRON._(_ NATURED IWUWES I NJURIES FROM SCENE VEH.YEAA BY MAKEIDOOGE.CIIEV.1 TO MODELIDAHTNOVAI STYLE 12 DR-CONV.1 FROM SCEN VEH. YEAR E BY: MAKEIDODGE CHEVI TO MODEL IDAflTNOVAI STYLE 120RCONVI V -I FO RD LTD A! op. v 17 O-110VOTA At E VEH. LOL fl LTC. PLATE NO. STATE TRAILER PLATE NO. STATE E VEH.COLOR l>C. PLATE NO. STATE 1-LE11LATE NO STATE H L- WFl• H I' rRN - -1 13 C VEH CLE DE TI ICATON NUMBER OOMEIEq (,` VEHICLE IDENIIFICAIION NUMBER ,_....: ODOMETER ... . E 2 O E 2( 20 REGLNTEflEO OWNER-UST .. FIRST .. MIDDLE R EGISTERED OWNER-LAST FWST . , MIDBLE N .: 0. 519 A.5 A1301/9 .0. AFT O ? ADDRESS OF OWNER .. •...... ., -... A DDRESS OF OWNER _... .. ... .:: ?..... ', ' 2 . NAMEANDADUHESSOFWSURAN ECO.ORAGENT.- N AMEANDADDRESSOFINSURANCECQQRLGLO BA?OERRS. Al SMEE 1 J2R F2 J4T Tocon2sy CHARGE, C .: .• ITATONNO. ENfORLEM.ENT .' CHARGE. "' TA L, 70 WIZ 00-C ?R?. .ACTION EG? NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES. 2 ! 5 sE % AGE STATUS I Y -T UT EJECT. `. N AME: C A DDRESS U N P I ATURE OF REMOVEDf110M NJURIES' SCENE DY TO N AME: N T A DDRESS: S N ATUR UN,FS OF SCE" ED E 0,1. FnOM TO IN H N AME: I A DOnem: N W EUNIF.A' SC NE RYD. 11 M TO 5 N AME: S A ODIIE" SI IH 11711 fNFRY T O 0 111A1.1 121SEAI POYIIW IJI INJUIIYCLASS 11111AI MIT Ill EJECTgN C 2 PASSENGER I1NO WJURV 6 OISADLINO -41 1. NOTINSTALL[D INOf EJECTED i DIICDCU9fu1 r I ? E i i 1 E O _6_ ?_ 1 . I? i uSMO Of C Y CIFI 1'ED IN HOSPITAL i. 11'OSSIOLE INJUnV UNMNOV%! PARTIALLY EJECTED 11 E 5 1WTNES5 _ S 2 OIOYTIONUHKIIOWN lSEATRELTTAILURE EJECTED A k 1 I.E pEAid, r ? ? r? ? I I ' C??7 ?ti?l? q I a. 1 ; ;7 wl J l 1,('. I i IVY ?I{4 wr VI i r 'U y1 ?' p I 4Eq 6??At S ? I ?;?? 1roJ n ,?a9 ` r 131 ?rwr I ' ? e T I ?? w L >tz F xrra ? '' •?rt ? ? (VEHICLE DAMAGE + ?tac N ,..an nEl. Ftgc oArnA$? O SHAD[ REFOF SEVEREST NO PACT. /? I^ 4 INSTRUCTIONS: RAN' gHHOV1151 T O $1- PRINCIPAL DIRECTION OF FOR { DAMAGED VEHICLE NO 1 - Nis sPACt Fnx sKttcHHIG DAMAGt To TRAILENS MurOncvc rc l DAMAGED VEHICLE NO.2 G= _ - SEVMRNYOFDAMAGF: VFNIClF K01' ^MY sE NTY°FDAMAGE IOTN CLEI _ E ITYOF DAMAGE VfNICIFrvO]• 11 O..,r •R ',a '?`, 1 ` ZSI UxAeL NC DAMAGE J Q O V. OAAfaGE p t °ISAaLIHD DAMAGE :F?OTNEn MV. °AMAGE It 1'1=IHGOAMAGE l p IT.--M O HAG[ 47 t -tL ]p FurvcTaNAL DAMAGE , ? NTNERoD .E ] ? FUrvcirONAI.DAMAGE ER AMAGE ] Fux .- , p NDDAMACE - ' TOW ED BY sT O MA OwEO BY SL DAMAG TOWED EST, DAMAGE To u DIAGRAM OF COI [^SION may' j ;DRAW ARROW SHOWING + C I NORTH IN CIRCLE 1 " a :mu. TDND, INS 1 -. c[r„c". coxs,AUCtroN .? Y [ Tor E ? -- ._ , I ? ?' 1. L«„L FAD ? F 'o'inncoli"i ov?DN I I 1 1 t 1 I ° ll 1 DESCRIPTION OF DIAIR M. EC. DRIVER ;d. COLLISION a WNED CED Y, EDESTRIANC LOTHING LOR.CO Z-AS . I C1.111 11 TO O"NOR F ARWQRK, ST 1 D - VEN4.Z Srotec -_AT_S7oP5.iG?V._V ?1.#/ _FL?I?cn__.Ta_STuP__Ju 71etTC.-?x?o_N.?x ?6>?"z . 40--AN P4-, AR._ AS_VGN ,pZ_t?ur uca_Iltlzo_TNE J/i?71 vsc?Zra J_7Nc_1 oEce-oF-rNc lmPAcT A.4nVE-.?doTA-tLEtrlcaES __il?ZO 7Nc -. Ik)Tt"?5??7,n -A-ff-lbox--G.?s_FFc .------ " o op Laves - - --R a •'i POSITION BEFORE COLLISION vvEE clY ..•?- -C D', NEA x0 wGHwaYNAMEOAN°.? O IRECTION O w5 d Si G DECRE S ED OCCUVIF,D11 7 7 _ x l?lx WI L? L..I' GA uT FZ(+AD 71.1$ -1.. 1.U O U J. "" rrD ^? r ^ ALOxcrRlonlxc ofmxtcrcu Ts w. ' _? ]; ~ ALKwav G' 1 o LDEn CROSSWALK 5` icnoSSIVKE I N E v S, OTNER ROAD SURFACE ..WEATHER... CONTRIBUTING CIRCRUIMSTANCES UNIT I C CK UNEI NfCK ON ...IT A? O-]v E L "i t•CI? .11E IM E % I E, S "IN" No L .1 1 .2 ° D FR C FR CEOI? G G N D v ea' Or 1 G r' r. O A G G GE ?v -I I DR 11.5 OVERrASL .._.I f ALCUNOL_= F o LLPFL 1 J ? ] ? 0 ING q NIE' # ?] ?HAm -_ I]?nRVGS NCEOr r x_i-JI 0 n f IEF.rvTLV ?0?1 ??I"G •F n???? w T u 10 r RP .NG? .?A, T Un x J I S 0 G I [AC[f DINGSIATED r 'S A IN"ANLO J.s!'.[ED LIMT LQSATOx An I J?LEFT TG n AKIN r- 4r- p _ 1 IC O -- 5 1 5 M CRN , U TURN 1 6r !- D NO G HAV OI r ?51 T E _I 1GIB 510111G T [A IS tE1 TNF ,. - l-;a? I F... A/ ]( S'c E G u (]r i o F I-- I-r'-1 r r EO roH 1 HTCONDITIONS TRAFFIC CONTROL _ TYPE Of oROAD VEHICLE CONDITION, SOBRIEf N f ! ' stn DPrEDA f,rSIGNAL CIeCF[orI[ O.] [ C [ D ICNF D ORE N LJ x'?\ R STOV, SIGNALS t E-? r-. O wAY nE aaF kI 51?m VEHICLE o.] oNfi srTown.. - --- I. 1 D Gx ] s., ] OE ..... vt NNDA IT, ?( Y Y x No I X_X.sIGN. . .. _./v ?wAr___..__. -. d _nnAKLS T rmiANE nu. 72 s ,.A. cN _... SnARTI UAwN r, ] -._nLE ni (rlcnis.. I> I rN+oi MrnieiD?_. -- ? o".°oiR ON 4 , OusN nIN6 PC[ J..nG CT VE X '' 1 NeD SOOnIErr Jnr eA EGI N.,IENTEN Ne J M E .. s._ 'U ODP A - .,.. iS -.. TRAFFICI ET [' C K S "I T E F. S G I` Le.. H '- X DN T r-its J- E,LC.NG uN sD n ._ otLSMUO. n . • 1^ H Unme Nr. ?f?-??? To I No I -IL VA ?EIYEi. _ D t5T CHEEM TEST I lJ fn IS-1111 .,: _/`. iN[tl ?G i3 s cuAH 1] T 41 OC -._ -?•. -NO DE F11TS .' TtsT-USED mNtR Ivte _ ] xDIVIDen It I rsrrelrn x TEST ntsuus 2 I XI l arlaAT co nn,N, "-' Doan -o 1-- Awwto ""R ED 'M OW ?11 ?, INAtr .Q N ?f'? x l3 ,b ]t? IV pE s ' S '1... A 15, F -? x etv 'D151 AULT UA¢ IN ui Dnt N I NSv UAII U Y v l 1'; f Ir U ?`$ G0 O_- -- 7-3-14 AI.IRD ??J N {( g?w ?' r '? b t X -- N ONE 0 G NAL COPY . Sl11D 1p WASN NGTON SrAI[ PAInOI-OLYMPIA VFASIUNDTON 9x5M --.? 1F•r`ly ?? + r aa Y T' OU ll i ATE COPY' LDLAL LAW I NFOHCEMENT AGENCY S COPY-TIIPL ICATE COPY INVESTMATOn s COPY . TI Fy C;j Ui A k ?K A ra? y? t,i W's, t {1 it •IiA.T.,i,' .j, M77.k, fi'AIdR,",",^m "-ry"*xw" +v a t,o E ?In:,n? iLn`?j r yf '? Y I wu'M ? D `JDATE OF COLLISION DAY OF COLL1510NHIJR THE :A00 UPI SUN 1 MPV 2 tl• ] O 5 F ,THAI USE WE J COUNTY NO / CITY ND ?URBAN RURAL ' = ROU I E OR STREET CODE CTION LOUNTVROAD ?LIYSTREET UNT Y ? SLATEPOUTE O CO O - '7 ,` OTHERISFECUVI ? t IJ Af ?•S'0'j L I ORIO L N E POST ' I. I V N 3 E v O MILE? ?OF B. ZA A C ETORHIG O P T O fV NON IN1EtiSECTION LCIOENi EET OR ROAD OR RE TER ECT G STR X.HD EE RII fl0 A N -. .- STREET PND EET OEIWEEN MLEAGE G SE . DIRECTINFis MEFERENCEORLROSSSTREET DLSTANCEO W IN U . 9.:30? y ?' MI OF ?FEET ? SEVE0.ITY 1 ry] J nVEHICLE VEHICLE ? VEHICLE-BICYCLE ?OTHERIWRITEI ?HIT.FUN NO KILLED D " r COLLISIONINVOLVE : ?VEHICLEOUIELT ?VEIIICLERR TRAIN ?STOLENVEHICLE NO INJURED ' OTA NO ? OF VEHICLES Z ? VEHICLE-PEDESTRIAN ?NONCOLOSION ?HA)AROOUS MAZER AL _ T _ _ ?PPOPERTY DAMAGE ONLY DaMAGE E51 JECi STRUCK F - '. i . S E LOLAt ON O OU OWECT STRUCK (NAME OF OSIECT STRUCK AND OWNERS NAME) OF . , Y ,. N ?POPOWAY FEET ?.? ? ? RD SOLE S :i 4 ` FIRST MIDDLE Si DRIVERS NAMEAA DRIVER'S NAME-LAST FIRST MIDDLE I V bIC VCLISI OR PEDESTRIAN CHECKI U - ( ?'wAf D . ,. .... N R T'.NS Ind, I to?+?Ec #r ":, a. R STREET ADDRESS - I .. ..... S10.EEl ADDNE55 ?O A > j -':, :••. V V E GG ?3! ^?1?? ^IS711.L1h PHONE NO 4 ` E . STATE -2P000E. PHONE NO. clTr 1 Tv. R . R J3S8 f ;^ ? . bEX pMT E OF STATE TH 1 ,• N DRIVERS LICENSE NO. STATE SEX DATE OF BIRTH R O RIVERS UL SE NO.. .... HE . DAY R MO `4 o. D ? ? e i i G NAME I'I,V1+C N0. 'j NAME FI R V EH S.0;LUPf11 D .. PMONEN Jy, ?. DRIVERS OCCUPATION. FIRM ? A4. ? t P 7 c S fZ t?L C b , }I CODES > 31 C1A55?- -- 1AI SEAT.ELT ___ 11i1 EJECTION .-__ . CODES J 131 CLASS 1 SEAT DELT_2 151 EJECTION .J._ RE OF A TUPE OF Crf F ?s r NJUP ES S n } INJURIES R CE - 7 TO Irmc - R MOVED TO FP SCENE BY' NE OM S F RY DODGE-CHEV 1 A E MODELIOART NOVPI STYLE I2DR.CONV.) A .(F' _' - yy5 . MOOELIOA0.T NOVA1 STYLE 12-8 ,ONVI VEH.YEAR. MAKE IpOOGECHEV.I.. YEN YEAR . I 2 CLo ^ S L? TE NO DL) STATE Oc .R TRAI LER PLATE NO STATE I E E . C L R LTC. PUTE NO. STATE T R A I L E D PIATE N O . STATE H . VEH. COLOR. UO PLA . " a 2. 1 ? ? I Y' m? L E IOEN AIION NUM ER E IC 1 ODOMEIEN C ODOMETER .. VEHI lE IDENi1fICATN)N NUMBER V H L L 3551.2 t4 _ N?J7 ' y - N.IDDLE FIRST E ST pDIE IR REG3TERED OWNER-LAST f N O ... RE IS ERED OVMER-LAST, V IJ 18 t j • ?, -? fST V C , ER 41 S 1'J •. T .. ADD ESS Of OWNER .. ... .TUT N Z AG A00RE55 0 O - - _4 Z 1 ,•: OR AGENT . S OF INSURANCE .0 NAAIEAN ADOPE55OFINS'UWNCE OOR AGENT , NAME AND ADDRES CR1 AiION NO EN CHARGE FORCCM CnaHGE CITAIiOrv ND. I J'' y I EHT ? O ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES SEx AGE sTius - 2 ] ; S EJECT =am `. C ADDRESS' U . H[MpVLDFROM iURE Of TO P A SCf NE PV NPICS t J G_I'r •? J ?_FF •l'? TAME'. ) , l 1p IM ?] /.,, ? y UDI1C53- ?-3.I-? ?1'.ti14-. lV 5 'I [ZIT Z ?1l• `? _ T S N , ? OVED M o IV EOF SCEIIFDV. TO i N URIEb w NAME T ADORIEW TO - W A .1 N AI G E A_, l) S' ADDRESS - '___ i:M FF ?6 TO t E S' N i ? I•J.N 13 JI wJUNY CIASbN 11131ATU5 N(3L AT (N),Li AIN I NOII R 5 OISAbI rvf. NJURY IV SEAT OELT INOIINb1AlLCD 151 CJl C1gN NOT fED r ( ^ O ?ASSENf.CR i UCYCL 3Tµ S ) ). DCAD AT 111 NI IO NON pISARL NG Il OIORGVCLEI T DIED NHDSPRAL 0•LULEIINJUHY %E A ^. t1OT IN USE UNKNOWN IIE 3 Ai LLYIALFLYr CTED . UHP11AOlµ' `JECTCO IED T E ' 1?XCS3 6 ] tlPU5110'FUNKNOIW o 56 [Ai UCLTfAIIU EJ[C HT d a v QI saLa st ea eE _ "Aw -II-RA 01 ` ARE INSTRUCTIONS ) WI L r EST cT O I • ?'?'I. a DAMAGLU VE111CLE NO.1 ' ASAglC1°u'S1lU5 OW CPA UIICCTION Of ION •r` ?T +KI ICNn.C UwMAG[ to rNnlLUls.NO, DnC ,c., DAAIAGCU VERICLEINO.2 ? sEV<nnr o ncE v Ve NO , Y r???•1r • 4 ' • o8 ars.xunc anMACELNn s O11 •f7 Nrnm MV DAMAGE 1`0'o ar DN Ngee, O cm NO I v. N n IF D Mwee- vtNrttE NO?) rntnM V. M ^ Er LDw N,GC r wLl [;]% LIrrvG Owr,DC ry-?r A. Dw ACE • IOWEp eYC, N,'l DnM ?[ °l gMwcL AD[O r Ci10xgL O.MwG[ w F' . F wGC w )EU ouN ? LJ NO °wu wpE uwNa - °L TDrvto srcT? tsr• AMAG To (E LI r.:•I It U.f1L s5?' .ro f U t { DIAGRAM OF COLLISION _ --?--I-r--?- :__, D 1 J 11 i , DRAW ARROWSHOWING -ry-•? NORTH IN CIRCLE s+ G I'll 'Al r ..... .D ,rD f w •NI {-- - ?__ ? '- -? - ;-? I I ?- I I E DESCRIPTION OF 'INDICATE W"Al'"11-1 -1-ED I ?• COLLISION ENSAefu..ntpvcfnvrs,..... uurR ::,ECioi' CRw3Nl W N NOT rv -IRAM,EG DRIVER LDNS1xaDlIO N OR On nrIq K, ETC.IND •? iJEy!/C)C c_' ?? /?0?=y ? CicJ C/ .; ?? r "c COLOR. on ' • _ O P c5 Ly Tv_lct _5?un/• ?u?G,Q/!/L. 1G .U?I?Ziff'tr_ ? , ?f5 L/ it/?r•????ur r'? ' r U 1 (?' - _..-T E t>_ D? ? G(ltN_•O?ct.L /./%1..?'D..Y_3a??a.T al .. / ' --- k POSITION BEFORE COLLISION +?( ,_, '• `CAGED MI f IOS ECnFA ON S,nELT OR NrGNwwv NwM[ On NO. ON[ DrntCliDN ruUr C Fns INCRf wirNL U h ak4r 3ND _ _ RKED OCtuP[D (+ I f f IN ' SIGN _ rRON?_" DPn O. io ?,? , ' relCVCt Sus NO. 1• frOEww IS •I .u,R we 5 IuNM KFD 6 °[vCLEROUTF?- '?" ROAD RFACE WEATHER LK CON I111VI GLI NISTANCESSSW rrffR ij ,}yr C ON[I CNFCK OnFI. E vwY r IC [ 0.1 01 MDRE, r ATFD DN WEERI- C P$ vER?R OryIVpFR Owl FR OR Fn I[ ^?'''T x0) rrv0) ?1T I,n GD D 1 1 1 IDRV nC wR CLOUDY 1 UNMRrNrLUCNC[Of p G EAD D-AIL Li_L?,LEDNOt' I ?,I ? r OmNG DeNFSL,RDLD WwIiN' . -_t_--.•JJ Ta951p5[l I ),?_ N Ia. I?)?J :° r c a - r n wE_) xl RL r_ D r?r)I! D??F INr LafNL:L OF ?,- 4 NE' L:FN I .neNTLY - I ri M.KIND "c ?) R LNT TURN - ll. l SNOW i ,^n SNpwIND 1 IT i 1 E 3 AT- - ; p T - EE -_ J .E.N El I 'e?i j!? ,CE _ , I fOG ?LJ?•_?LJ? b OFD r 4 wSFD SL7 A°DNG ,RKIND 1.3 Llr1 ;URN ..1 JJJ --'' i5] u KING IIIECirYI- -M'- L?,1 [ F -IN S, Or. DO I I _ Ou I-6? -AN.. DR., A ER ISIL[ YI - ! ,r I Sx NI[n 1 D L OsTO OlN[n SIf • " 4 ,) q .. . stop 'f Glrn ? 1)11 fE,D FOR LIGHT ,CON- _IN,, 10N5 RAFFIf.CONTRp N LE TYPE OF ROAD VE/IICIE CONDITIONI SOBRIETYN 1'", R C Da CfICA ONL )YOPCL[ Vl O.) ICNFCK pnf ON MONFI - OIPCDIT SIGNAL ON[ WAY L Sg ! TNICIE r PP.-El Of I - L tfL ( .. r ?cNA 1 0 1( 4?IKSiIoI U NO ) aorlror.fnlN N, S ?'J4 I d}I, ?lu IJ nOADwwY T(1 D rucnT )I I v_.. f L v[ ^E Su C? FF`! "I A - .?vicL _. I'X?'_I T owA. 'rl z n,n [s ?1,-? Nv ^waCro rr. 1 ?Ilo1 IIARTi"e IN YW ; )C I DAwN L'L LL« vlnNeLF I?`-; n 1U[nvl ,,• - SV _ RAI ILANE (P sG --EE --- l.? r Asr. c L L-N? m Drnonci - J? mN s 1 N. +i':`emiD--._ n"ITo.o 10oN ???{{{ LooI UAMY ?a` ?rnom[ 1). o nr t? n ?r D.nK-anrcT r-1st nrofr c ._ - un aunts _J. R `J°IJ ix nr°i ciuNif nrNf r r? , r ..J n:.DiR IJ Llfr ?•_I_oinl5s n ° NOT LIL K.EI BELT .?'' NR UTn U NKINL L- IIS NCKINp _ , N,t Drr 1- .-' SIGUAI •__ cl 'F UrT 'If' fn NCREf .TEST E J tiNll?GNri -r wwlc? ..?rIA +3F[T- 'cI DING) ' t'] CIFI - q ?i7 ?,] I ncrNlN i _ T T?O1NE?rYf Cl?ri fr 7,1V 12, `J ) I _. ! NO pErLCTS I I I TI Sr Rrru5E0 IIII ,1I' yIII1---I'I'F f kYp r f X 3' N D n11l rSVf <rr Yl 11w---I, ?LL "GPv s , 1?' Nvl it 14 I ,.. r <,i' fi n,•f, • r ?NwN In.l nD. X X TCSi R[SULTS 2 uSrAll,rrl, wrnn rU TA I .r?w". / •• u?- - L-?r /L/i?Q (1G7.7„I"s° a0 E>'Zr _ ?J/$.V: ?•m' Dfo _ ?' 1P?' DVIIIYY , NYI w,IIN,. rKII/f N,,., ? Joti•/u T_ApNLL • . ? r. ?xT. >:,LT 01-//rn,?•G w(: L/ ;? ` :?JS "R??-? f.+ Pr1111111 , N UIUIilrrwl frA•Y :1 NO lU LVAOIfINAiDN SIAIC PwillOl OLYMPIA, Wwe11I11f310N pAIJN ' ' 01n'LILAIL CW lUlAIIAW INI OIrCI MI NI AI.I. NCY'S COPV 11111.1 If.ArT fOPV . ' ''A A ?ri ,%"''"""'. rr?M; z,?;„nnEerl;•? 14ri41 r1. 1.v ,f Jg Gu .ti T; ir: rt 7X", t+ n 4 1 r ? A f } ,y iA, 2 All D -IC Ui' COLLIS•'IN ONY Of COLLISION TIME COUNTY NO CITY NO. fHW-Z A MO R/)Y? 2 (( '' `J .. s JN uw, Iu15 r I 1111 •'n I Iu S? AnvRn f 1 x ]wlyA llrS E RALI . 1101 COUNTY ?ETAICROUIC WCOUNIY ROAD ?01TY S1RLE1 tt' O ADM CLS. REFI% ROUIEORSTREL1 COOS S CfIUN _ lje J es?/J ?O,HERISPEGlyl _ ?? L / N s c W ?1N 9 CITY OH tOWN W PREFIX EO. M ILEPOST 9 C [? GEJiUSl?7VU MILES ? 2100 OF / T _.TD V 1 I A IIAMECNO.OFSIHEEIORHIGHWAY. I II IERSECiING WITH: SjREEi On ROAD LL RAMP O - IAGRAMIAIA OM b NIXFINlER5E01WN ACCIDENT 1 1E NON INIER A E AT NIEgSE011NG STREET On ROAD URREf RE NCE OMSTRECIORROAO O n MILEAGE '2 0 N RCIWECN j STHCEIANO u _. STREET - CODE ..-C110r FIIOMREF ENCEOfl CNOSSSIREEI Sr "CIALCO 1-CE DISIANLE r.uH?pntl 6 - _ MILES N Is E ? ?FEET ? _ ? OF TY / SEVERI 1 ?VCNCLE?VEHICLE ?VEHICLE BCYCI 1 0OTHERIWRIEI L] NIT A RUN ND ILLED COLLISION INVOLVED: C i G L ?SfOLEN VEH CLE O.IUURED f LL„/?/JJV? TOTALNO ?VENICLF OWECT ?VEHICLE Rfl1MM _ V ..t CF VEHICLES ? VEHICLE PEDESTRIAN ?RONCOLLISION ? HATI.EOUSMAIERIAL ?PROPERTY DAMAGEONLY , -ECIISTppRUrCr??KIII?AMCOFOGlEG15 UCK AND OWNE M.1 (??,//' /1 LCCATIONOGIFfI_0??.{{{ECi STRUCK _ ESTDDAA.AGE 11 1 ". I 6<vti 11 0 7•/0 .. A l ... S j : a oa •- ROADS F F . . S. D.E % VC. ? EET R I_J.] 1?(? O OAOwAVI f lT• c + DRIVERS NAME•LAIT FI ST A110OLE RF Ell .-I ON PE SR11Al HLCKI LI •A1?T•E G ^f-y/ '. n ? L? l G ( ' W A KK R STREET ADDRESS R STREET ADDRESS ?- v v t252 -3l s- 1 ._. _ZIP,000E PNONE NO i.?.. STATE P.0- NO. E CITY t ... E CTIY STATE. ZI COOE + (? :? .J f R -r-, 'tom-t17tU fib-xJ.Q 7 ^2uA. -(S G& R ? ? Y Stwl/Er SEA% - MO?T OARTE OFP RTN N ORNLi+S LICE`ISE D 1 •• ..J. STATE :n Ml Oi BIRTH 0. N DRIVERS LICENSENO. 1 (? /t , O. DAY YR ?QF Ay r ? , L l 1 Li11'\JI'\? 1" 11 110N F1111:AME PRC.ENO. 2 OF E,SQ2QLrA{ON FIRMIHAME _ PHONE NO -ER5000 L'PA \ ? ?L• F`?` t CODES Li 55 Lt!K JI SEA __ ISI EJEc.- .? > .)I ciwssi ?• I SEAT BELT .._ 1"I EJECTION. _. _ CODES 'J' 'C x - I "JURE Of ] f ?I p? A t r? ?T') l'1 Niua ES F A ` 1 i J ' q MovEO fgDM SCENEer Lt - - U,U: '' ?• q M-D F O .GENE V i7 To oy/ VEH TEAR GE.CHEV, Mn MSLLGART?NOVA STELE 1208 CON V.1 VEH.YCAR I EIpO HEV.1 ELIpARi-NOVA STYLEI.OR{ONV.) E VEH. COLOR LTC. PLATE ND. STATE TgNIE. PLATE NO. STATE E VEH. COLOR . . STATE 1gAllER PULE NO. S1wTE R ZcJH. Q)CM3 !3 A• i r 77. C VEHICLE IDENIIf K;A11ON NuMUER ODOMETER .. C VEHICLE IpENt1f1CA110. 1 MBER ..._ .. _. ODOMETER ...... ,. (, L -7 HEGSiERL.-.-R-LA51 FIgST ... MIDDLE REGISTERED OwN -LA T. FWST ._. :_?.a_:..... .:: -..MIDDLE I7 0 ?rAG O. , . JOFIESS OF OWNER . __... _ : ... _. ._: ?: .:..-. :.. .:... . ._ ADDRESS O OWNER ... ... .:.... ..... ...... mf{t. 2 fIAMC A.R. ApDPESSOf INSUMNCE CO. OR AGENT NAM .. ND ADDRESS Of INSURANCE CO. OR AGENT - CrLANGE CI I ANON ND. FRFORCEMENT CHARGE .. .. ?.._.?._ ...: ... ?._._ GfAIIC%l .. - f 1. ACTION ADDRESS & INJURIES OF PERSONS INVOLVED NAME coots _ i ) , SEX AOE STATUS A EJECT NAME L11 "E- C ADDRESS' 11l MOVLDr110M E ',•,'_ U p N lUR E Of W-ES SCI RI .1 To _ A T AMt DCRESS: 5 „ .RECF N MovEO rROM 1 NfS ACf NF n 10 - ' W N=E -- 7 7 1 1 i D Ess - L N 1q inUVCD1I,OM Tu rNnw Scr Nf nr TO , 5 11AMf ? 1 5 Anrnr 5 I E r 1w 1D S rll'•IAIII.Y x VA :FJ NlJR .U AI, ...at w I• K JrwnrNF CIA'.S DRIJUHY R:AfIL1Nr• r1JURY HI SI wl 111:11 1 NUI IRSIAIL CD 11 IlJ'CODY 1. OTEJCCI[D j C O TITNI •.IJ FN J114YCt1'1 I I ! ) IOIHIRPOSrIKYN xMANAf SCI NC I DIIIADONAIIPNAL r UN R.'. R" HG f N IILnOf IIINNJURY iND11NU5C 000 ]0 xPAR R CJfGIC lAllrlJCLlE O '- ' A D Slllrnlr I A T- INII?401011CYClFI .................,......... .UL DINHO`+1RIAL IPOJ'+IIIIL IrIlu11Y i :r: NOWII........r YOWNIF ....... : I ... 1.-...:?' r: rT F I n rit ] w)nR nr IyPryd? iR%d -..9 ,.N g E r r 7 ? 1''p 8"rri??.`1 ¢ rY 4 99 n 1, +Y \ ?. T Imo. .. ._ _ _ ... ,. r •.I'. I?. 9 11 1 ` ?F ;j p k M r .F ? - AAA ' 7 da r µ 7 Art ,• } ?l UF C?r.H, ,. Ic "?•••r ?, VC-1'11L.1_C LJAMAUft - - ,. Z 2?1ADE aPEAU 5E E ES VACT ?- - , . INSTRUCTIONS: D aw AHHDwr ,rDS o P Nu PAL DiHECT10 D L -? J/ UA U 0 - YL NIAGE VEHICLE NU.i ? s EE 1 HS.cm4 ?AMA4s TO THAIt[HE OrON cr DAh1AGED VEHICLE NO'_y A -1 IN. u^ '....... O CLE N° 1 HEPM V.OPMeGE ? Irv pf Oau.GE. OTH E CLEI IE[]DIS11tIN4 D-,MADE kg AMACE iTY OF DAMAGE: VEN LLE NO IECINOISa9L.nG O.iVAGE rHFiI N V - A.EI ?I f_ ,A rauE. r NO INC aI y snu CTrOxaL DAMAGE MADE D E 0 . . ? xO OAMaGE I'? ESr. DAMAGE IOWE ?? 1 I=Y?1 Y DY TC D Ea'T. pAVA4E TOw E S ??UO rD S'1 TO DIAGRAM OF COLLISION' DRAW ARROW SHOWING / r vXr.r «n -..?. CIRCLE rr T wa.! rowf OS I - -' av lR ACr _. . .. vWwrXOrArtE V!«Ct[ N PEV<nXr.N.Ansslr -?T "--' O -- - -- -- v« DESCRIPTION OF anprwEwHAr PROSasLY HAPVSNED eEfGHE.D GA.VR AFr RTHE CnA- INCLUDE '1fOHMATWNNOTOVO DPAM E G -E. . 'COLLISION.. , , . , ° rsnbl ITT'rE.EpvrsrbrLITY,PEOEnNUNCLOT?NCC°LOH,CDesTPpenpN..REVAIH WORK. ETC, - e -/EeL=?/_,u`I,C v ? c ? v ' - ???l - . G__Y< Gl/1?rp-i,u ^.u?D d/rJ- 0/??fp??. d'r??iL?Tv-?G=?Js? ???7,?-?2. ..... _.._..IALLSiT N BE REC LLISI -H roST HIGEr I NAA E OR N A - ON .-N- rq EG - ON ET On ? E D.. I p I I r !?-_ CA P90. ON f re CVCLISiwASETNa+. I?SrcEwPt` x1''_ SXOU .w OiOST.YAtR .N ED E 1o TE T? p0Y •? >' KwA LOtR _ :.. TE ..'an- ROAD SUfl FACE. ICHECK EI !. WEATHER K EC ONEI CONTg18U ( TING CIRCUMSTANCES CK ONE OR Y ' _r:. J E rCLEAm oTU M6 T NO.: ... . -.: x - .; Hax ' aT. w ST D E ._ c ctaum ?, so exAar .Tn. ernlo .. .r KDttowrNC _/1 so°eLOSELY. eD rM N..- s ,-se.u ,c W }, ?' rfE Srvpn ' X. G Lbw 1 ^ T N...... CE f E 51 S -N: PCENTER I' qG __ ' E NG AK TNa? E f °° L , ` L WG °P _ OCA O!E X X -- O HE6 R IY C 1 .. ,. F i SA E 6fEf LEAN :- OO T_R - ' ' O A GO Llc OYC,?VN, ..Erte E ' A, Y. [ v X I? SLTOUwPiNN a P- r OM C 1 Dn - f G DISREGARD STOn .. SlfxrSrf.NAt A g ITYI E /'•' m STOP fDfO - i K LI HT CONDITIONS RAFFIC CONTRO TYPE OF ROAD VEHICLE CONDITION SOBRIETY _ OEPFD A MICR - IN62 LE, }w Ls r ?. q? C ONEO L 1 F.. E "Al H'La' >:rjflj?3..0..01 ENO.} K fCK ONE Ac.Y ! pN ETOrf GfE L aT a. : : s !wr cN /\ T srw_ XT iWO e<s r no g O I . T a sr wD , .:I 1. - 12 ??_qE [ LE-_ I l X [RIGIITS? PfDl ._ T,_ N T !._N LMYAIHED .? KLIVle r 1 r K't'i1O1` ? nE ?? ' l00lq µGE 5 0?...1 _. 50tH ETY-. leNreR L :If 1 E 'E O.wR t __I. -L ONriON . "S / N6 .z? AM sN S ALE, L_.l_ PUX6H . '- ON S4n}OTN, _? J ' N .? / l FtN O '.RIHO r .. T I IS BAC EMG '. ..? DANK frN 1T f ..:.: LH}Hri0 _. E 'I SIGNAL _? LANei - INHUr ' M'Gfi... CHEM. TES \ I t . -. ,. ET.Iei LIDIGNn .:? .>- . ° cu 1 ? set ?- .. .. ?t" .:: Tfsre f ... O n • n V • E L.. ' - ?? j }t (/ Y `P lf :',lei l 7•l lC.l( ! O OF •-_ Y`? .. _. I j I TFZrnEfUSrD 1 - , Doi?w hrenrvr . . -r-- P coN+:a: _ '.-- ?' 1 --!D .N-Ie.eclr Yr .. or TEST R[WtTi . STrOAf{r1 ONE r r Tk'??. ?I ? CENy N11 tlgA (P?1t L't"c ?5? ``ll?? fADCf?° rot (7c? b 1 ?T n EO ? ?ti ?L1 ?'.. a°n rULICf AHXrvFO AM t bo r.aO ANNWef??/? " N o T C .. ? nO o RrW? ?- vssTlcar NE`OrPL NwNFfnanA O q?= tlAOGE NO aE c ".vrr o 1 oar YET` a D rY of eroR wnav ? Da K F ? r u ue i S Rd "s ?' r f n hh`` y L4 . d + . ; + I • I AL NDrO IASHINGTONSTATEPATROL OI.YMPIA,YIASHINGTONON50E OUPtICATE COY LOCAL LtW ENCORCf MENT AGENCY SCOPY-TRIPLICATE COPY• INVEST UATOP'S COPY . 7 iE"?. . % . . i __ yd J, M I Y ? 1 ??, rV ^ ? A fv f y. 'C? • I R r y? ? , , r bar .. ... ,. ... _... .. ? !. ?N ,'STATE ©F WSHINGTN.wG[ I l 11iU• T rvuM UNIFORM POLICE TFIC COLLISION REPORT ED _ O a. DATE OF COLLISION ,,,,y yq AY OF <DL .1- u F n l NI - I a Iw us uR) > uNTY 7 c H i -iGT. a S S O Z ?nu? . ' COUNTY J?? U..-T.- TATE ROUTE LINTY ROAD CO ° DTHERISPEDIFYI O w N P 3? T O X95/ ?a - L 0 / IN Irv OR town ]`? MILE9 ®?s L) ? CR?F W e0. E P03T O A . NA FSTREET HI HWwY 0N MCt?Z I HTERSEC-W'ITH.STRFET OATINO $ I LL LL O A nD nH ?? cT I O N INTEILSFCTION ` _ [O, IT{?, LYU• MOM V BETWEEN ?? STREET O nT E NO INT C r <IAL I IrvpE EC 1C 9TH O U NE ER ENOSS EET OR HOwO •???? : ' p??1C QMI ES ECTION FROM REFERENCE OR CR093 STREET N CIF-T ? [] ? W / J urvoM1 S E .. .' (((???111 pDTHER IwRITeI ?NITe HUH ?VEHICLE-BICYCLE COLLISION INVOLVED: ICI VEHICLE-V NfCLE UTOLEH VEHICLE SEVER Tv ENO. KILLED I j - TOTAL NO.--/?r? ? HICLE-OBJ ECT VEHICLE-RH I-AIn OF VfHI<LF31?V..J VEHICLE-FEOE9TPIAN ONOn-<OtLISION F-1HASAROOUS wwTEH1Al INJuREO ROPfNTY DAMAGE ONLY P ' i r ....... OBJECT STRUCK INAMF OF OBJECT STRUCK AND OwNEA]HAME1. LOOATIOn OF OBJER STRUCK-,. ,- ?ROAD- 1EE1 ?0O? .. RD. -.1 1 EST.OAMAGl . -' L) OBIVErt9 MC-LAST - FIRST MIDDLE ?2v rt- =\IAAJ e D R -- DRWEN' N MEr`LPST FINST MIOULE BICYCLIT A-ESTRIAICHECKI ? oc ntrl t?NiklZ??s f 1 R R .. v .1-T. ES3... _.. .. - rz 1?c l9z I... v STREET wppRE93/E/??-, ?(J ?/7 ?S (J, E R clrv . - srwrE -.. cool .No. PT-- 'S-cu ,j sev E R CITY p sTATE. PCOOE o. END [a 1 Nt i? Cc e jai N p ORIVER]LICE148 NO., z ?s STATE ? SEk ? GATE OO eIRTN AY R 3 zs ae . O RIVERS LICENSE NO. q __( N E% D TE pr BIRyH AT A Y SJ !a- 1Lt M El t. . ORIVEI6 PATION rIR AMF.... ;, _:;",. _ PnOME NO. OHIV?ER5?000UrA TION "OZ: ,. - PnONF NO, CODES (.l C MI -T -1 uIEJECTION CODES I]Ir"LIAU,gg3Y I SEwT OE LT IGIEJECTIO.Y H?ES r eI?UUAE OF VEO TO [ EAR aMEIOOOGE-CN[V.) IsLEI -CO ) q -1. YEAR AYEIDOOGE-CHE R ?? `G K TO LIOwR O ASTY EI O -CONVJ ODE P £ do A ikE A 2 v ??n c,r? ,.. LIC.. T NQ , TATE. ?. M Llfl ILA ENO. STATE.,.,. _. AAA, ?,? I -cv E ; VE .COLD ,,, PL TE n0. , zvA 2 g STATlr, Ilf PPMi 1,77 c A. ' (,` L ' ENICLt ID! TIOHH ?,;, O 1 1TIPIG401 l a I . ODOMETER ., l l og ie V HICLE ENTIiICAiION HUw •;,? 115T51-Z b _ :,: - 00 METE •,: t? ?I'$ .E ALOISTlAtD OxmEP-LAS .._:_ "t 'T '.;_'.: MIODLE_ ?? Rf63TEPED OWNER-,LASL ? [IRS ... ...;'.? + C ` jV E N E er L7l O !9 0r OWN R i., a__..?V .? O•. 2P AOOAE3?•?OwNEA (f'???/ )_ I AME ANDADOREY^OF IHSUR CO ...... ?. rvwMF AND AOOAt33 Of 1-..AAC!O GFNT••« _.. ??:.. ft 3?c- rTC , D K. _ ? CHARGE :. _ -.: ?;..!e- T•.?..w-.::r . CI TAT ON .. ... -ON CITATION , ,_;1.• ; :' .. CO Of3 l - ti _ NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ex ADe sTw rus r u[cr: ? ( • AMF: - Q - OOA[S3 5{• 13 z I.' 3 1 z ::I• . . P or RFMDYED FRDM .,:TD' M :?/s - F ' T NEMOV aO FRDM oogess: T N M Ae or ro ?" S AMr - _ S•. H. SDr 10 Y • „11 siATUS ?ISGiPOSITIOM 1]INJUAr CLASS NO 1 1 ] LIN RY Or, i-I.-Nn LT Lf T.400CTIDN -; T F fG fL J C O p S 35l NOlA 1 /O[STAIAN C DLI]T A l.O1 [ r T, OTH[rr FO]ITION !] IBU]-MOTORCVCL[I . L O[ OT 3111 AL I B IV Y[N1) OY L• Y r O S! l 3 D a M OBE TB TFw i T [CTlO 1 ?rl Y LC1tD N O 6JEC D ? TMt 0 ] A. POSITION UNKnOWM Ids 'T ?' a d3]y ' ? r 1f"? I i , r+ t ?i I • o r `1 ' , I / ' ' ` " 1 nom ?- ?ee^? II.As L?r,, ± Yo ac- rtr +. L r' t ?gt?mpi d cH.;rr,. . r < MO TOR IAILUi- ,: .,,.. _ ?,._ .. ___...._:.,.?.-_?._. .... w ., ,.,. _....- ?._?.P. B z L1A IUCJ VEHICLE COLLISION REPORT NO. ?'r •'• DATEOF COLU90N 11-1 D/ COLU:'dOr: TIME OF COLLISION AM CUINTY NO CHT ND ? I.J ?j Wr v[C Hu yr x n(/? uwur[• PM /? ?A• MIL' Yr?"N x fALNIY CITT.TOWN [% MLLE O© C.TY.IOWN AOM CLS PREFIX I[ASrw Fr too[ SEL1*11 ?. ©© pFC / n? / 3 95/70 GIVE NAMEOFSIREEi.ROAD OR HIGHWAY% 11EISEC1INGYAT1 1111111111. PRIERX EO MILEPOST w KCDD1 C .? Ltlc s ?r?l r.L f` -zo v • _ NONINIERSECTKJNLOCATIONOFCOLUSI N MMP DIAGRAM DATA ' /' 6 BETWEEN STREETAND STREET LJ1 s1q? N RD IFMIT ©© xAIxOAOCR054nG MUroSr ox mEnr,[rvaG[ANW:w.. P.ewocE. INIE INNER LS IE OSS6rq[`EnI_& ( B RunloN: FEET ©® [? HER ? S' /O' *" 1 / CIXUSOrNHVIXVEO KVEwc wclE ?VEn ?0I -1 / •+PEC.CODE USE s+ OFVEM<[[5 p- Lr U0"['-=E- W 0- ?nn wln .? j A L' (NAME ei oB,'. OBJECT STgUCK SccT Srxlx:Kl OWNER OFONECIS NAME AND Ap0gE53 LOC ION IN ROADWAY DG 0 FPan -1 1 FEET •' F.LSe' ,? .. Fupa 1nµ E "/ ( f DRIVERSLASTHAIE EFIRSTNAME.• MIDDLE r vocvGAVE DRIVERS LAST NAME FWSTNAME MIDDLE 1? {3dG' t ?f?l, 6 Ctl%l 'c Rd C.NSbN'OR ( SIREETADDflE53 . E S R Oe S _ ROUTENO.ANDBOXNO. p"T"l - TREET ACTOR r ROUTE NO. ANDBOX NO. L GTY SPATE LP CgDE MWEPS OOCUPAVON w GTY STATE TIP DODE DRIVE AUO'rElro RDOCI?T•?. O (f PL r/j G REPOc«RTrow k d tvNSzK) N93L - ol???udLn 4?. L15 y eGl! e v -` ORIVERSLICENSENUMBER,.„"._.,,. STATE SE` IATEOOYDIRTHAR `A/GE ORrvERSLICENySE NUMBER. ,. STATE SE' 'WiEOFBIRTH AGE 37 Tp - - !1 .. 17 J Lj1lU .? Q `i (-()t? M X .J VEHCLEMAKEICHEV;DODGEI MODEL INOVADMT) BODY STYLE12IXi.) VEHICLE YR. MAKE ICNEV.DOOGEI MODEL INOVADARTI BOGYSttLE (201.)-? / ?oN It l?r m /v's -2 D 76 Olds S w/r m U LK:ENSEPIATENO. STATE TRAILER PIATE NO. STATE UCENSEFLATENO. STATE TRAIL RFLATENO. STATE DOMETER (MILEAGE VEHICLE IDENIIFICATgN NO. IIBGB MODELSS NEWERI ODOMETER IMILEAGEI VEHICLE IDENTIFICATION NO. (IBBBMODELS6 NEWER) 1 L J3?37/zla l9 3 L50m. / ?rs?l REGISIEREOOWNEA.. ILAST?FIRSI-MIORENMME) pRNEflSLICENSE NO. REGISTEREDOWNER ILAST.FIRST?MIDGENMIE) _ 011VER5IKENSE NO S?m? n v r. Liu. f2 7a - ' OWNERS-E- ISM REET.CITYANDSTATE) DATEOFBUTfH OW ERS ADDRESS ,ISTREET,CgY AIOSTATEI DATEOFBIRTH w - rE n 5 f/ M G S 17 6 U 1°_ ? X? PMiSOFYEHI DAMAGED, [s,u. ?c?oNSCr?E PARTSOF VEHIGEDAMAOED [sr uML fr IfG LV O )L ! l? WAS THERE AUTOMOWLE UABIUTY INSURANCE rAVC LIABILITY INSURANCE INFORMATION•VEHICLENO. 1• RAGEIN EFFECT FOR THIS AC-ENT ON YOUR OAR •®PES ?NO 'aka - NAME OF VA&Ll1Y WSUflANCE COMPANY,. NAME HlDAOME550F UABIMtt P15URANCE PoLICY HOLDER - _ OMV 2? .y E a h?V2 i?M O ?o cLLN'.'J •rE N ! /S/ N.vAE ANOADDRESSOFUA&LITY WSUflANCE AGENT, , ,. : SiA UA[LUTYPOLJCYNUMBER U. a2 s N sr_artsReNTON ISTNJIIFtY AGE 2ND INJURY: IUSESEPAANEx[roxIFOR -l-ATY-YESI AGE NAME .. TOTAL NAME _ ADDRESS --_-_- SEY F' ADDRESS SEXp 11 M ? :?. ",L wn `` ?«MDR ®[ oDnrGn ® El N s STATVS OF PARED NwF MARKFWST ONE THAT APPLIES STATUSOF NJURED •uL M-RSTONETHATAPPUES ZI I?3.- TXIA" ? oRM W VEHCIE ? Bw W VEHICLE .rp ? WLLED I=.I N[-M - ? KILLED IYH Eo NOxu ORI Re Au 1 11, NO p:. h:1. x^1 EOm ? 6[:] 8? 76'C' On rn[P AnnE .1 ? 8? 8? ?a GC ' yy .81 S ,,NORTII BYARROW INCWCLE \ ICE DESCRIBE BELOW WHAT HMPENED. IIIEFCR TO VEHCLES BY NUMBER) facaE bI MCpAORIY O C -_7= /7 c R6 ? c? ?_ I '?, I1 w ` o"?ur?caMlp1wn \\ ?1' ! . ,S T.1 'Nwuro ? s < .? S h? [t Adc L '.7-T Tu.•- Y wT _ E ?w.w1E slow LsFs1R ___ SI,.. .t r-. 4_ I t VEHICLES POSITIONS BEFORE COLLISION no?lAN[s YEwcM Hcq ".A,[B"•[ a1crtraArt?BfR :Yb VEMIOL[ N s E w ON STREET OI HIGHWAY NAME OA AO AOnE ITGNLY Sr ANWO VM1U "r0 vllKlf OCCVfD 0 0.1 w ? Ia ?roucE n L , NaI,.R 1:3 ? ? ? MONO aossw FROM DIRECTION 10 DIRECTION ` b MD[STAIN[ WA4lIW110 1 [03 WOEWALR 7 ? WALKWAY 3 ? SHOULDER 1 ? ='D.. 6 ? CO -'.- a C] OTHEn }..,, \ -I ROADSURFACE wIAIN[R LIO Ic-DITION3 TRA'c CONTROL K:r?.CV bN[I " OF ROAD G /VOICLEACTIJNS '? P:'• r4<C"MI r1K I[wCUT '__E vf,t[! ICr,ICK DN[On AAT1III ?` (MIVA IPA,:' w.n[ [I--;?T Nu rr0 rr LE 1 W I i 1 W irl AT [: ?? ` ? ???tfi 1 A9 A 1 L11 o1rIKU1 1 K DAYl10HT ? 1 ? GOrIA6 ? I ? ONC WAY ? 1 ? OGNO 611NGNi AHEAD ? 1 ? rnr - 2 ? RNHWD E ? DaWN ? 2 ? 31OP WON © 1 ? TWO WAY ? 2 ? OVEWAKINp AND PA44 NO 1 "! i "? ? 2 ? WET 3 ? f -,, J ? DUSK ? 3 ? YrrLD WON ? 3 ? IWAD WEE ? 3 ? L'AKWG FIKIHT TURN 1 ILASH"p RED 1 Nli 1CHNIG[ MAKING ICfi IVNH ? 1 ? SVOw , ?NOB . ? 14nI50NA ? (3 ? ? ? • ? • c[ OfINLR D-I-el M1OOR:IANPI y. hlt A 1 t ? ? ' ? l.q IYI a ? L<?n5 0f1 ? 6 ? «A4 IIG AMOfR E) A ? NLEV C] 6 ? MAKNG U TURN V _ ol- )- ? 6 ? 511C?1 6 DARK NO ? e C) M WIN ? s ? lM, WAY, N ? e ? AoWHTT f ', I K N RCA;pNIMNUT B[IRIGOAAIR ?Bflll Lf lKJIr! lNIC3 +A 1 I, ?Ol ER ? I ? OIICIR FLAGMAN ? I El STOFPIDFONITRArfc t i l i`I "? ?h Yl„1 I Y,WOM/w o.I.YraM 11CI EF`LCIfY ? 6 ?OTHER fC"V ? 1 ?ffPMar[D ? e ?OR 3'IG`JWGINONAL N {{y]?A tJ 1 ? 1 ?r[Y'Of0 1 ? 6 ? 6TOm(D PI 10a0WAY ?Nli 1 j. 1''? q?? f 1'1 't lR ?C 'i? 1 I 1 r,0?v 10 _ IJ 0 l..J STMIr Nf l ' ?! , y "? k p Tl I .. ? 1 ?? ' 7, f'A -71 DAMAGED VEHICLE NO 1 - ..., x ?..I t .HOOD 2 TNIS SPACE FOR SKETCHNG DAMAGE TO TR.ULERS,MOTO ETCT DAMAGED VEHICLE H0.2 u •. R 14. e l .UM ORn1rq _ 6. ... 16 TMk: x O "El ?? j UnOxCe,Mpe 6EVEHRY OFD N 1 DISABUN6 DAMAGE--„- 3QOTHER M.V OMI SEVENTYOF DAMAGE: IOTHERVEHICLEI 1(]pSAB(1NG OAMA SEVEWTY OF DAMAGE: VEIIIIXENO.Y U. \TI~? x NNCiIONAI pNAAGE? '' . NOOAMApE .. OE DQpTHER M.V. pAMAGE 10DISAOUN60AMAOE "''-"DQO1HEfl M.V.OAMAOE .": x NNCTIONAL DAM 1G TOWEDBY L-rttiKSO-t ? l EST' f.oS ' NO DAMAGE DA EE TOW EST D 2 FUNLTONAL OAMAOE = A NODAMApE :' "? AMAOE j _ .._ .. . EDBY .. .. ^ _ TOWEDBY ?' '- ' L•:'? r T. DAMAGE -- TO '? Tfa.. w`F-_.I L .t To .' ,.... _ _ f . TO F ?., a ?. \ ...OLGRAM OF COLLISION pt RAW ARROW SHOWING NO RTH IN CIRCLE E. • ' PM°C'ri,LT PPOB"IX row a x xHOw EFE SDCAN DR L,MK ? MPAPT 4 7?- .. -F -_ ` ,. - ..: •I. _ ?7. kt 'DESCRIPTIONOF i " OLLISION ;j. ONDM qSA :AT WUT EVMATPROBASLYHAPP Y,REWCEOWSIpIUTY,P ENEDBEFOR EOESTRIANC E.WRINGANDAFTE LOTHINGCOLOR,CO RTH HSi ECMSN.INCLUDEINFORMATIONNOTONDIAGRAM,E.p.DIWER RUCTIONORREPNgWORKETC.I,•. I ,. U4?GJ%1S 52 70 I .?IirL+11 e VA? L uf?L{ . :;* .?'1 -?--!_ri ?I Av ?{ .-.. (Zi?114??\n1o - • 1 0? ?'?U7 - t9 PO RI HD OR VEM. MEADEG MILE POST NO WCREAN OEC LI ..I.4A., ? : ?' J+Ar}Yx.. F NO OF LANES 1 DVi._ ON STREET Oq MgHWAY NAIAE OR ND -?"?? IN p4E DIRECTON REA - / '- ' SPEED S". VEHIC 'IFPMAED ypE LEGN.LY WAS VEN _ _ . .. N 5 E W , _.. . .. .. _ - r PMI(ED P OCCU ED is ,. .?Q? 1 S2 20 cIt IZ cP ?1Z, r YES NO QrY N 2 O?? _-_? _ _ _ _?.1 , _ .. - FED' ? ? ? __ STNUr ORHroirN Y ..: M COrwFA IFN ? .. .. ? IE O J PED/SCCUSTWASUSM 1(??'7f1 (? ( "? i IJPCfWA,R LJ AUM• ?pgMOm ?Cq SV LJCrrvR0G5 ?-I w ?LI RPUtE? I 'Pr .r •-_. R ROAD SURFACE - ICHECE ORq p-,?.-WEATHER. _ ION ONE) .....i '" `CONTRISU IO TI«O IRCU?MO$TANCES, h4.?Tia`w r '. - 6 JD[r,?e?LtucKlcNe , . O,aYFn _ I10 -.-. MiNfB -. = x aITVFR '. '; - x ?beVpi -.{Ly.; r N]. ]4'4.vr... r X-E yD?, aiRMDIrtAHFAD P p ? , - DK>t/eT _ ? ? NWpLa OETLr T ? ? O P.RED.RnEP ?I S ? p 7 ,, py?., `G _ II w[T. ..'. IXwMM?RMFu PYER CEMFIi . rq ? ? eNDn x ? s a b L.J, E.ff bRD_ ?e ? - P ? ? E GR r ? r, cE -j ? m- ?W _ f - NOEOMP. ?' ATM; a ? ? "? • . IGHT CONDITIONS RAFryC.CUNTR01. LJ° ? .:w.ca;F:TYPE.OF ROAD; e? wv1?wN.ifaP D-0 VEHICLECONDITION f F?vY?Fn SOBR IETY, ++" i °m.r°?FC °A ? ? - nor,4P a A `?' ` dr ... ICRETit PNq 2 , NP x I oNE I .T,.nE c n „, YT,:pi I ?e ? wN L a .. - DR ara. eoN % ___ DFFEe _. ... . - ? .? .+u _ /? ? IWNLB : J ? L? .mc "e . -• ? a lk'iN ,?'? x I wAw Lj PDT , t n 1 nEE ? ,Ni Q,.4.-.7 __.-._ __ l i...J , . - ?.%. __ ? L7 ? ? ei°'Px °µ ? .6..:??J .u r Aux - f-"1. i? sslao JJ 44 _ _ __ i--l?f ? " No?i.NRPU eEE ? eQ "e.cina r?'.. M I Lr wreaT _ rl ? ,uNUE IJ axsr 13-1 T,.o...r - ? efl anaaw fu,eD LI B CHEM. TEST x ? - ern LA1HIS ' r-T ? LJ K m 1 _ ?_ Kz? _ . ... onrN . iH rIxp Fn rd 'I T (_..! LJ O L J 1? ?? f? WIX C I ; f[n RIND ?.. :^ r' k _.. ?. A I I I "i arlma .. I u`n'0FO ... •-•o"^?'?;?o r?ic"1 . _ % ., % TEST RESULTS -2- Y b u u.,uReAAMEARUw? .m . R,ocew .urA ,eren .. ...-.... PPUCE Urmp wCe -;II:? ;M . x RIn ? CDNJw _ HRa39 , a n.,warcEwsl .?.Je Fn.u.c e+rc ,n. .uJCC .R : STATE OF WASHINGTON PADE OF No i - EC <.•, UNIFORM POLICE RAF61 COLLISION REPORT _ -;•w __:,__ - u rs-_ Y , _?; }E[[ Q -- DATE OFCOILSION .a ,=?.: - DAY OFCOW610N , TIME O YNO -' j? I FHWA 1 [ A . OMO DA T SUN TyNDI Y IULS ] WE A MUR E FW B BAT IU E2X00 NOUR)}.1 t'/ RBAN is 7E '? Z RuRAi ?? ?STATEROUTE ?COUNTY ROAD ?CIY STREET Q PREFIX 9O IE O//H' HCE,T/Ci?OOE /?CTION1/M -T, "?.T +v T ?OTHERISPECIF17 N J • ?! ?(Y !f? V-? -? J1i PREFq EI? MLE PO6T ?r7// ?: CItt ORTOWN E 'W'-?W W ?./I \ '•-I .: Q 4n //`i ?( C ? I'D ? OF A ,,:?::'MIlEA 9 •. ? S NO OFSTREET OR HIG HWAY -?'?r .BliERSECRNO V/ITH: 6TREET ORROAD O A _ (. ?/` f ?, -__.-CIOENi RAMP gGRAM OAT - NON YiT AC _. P _.. •- -.. _- I,M(„W SPE 1 COgNG ERENCECT NO 95 YEMp? AO OF vF N BETYEEN STREET AND REST ° 0 ?IUS N M J OF: ^ '. gSTANCEAYOEgTECT1 ?VENICLENEH CROSS SiR OVE CIE.BICYCIE ?OTHERryIRITEI w^ ?6TOTEN VENNOt 10LLED t [ ,u? f V TOM NON? INVOLVED: ? ? _____:._ -... ?NO.IwuRED -, .: .. 7 f 1 TOTMO. ?VEHICLEOBJECt ?VEHICLE RPTPAW OFVEHICIE6 ? ? VEHICLE-PEDESTPIAN ?NONtOLl1510N - HAWDO11SMATERIAL PROPERTY OAMAGEONIY IE LOCATION ?1 FST_ AGE-.-.. _`, OB OF OBJECT STRU NCK6 .1E W _ .-...: JECT-SJHUCK(NAME OF=EGT,SiflUCI( .. -?? - -. - IN ?PROE$7FUN C,pEGK1 ROAD- FE? - - • ,... OfDVEtLa NAME LAST -.,,?J ^.-v?ys..-.AFp19T';} ,?,,,,?:.:a MIODIE.: DRrvER;S E UST FIRST MODLE.II? El 11 ..,.y _ O ,? I 1 r0_- i! ?'><S-l 1. l- r R 3r r 1 4 R ' L'.::.v-nl . •. 1 sTRFET ADDRESS :arm.. ?_. 'L.u e? , ( Vi* -TY 321: B V V a E CRY.„J,.,,_ '..-5 wJ..L?.STATE dc??r LP COOE:.-a PHONE NOa E CffY.::e` f...e. -.u.n? STATE '. .. LP CODE ?y M E NO, ( 335 t o R- R t l 111,1 0, 1 ??' c.? 7 )i` OF B RTN . giN E ? STATE S/EX. DATE OF &RR . -,. N DRNERS A ENSE NO,w -----.-.„. STATEv SE%]LATE OR YERSLICENSE N0 O v MO. DAY YR ° x? O - { i? O1Y 7 i S5i ^ - T FLS,000UPAtgN FYW_[1rVAE t ?u.:'.-':t: )+-iY PHONE NO. Z OTLVER6000UPATION FR AMEN! L tyy i l.,. _ ENO. r CDD > SI GlIU1AS:.-. •) SEAT BELT - 51 EIECTTON - CODES > 1]) CL;V 0) SEAT BELT I6) EJECTION - J, V?LIU I?E.9 ?•Tr /J Lc tc ?^ lJ - Fl lJ?-??SRT^ to NATD ?. ' F SCENE BT: 1 : 1 F 5Y. 1,^•t a ` L 1 To F •. a:SC. ( 1 EOM SCE E BV TO VpH.-YE?Tf} - MAKEIDOOGFCMEVJ... AIODELIDART NOUN STYLE (3 DR.CONVJ.:_: VELi. YEM. MARE IDODGECHEV.I.J, MODEL(-TNO #A STY LE )T WICOHV?,Y/y?;j - TE TIWLER PLATE NOw.- STATE 1 •E;(1 yEry ,_ . w. UG PLATE NO,;;;? STATE R.-.. MTE NO:. STATE -:: E VEHCOLON .-•. L1C: PI-ATE NQ:` STA Y + ' , a ', G IFK:nian NUMBER;;,y? l.:w t.u ETER.,,, -6?. ? VEHICLE IDENr FICATI NUMB 9 J.?-.s DOOMEfEIi•+"?, E e t ' 7 .?Fa+ JE RE(iRTF^F^ ER IAST.t.,e.:mrC FWST OGLE . 1 REGISTERED OWNEiT ?1A5 FYLST?,,:.. •5„-3!„ ?E:J , 's C\ ,T AO-R OF._LA .'_.f.K'. !. ADDRESS 2 _ HMIE ANDADdTE550F SURANCE CO ORADENT _ NAME ANOADDRE„SCFI SURMICECO.ORAGENT _ EN ORCEMENT .. CHARGE -w•y,? i,.:wti_:. v. CITATKINT .?:f Pfi CODES 1 2 .w 6 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED sEx STATUS F ECT; -ye .. - A& t-0 1 C NINE' f( U NAA? REMOVED FROM I NE TO ,;; e11UR,E3. SCEBV' ay, , NAME ' fr T NT .. N^ORE SCFfl ?E9 a ?G tl S EE- TO INUU i% W - N.LME A?It v AGGRESS M D - J N SCENERY' TO (I .A'!6. E n NAME' a z xi f S AnoREes - .. k W - ... 4 4 A a6 S 4 5T 1 5, INFAMFefT _ _... _ - tt[1NEYTO • ]IEUAIYC "' IN SLAT MLT 1'+)WECT)ON A J{ •. (11 STATUS IlISEAT POSITgN 1. NONIURY S fxSABUNOINJURY 1.NOT WSTALLED 1 NOT [JECTr! l )G. C 1. FASAIMYR i-a L PCD[ST A 1 ]OF /1D Al SCENE B.NON OISA141NO t.NOTW USE ]TOTNLY EJECTED USED OT .NCrOU9T T.OTH[A POSITK)N J. OEAOONAIIfRVAL•- IEVIDENTIINNR'F J. PARRALLY EJECTED Q O - , E:; eKT MRfif e ] musuoTOIOCYCLE7 X.OEDWHO6%TN. I1.P0951nLE wURY.: 6: SEAT KLTFMwnE AFJECTEU I IF U 1 1 µ 4 ' T ,E J; I T f i ) aI Ai 1?as i ? ? ( 1 ? ?d t F i 1 7 ! `? L L s •.4 1 r , r -Sr 1 ru, ff I ?, U ?.IyY ewe Pe 1 ¢¢M1? Ir?1Tu O - --------- --- IT -T. N :' ?eT=cas Lhl MN V? -Ln?L_ *o M on GNE NAND STAEfii p qOR HIGry T.a.: F NG TwE< pOAO cc -'1-1- N I TION.LOEAnON OF oa ca 1usloN UETWEEN ; ! STREET ANO S .r D PAEFI% a pNEFI% L'O Mr EppST/, GN MP M DATA srREEr ?© r.,?,.._ a ntaxrai ?x an uxl .°....°„ °x, ee` ?T-•S,Ca' ??EIC n,x wa eal V1O- /1 x ? x ? N 1 `f O n xaac I TF o SNEU. L?_ USE ?V ?iJ0 rIti i U ECT UC . 4 _I' N FO J _ E O. IL .WAY Ill]. ? E n S P E 'MID LE R T E.'.. L R'. LAST.NAM , f •.. ??SmLS,v ?arnG T / ti ?5L5 C as c RECTA D p ° %' f? ?. J? R U %-N A T ESS _.p END. no. F 7 `:"i NO. a 4'C. CY LIC CIa 1 sT O v RS OCCUPATION f. CITY „_ .. RI OCC - .. .. 2 OE D VERB U O * y. , oL. bo °Gs?310 F I n??mr ?' C / NE0. LICEHSEN [ T C S¢[ O B : OHIVE LIC ' .x TF3lC,2 7- e 3 of D ? ?_oK/ Ci 7v C7 .C _E a - LICENSE E N- ..y T ? _TRA{LER ? > L?f?7 J? / ? ? ?? ??...-_.? _ /??v .,. _ Pll1TE;NO.:: .:CAS? E..?.. - .. LICE P ._E: .?.ST TE a T eER-P/ E O 6v 6,7A, 336 P ViHILF E TIFICATIO NOx.??)19a9 uooau Q:Naw[w{ODOM¢TEMM:LUac VENIC ENTIFICA O ,,;y:{ B' vrtw1000METEW wr,GAa C, ?SOS L lob _/. 9a n4 REGIS E O EW 7J ?Nn.. r .... , _.. _,'nrvP U , e 1 " N RS lIC[ _ E? Ot.ywy? _x,., REOt EREO Oww(R I -n_wsi.w ,.. ?a D. IVERS lIC[ 6 NO;r`. "? I?'9 ' Alr7 aS ` •. NEflS DRC DAYAG I c -M '- .`.. - OA°TE OF.0IRTH O [ DDR ?? Y n, ' c?7D .: r I nNr ?r4 ?? fir:. a.,.x,_.;..,sn.?-....n.:..,•Scucc'r?loc va * of ??? "«+L,?.: _.:.a .n? o T[of A_ ? LIABILITY INSURANCE INFORMATION VEHICLE NO 1 s E u .-c LIABILITYINSURANCE cove O NE Cr R CCI O CAR'° ION YES NO N[ n AD011G5 ?R LU[I I SUR Hcc Pau llO a ._ sr`.a "a'A-,CQ <,? _C Y ?•? ? 75{3 ?`° ?e ? A r+ . co S2eis {.u.._. r /.E 13oA Z I G ? Ls ba . ? „ ,_nc .._orLU[lurr•1 sun ccac pj1 Y' O S' rn m,CAJ{el.- 973 ?` ?IasrYe? 4fa ?f'7 / 2 :f^,??Y L!t".. tw c:. N,/u Y 4,•o Aow n { f .:1 Aar tatTr?IC a<C??K __ q? 5 To- A D ?Ame? i Q A111111 loq ka{mctrlC .fA3?o?S '/?G F?x,?s6c?1?.3?r I- A Ess ' ; I°+`rL^+!Dy cc. g '.Qijl kccCSh Llfie',?r OS? r?? ?Z,snto g?,L,i?ns'..P/YTAU4fuczEa??'v?; cp..t F w 0 o In.uY Y. T oc5°a f ...Tun 1 _ a°UI }TYCT.tr, f'G? A ? :55 i :I 5 T S OF U [D , AR F q4 [ THAT A PLlC9 ST TUSO I URED n- r v H [NIC [ xa xox:or,.a .J A KFIRSTO C'TH OAPP.L CS2 A/v No. ?,?A2A- _ Y MILLED r Ix I V ICLE L%F{ nDIoSM Ixon<1-ll Ilo „wr'IC~ IRA, ,tS C,-;Y SIR- OR NO COq NO. _-? I, . II ??P. DAT{IGIIT . ONY !u A'iNiMG J';J D,WN -T In NoN- I n , ? 9NOW . ?-1 FDD % n GA.. -Ell ?_; ? ?-; LEE ,r.; ;.«r.Yl , ? I;r?r,A.:,FT n c; A ?? rl:pn N? sTI,.FTL?GNrg ?r:noti ro`?ior [¢[NN?D•N/Oaw T[J v d,,N.rf< R.I I'P2, ?1 c1 C "rc.T - .Zoe N-o ?n?e.?bc?c11C+?.? p} f1 't"Ick Zoe-4 'J MOTOR VEHICLE COLLISION REPO _ RT - O TE OF COLLISION OAY OLLISID NO. I T MCOFCOLLISION COUNTY iYNO L x to 45 °rE3 0.M t 9 1 vCC1 _ 9.SM2G?L ' COU N CITY TOWN . MILES. OO ,. ,;;.. ;. CITY;;ToWN -.:: .: AOMCLS Pq EFIX xOUrEG Fci Jefferson Chimactun =4O w // CCI OF /?• - GIVF NAMEOFRR ... . h . EET.ROAUU HIGHWAY •-L„INTERSECTING WITH: STREET OR ROAD.,,.... - PREFIX EG MIIEPOR A??c Hi ]ray-__ t uN< Hiway 18 Cc.vrc R 71 I NON INTERSECTION-LOCATION co/ ISION-[-Y- RAMP DIAGRAMOAfA r l_ i ? lN0/ ..:.cC •Sa< JY p.e, BETWEEN STREET ANU - STREET ' . N xe,Lxee x, tlxxx,t. S ? °wosnxv M?uroa, Vx,oexnsr,xv aawcv.., 1 E x0 ? OF is x O D[ vex cu [ '- - E v x ct[ JI ? LLSD"L[ Drx[x wxlr[I PECCODE USE j v[x cLE Pe+[cr 7 D , vex c[u vexcu.to[sru . ? ?/ ?? x xrR„x ;. - ;Y J OBJECT RgUCKi:f.-`er PUM[p °y[er E,nueq a.,.r ?,y,'. `CWNER OF OBJECTS NAMEAND A0LOCAT IN ROADW -"i' "' a OE A AY, FEET S W •.. ... . f DRIVERS LAST NAME••C„„_.?y-..a. FIgST NAME _w. „r,MIDOLE-'?. ? DRIVERS I.ASTNAME? ,-,:FIRST NAM ?WuJ/1pOLE:xc..t Berman John Fredrick Schnee Teri L, STREET ADORES- Y,_?_ ,•a;, ;,gpUTE NO.AND BOXNO"- •""° STREETADD.ESS j N' gOUTENO:ANDBpKNO 11630 21-t S1. , Hadlock n $ . -plT}"' ; ; - "wwaSTATE ,21_000E; •DRIVERS OCCUPATION I[? •?r CITY.-_ ZIP CpOE..DgIVEgS'p000Pg710 Seattle, WA Truck Driver i ck ? " F dlo , WA ?. Unk ? DR IV ENS LICENSE NUMBEA,r v,i;.. RATE SEX. j;OATEOF,BIRTN'r AGE. -. - DRIVERS LICEN-Er UMBER. ?ry STATE S;pATEOF BIgTN- AGti• .. M BE-RM-AJ F734JJ WA e . . 50 N r one E IDtE vq. MAKEpIdFY,mPCF[?+; MODEL. @OpV STY18 J i ----x• - - .+--..._. vEH,CLF A M KE ?IU, i- MOOED Aw,n,, BOpj•-T.YL 972 G:9C Tractor-Tr AutoTranspo 1965 Ford 4di C t V T us om r LICENSEPUTE NO,. y:,:31'ATF, -, ;;SFIAILEA ILATEJ[Q. r";?-FATE ,yam LICENSEP TE NO.' 'STATE: : Wp i1gg1 EqI TEN Y0045$0 OR FBS7rLj 4 u W 'drSTATE VEHICLE IDENTIFI T NND' L•;?,w NmEUAx[wtgl+, •. ODDMET{P.ur '' TDH9?AV500fi? +• VENICLEIOENTIFICAiONNO' M.-4j OQQ?1F]?q _ yJ7isSmMw REGISTEAEOOWNEfl, Vi i,+srJl?nranPP,A [•[AA,,,, :yE"DRIVERS, IICENSBNO i.;___. REGIRERED OWNER - •:,,,AFr .xxME ICEF ENO Convoy Company --- plU 7 , - - Morris nk = 5 WNER,ADDRESI...Y.?-3i.. _?:, ISTAEEi, Lift D_RATF)• ?pATE OF BIRTHI OWNERS ADORE55 '. .. - GTREET,CDYAMp EI-•.+--. ; 390o N'd Yeon, Portland OR 97210 GATE OF 91 RiHi AV Y "O S , ? EAR F.adlock Apt s, Hadlock, HA o uA YEAR PAflTSOrokeFVEHILLGDANAGE6- '- -' -•^.?w^ tsrirei[DeWr:,_ .FVEHICI DANA PANTS B driver's step,Lfuel"'tank;lites '•roA .xKE.. -x-:J 'a - x as• ?• M,N IF area, radiator LIAM LITY INSURANCE INFORMATION-VEH ICLE NO. 1- WAS THERE AUrOMOBU.EL.ABa1TY INSURANCE , F!pLpER COV ERAGEINEFFECT FOR THIS ACCIOENTONYOUt CAq ®YES ? NO NAMEMIDAOCTtgSOP,UABIUTY,INSURAMCE PpUCY ? ` ,, NE C • •>=+C?-'LT%P iE UABIUTY.INSUiIANCE,COMPANY Convoy Company 39091ty Yeon, Po-tland, Orego 97 n ?Y0 j Tru ck Insurance Exchange NAM O ns E AN ADOIFESSOG LIABILITY IN6TIRANCE AG ,,:.r ?tlR3?.l x„?a,-y ;?e-T TE T ??' L;y},--L1A pI k u,;... Truck Insurance Exchange, 8010 S. W. 1XCirrus Dr Bvtn OR ., , 0353 00 65 ' _-"6g'?"'T""A'?2""•AW"}????[Xr•+ k-t,a ?.??:_. E': ?1NOIN.AJRY(• LIDSF SEPARATE gHTFOP AOO TIDN.[L INAIRIESI_ 4_,; _AME None reported --";LCE, AME ADDRESS ? . ?X At F ° 0 w [o] aM STATVSOf INJUREp+,. O "'O? HM1iTMFTRATAALILS-- -- '. STATUS OFIWVRED ,v •...+.MAAK FIAR ON@THAT APPUFS.. '"?.L•iS ? IN VEHICLE x? xur. ?' O IN VEHICLE et n , ? KILLED ? A v " KILLED w Io7 ? M[v[x IMixurl TC D S QoT ' I a I - , w .ER WRI-- ? 50 60 , -7 6O 7 OC.I ?..r_94'/nliE.ll; ? $? SI-OWNO RTH BY ARROW IN CIRCLE ..ECGR18@,@QLOW WHAT HAPPENED; REFER TO VEHICLES DY NUMEFRI:JL'A.yyJy. y 'p 2 stopped at stop sign made left turn in O , ........ Mew ;^ front of 1, 1 pulled right, wou ve Lr sedS-butt-accelerptes]sssusl sJcid on q W ? tt- ice and 2 struck left side of 1, continued ow ? " Sxa ?3Z?s33e o? creas ng ue clearance lights bent tie-down ratchet. IA VEHICLES POSITIONS BEFORE COLLISION m Br VEHICLE {ADep er Lu:i i?,lP r?i c,.cii' ! E ON STREET OR HIGHWA wY{sncA* 'l'P rD Y NAME OR No. cr, ' ?I^ 'ox ` " ° m A O Q O a LI E un) ; ? Hiwa 12 l ? ? - ? ro L ? ? T ? 1 xD,xvrrtK.ArKw •'° IOTHERI LI L•1J ? ? Hiway 1 .. K[ -- S - i ? ? ? ? EY ET CM ,P --SL S!???EE?T^?TT PEDESTRIAN +?? f LJ-r ^•. L::L.tJ..l AEf..V2G4h.i?: LY' t'. l s- ' . . , .. L Ly FROM 2rAE Tq.l••,..':'..I. PEDESTRIAN WAS USING 1Oro Z?„• 3O??0S3IN0 S...w, ..? -E{{{L ,wet[ we - " A [nn,.neLa S Oin?tl?w.,: @ Ourx, R NOADSUN,ACE_ ... MAT.fR.. c, yy LIGHTCONOITIONS TRAFFIC CONTROL TYPE OF pOAD . • xKtL OAIVlgNEHICLE ACTIUM °"' x S` .. ..: ::.:....:r r w v,"wa, L' '?j b:?'+g:?w ' ?OAYLIGHT (rL71x*?CRY T?nAINING 10DAWN ? 1 ?SIGNALS 1 ONE WAYS n'• IKOp01NO STRAIGHT AHEAD , S ' STOP SIGN TWO wAY = I..J ] ? IT l OSNOWING ] pUSK C3 ] C) O OVERTAKING AND PASSING smfET ? ] 0YIELD SIGN ? ] OnROAD IVERSIBLE ? ] O4A KIND RIGHT TURN C] ] ? SNOW A ? FOG A ? DARK -I ? sm, ARK SIRE ET ? A OFLASHING BED LJ A ?II. IIAM IE O A MAKING LEFT TURN A . ICE 5O2'e ?'??• S ? L, ' Hi301 F G ? 5 ? NI,'^'?• A ( DARK NO ?' S ?FLASHING AMBER ? 5 GALLEY ? 5 OMAKINO V•TURN J , s NctrLIGHIS C] q C .-R 'CNAL ? O 0"I.? r'xNLA,R{ E:1 A O4LOWING -H! -Ml FON NOT SEEING OANCIR . T ? ?,'? r? , • t •• ,.,-w o, xecrK..,I ?, L,Oi FILEq'f LAm[AN I 1 u C]STCIPEDFOn TRAFFIC AT31(3 IGNAL ? B ?srrl ['iev JDf PAR Arf.D ? Mn OR TOP SIGN C]2 ODIVIDFD O D CSTOP FOINROADWAY _ ? E, C3 APFIC CONTROL O ] OUNDIVIOfD 1TARTINGIN O' O ? T 4 RAF F IC LANE }???pp?RF app ..5i Ax r". '-+lt'Ad.;.? l l `? .L:: ,,:. ".I n -7&F:7?, . ate.,; '. 5?•. I':; 1?-1?7'' '.? .. "A t ?'P?r.-. .... 1A .?lr ,?rd I1 3 xt 1 q, WT a 4 ?? Y , E'• ? J J MOTOR VEHICLE COLLISION REPORT NO. 7 DATEOFCOLUSION D AY U90N TIME OFC SION COWO GfY HO . pp / ??-J //?? PFArj G)UITY /CJRY.T YM oKCiaF• [o Li ' SC.v C? N ,JJ F soF w ilinr MILER O© GITY.TONM ©© OF ADM-C's I 9yl E NAME B _ - OF STREET, ROD OR HIGHWAY wTERSECTWG WITH STREET OR RO1Dr RD Or GV A/ va _ ?i55 rC-oe.!/Ce. .CO € ScwnE _o- _? TIRE FI% EO ILEPOST' r?rl TA - fIONINIERSEC110NL AVON OF COLLI90N ?'NOOY O.C. , MMP OAGRIM DA BETWEEN 51REET ANO STREET t WF ? © sMl N NOb CCnOivr'io uL[IWSiOn WLniv i,Hn [R_ew IT RUB ©®a eC /sR c'66 SL.L :µ6c ?F _ IlE 1 NON %RD IER CLS iE M ?. r ? -1111w Ro,o oR RE fpfHOS9 alR[ ? O - vFRKLE VEHKLE ?vFr LCNCVIXE ?OIHFA wN1N pw5KN NYOWD r CI$DE USE /f?" u???,' MvErvC t6 ? C?I?NENKtfO6IELT ?vErv ?YEH.aFPEDfa,q.Il oAGr?a;IagN oHrgAr ? sif OB:ECTSTRUCK Irv+uEUDHIFCT S,RUCN. OWNER OF OBJECTS NAME AND ADDRESS LOCAT IH ROA 1? ION BLJ Ho F0 DWAY EPAw FEET a.. tFIRST NAME .-E ORIVERSUST NAME .- IIAR flvEO CM+a w OtvFD DRIYERSLASTNAME , FIRST NAME MIOGLE {']' L /304A/ /-F"; ' ' - CAR ?'?, '.' ST REET ADDRESS ROUTE NO. ANp BO%NO. up4 v.0 A STREET ADDRESS ROUTE NO. AND BO%NO. ?0, / 4' a ,3 ` CITY STATE 21P CODE MY FS OCCUPA110N w,iM ZIPCOOE STA T E CITY BIT VERSOCCUPATION _ ?Loa .?i,sd 33 71 ?FtlCrKp[nyfo REPDRTr N ? " ' e AC?r ?uAr 9???? lS?i/h'?1) ETIVERSLICENSENUM R L - 60- P- 77 • STATE SE% U) u f DATEOF DIRTMI v 22 z3 AGE ?a ORIVERSLICENSENUMB CA-C'N/-fK g97Gjjy STATE SE% ° r DATEOFBIRIH D,r rEM AGE VEHICLEYR. MAKEICHEV.D000EI OOELINOVAD/UITI BODYSTYLEIJ OTiI 4, E R. MAKEICHEV.D000EI MODEL (NOVApMT) BOGY SIYLEIJM) L7/ota I'ran'?i co 2))R, Pral• ? ? C /o LICENSEPU TENO. STATE TRNLERPLATENO. STATE 1R/JLERPUTENO. STATE E PUTE D. STATE * -/ tea/ VEHICLE IOENTIfICAT10H NO. IIBB9MOOEL56 NEWERI ODOMETER IMBEAGEI ENTIFICATION NO. IIBee MODELS6 NEWER) DOMETER IM%EAGE 1TEG IEflEDOWNFA (LAST-FIRS'.."BLENAME) DRIVERS UCENSENO. y CKVLi e` E.J.1 CJLARK aG ' C REGISTEREDOYMER LAST-FIRST-MIDDLF-NAME) DRIVERBLICENSENO. O ERSADDRESS ISTREET,CITYANDSTATEI _7 -a , D. c3ox EEG D?_ae CD PATE Of gRTH. OWNERSAOpRE55 ISTREET,CT'ANDSTATEI MTEOFBRTH 1 11 I'll PMl Of VE DAMAG?fD, .. _ .... .. iEOCds PARTSOFVEHICLEOAMAGED =PLR'= WAS THERE AUTOMOBILE LIABILITY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- COVERAGE IN EFFECT FOR THIS,ACGDENT ON YOURCM YES ?NO NAMENIDADDRESSOFUABI-SURANCEFOLICYPNOLDER NAMEOF UABIl1TY w5URANCE fA PANY I RX NAMEANDADQNESSOF LFTY wSUflANCE AGEM r ME P UABILRY POLICY NUMBER 6a r C E ro .?3„, D 22cs oul _J SYCR)A Gc1 / ?93 a s _ IsT wJU1Y NAME ADDRESS JOE SE% M C ( TOTAL JNDINJURY: IVSF--ERLPoR,fOR,da,.Yr41NMnFA AGE NAME ADDRESS M _ N•,.ar n. Inc1aP ® I Balaa' "?E 7 d ° „N „p"B..IKx,w+ ®? °N°.cNc p STATUS OF NJIIRED MMIEFRSIO NETHATAPPLIE S STATUS OFINJURED -AA FIRS T ONE THAT APPLIE S ?.1 OF-ER OVAASf wVEHICLE KIILEp D¢ IlEVFREI __A_ I NaAAR I rAC?w?LE AN Cdug no VEHKLF. PAlsE ? Ew ILLED ? IEFV[R E' r aas,xwo " 1I Nu"Darl PDive+E IOFCPpiI F?IGII i. OMaaw NO ? 50 60 7Qf,c, IPAA pPlp[a,g ? 5Q 60 ?? SHOW NORTH BY MPO W w GRCLE °"N l?nLSgoe m° DESCRIBE BELOW WHAT HAPPENED. IREFER TO VEHICLES BY NU.BEF) V l u m K Er NM R: [rw,Mn 6 I SW/X rafFOd,tnbrr><Fw wwl?« ] ?u? K? H .r N.L•FS oR ? ? ?/ i __ S[2ttil? C_. ?yi?if/ N f?Ni?FIF.. Zt_ LCcd q P (?LEt)_! / ' ' , 8 'q/ ,? p eMG 7; tiy a , ? ' ' f nec?EK , ? ?',??• ? ? ? 1 LP.s sGTii?' ,u h/!Ce Ju GJf„rti _Vf OrVE .DiRGC ? z// , ??Nrn.'1? ? f• .__. . _. ---- ? r cli rd x.1 99~ ? 5a n/''s (?'mF•EE e_g S5 '{1/L' c_/l u /- - i L - F n_ /?%t a fS AR G _ L ¢ F7s / Cl?a?iTc.t ? ?-'' ? ?S F?•IF EEE / l - -- ---- . -I --St ' • J VEHICLES POSITIONS Bt ECOLUSION VEHKLF. N ! [ Orf STREET OR HIGHWAY NAME OH NO NDM„? YT ?c s I? [RrRATED Dr W arD FrcN ,R.rd wNC E L.%D , dKe .%r p ND ? r„nn ? iquci ~o IH%A+ Q ? p ?. ? ? ? ? ? ? , ? 1OUCE ? 04 'w",. . ?moo 0 0 0 ? o ? aRfr ? Q ? ? ALIDNO m. DIRECTION To DIRECTION MDES1gAN WAS l,SwO I ? sim- I J ? WALKWAY ] Q DFOULOER , ? cRUP+iinuA 6 ? 'f'iryiSwFy+ e Q OMER I RGADSERFA MATR[R UGHTCONDT,ONSI IR lc.OMROL K•RC.WI vl•.CF[ TYPE Of ROAD v1 r.G1 df<, (art pf11VEflAVEMICLC ACIIOM. vNKLL KRT'._'MMOIL, KMC. WI f••d? •Eq?E fYF l-;FY1Y FLU ] R4•Wgl I DTI OArLIO1T JfrQ'\MWN Q 1 Q 6KJ1AL9 Q J ?lIOR SIGN J ORIpnl1 In' I n ONE WAY ?y J XlWOWAY J NDJ e Q Dow STRAIGHT AHEAD Q 7 Q OvERTAKw0 AND PA5SN0 ? J ?-1 ] Q,•yDwNG ] Q DUSK Q ] Q MIDSKN ? ] ? RO?'IFRE Q ] Q .-GRIGMTURN ?]?JAW trop El J?lgnTI BIT ? 0"w'4R[D ? A QKneRCr. -E 1 OpPrR•MM Q % ?-11 LEFT 1111 ? e ?KE " OIN[ 6 ?IY'E CRYI D- sI.E[T ! C) DL%W TSOff ? ° ? rUrwwO .ATB[R Q 6 Q •IIEY ? a Q uAKING U IVRN OR ' ? ° ? ?411' ? SIR![EI'DIIWrtb ? 6 c] m 9fi•f4 ? ° ? lfrT TLIFN ? e ? 90YWffp nt A'ION rOR WISaMD vOfe • r Q pT[c,fY ? r ? arge n. rL•GMAN Lµ[s ? r ? sTOM•ERFORTBAFF,C +,c r.wa l,C, CPK.MPNI+Y. M ? (3 1 OTHER wECIfr IMATED ? I ? • M ? 1 QSTO FD.i 9GNAE OR ISI P 9- ? J QnwD[D ? 6 ? 6TOM•EDAIROADWAY ?Lp. fit Q ID n 1NrI qNE 1 ,P I yF F of K T F FI XI It+?vn ? .JI n L:. ?_? ?•1 sKT ? a ?R ? r M1 WY A X(L"? GATE OG COLUSON N TIME OF CALUO COUNTY O/ I hC / COUNTY CI Y, OWN EG CITY.TOwN ADMCIS PRER% SECTION A - ©OF GVNAMEOFSTREET, -Al. NGGY .-?J..f NTERSECTINGWITH. STREET OR ROAD PREFI% EO _ MILEPOST ?.M1 -,?C). NONINTERSECTION iO ATI NO COL )SON RAMP DIAGRAM DATA BETWEEN STREET ANO STREET - Y -E RR E + ©© Ruao.wcaaosswD.MKfwso_ TErINC LANIwwI• E. ' a c s TJr a - _. /' : . as[c,ON. ©® or E ? ? 'w . U C' (w, uSON NVO.vfD • ?-r{$] ?vE ?0-11111 11 AEI E'n¢aHC r ?vEHr,E wa N o ? E cODE USE } Y ? FS ? L..J OvE ?NON ON E _ .si OBJECT STRUCK IN-1- OBNECT6 RUCK). OWNER OFODJECTS NAME ANDADDRESS+ LOCAT - ION - ? ? n - FPAw DRIEC ON FEET DRIVEflS LAST NAME - .FIRST NAME MICME AN DRIVERBLASTNAME F FIRST NAME MIDDLE D rLO., Al Si IEET ADDRESS..- ROUTE O.ANDBOXNO. -11 - TWO ETREETADDRESS ROUTENO.A BO%NO. Z A V31- MAPbC -C- STATE LP ODE DIiIVEflS OCCUPATION CITY STATE 2W CODE DRIVERSOCCUPATION • VONIFOR Lo DRWERS LICENSE NUMBER STATE SE X DAtE OF OIR M F MD DAr rE•R AG DRIVERS LICENSE NUMBER STATE SEX M E H pgTE 0.1111 MD Dr rEMI AGE v'LL- - 54 2 kIN hl 7? VEMICLEYR. MA ICHEV:DODOEI.. MODELIINOVA DARn .. DOOYWYLE12MI VEHICLEYR. MAKEICHEV.-DODGE) MO.LjNO-.ART) BODY STYLE I2 DRJ M ,..YX-r 7c 1/o L V C? 5 r -I O fJ LI E SE PLATE NO... STATE TRAILER PLATE NO. STATE E N SE PIAT NO. LIC E STATE TRNLERPLATENO.. STATE f ' J E 4 ? VEHICLEIDENTIFICATIONNO. ,, (IBM MODELS& NEWER). DOOMETERIMILEAGEI VEHICLE IDENTINCATIONNO, (11111ODELSb NEWER) DOMETER IMhEAGEI L_ zJz S-q 5 _ 4 o00 REGSTEREDOWNEfl (45T-FW WOOLENAME) DRIV RSUCENSENO. REGISTEREOOWNER ILAST,FIRSi*MIpDLE NAME) _ DRIVERS LICENSE NO. ,. l,LG lP-O P KC A. AEASAL-0Z OWNERSADOiESS ISTRE T,CITYANDSTATE) ., OATEOFGRTM OWNERSADDRE. ISTREET,CITYANDETATEI DATEOF BIRTH ? c,r 7 11 2r /AR 'Ilk Y, PMiSOF VEHICLE DAMAGED [snu?Au[yOwsi 111SOFV LEOAMAGED N - _ To N£Nyn vUUCLE .. T. lEruN VDT I.." - 'Pn.JT - $ - $ _ WASTHERE AUTOMOBILE LIABILRYINSURANCE ? NO LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- COVERAGE N EFFECT FOR THIS ACCIDENT ON YOUR CAR YES NAMEF DADDRESSOFUA UIYINSURANCEPOUC?YHssLDER.. 5 NAMEOF UA&UTY INSURANCE.-ANY. f B-L F. ms :9D- + ( ?' 1ST NJNiYADME OF UAWU?SSURM'CEAGEH?.,/Q(..... SJ E 2NDINJURV: s?r'UBIICT ^UMBER I i? .. IV SCP E ... _ I n? NAME I.TAL AJAE ADDRESS SEX ADDRESS SEX .•r u. IN. URE AND lo v OF , fInCI IXx I ice. 1 D __ ____ ON+ ® I IL`?IJI ooC,OR, ®© ?uF '? STATUS OF NJUREO ARK FIRST ONE THAT APPLIES SIATUSOFNJURED MARNRRST ONE T -APPLIES r- IN VEN CLE I ST oN Da•Yw0 Po55relE tl ? ORn•F IN VEMICIE NON d5•N wu' ? DELI I Nun a A t _ a I - ? AS KILLED SEKR Mw "F" Qr KILLED IS[KREI IuNNdn ION f 1 t pnLKS ARE ? 5?ea 6? I?7QE 0-" AN ? 5? N80 7? p,THrnrr TE.m E E.N 5, YYNORTHBVMROWNGIRCLE \ I DESCRBEDELOWWHATHAPPENED(REFER TO VEHICLES BY NUMBERI D yc I ?' r woCATF W TmSD•nIIAM - .. . -. r Ix .eeTRELRnI"OHM.°wR[clli ?? SiGJ?hlLI.1G 1-2.4- .? . '' :"d,RCdIISDNecLE,L ?/?J \J \ \\ CnrcLS KJGNS_._i?nnD_..TUJZJ..__?!+K C wns?.nt..Lr,• s .NOd.ow :IMMB[R[ACHKHK:Le \ l ICr.,.E•p.? I TUM•?Dl:._,,_R?tE.O-?ND__? UILN?AAID-/.JV?? ?ia,?" :?t• ,. •dRln,f» D R.KL.. AN. ?czw S rv ?` N r r _ t 63y y .[z?'I , ?.s fA,LFS_ N/i ?F? TUR L/_LGaN-E?.?KOSS y r Ott lig, i _/?7H--fir ?A.2__ Z.__igN[¢Lf-_!eV TU2LJ- t , ?.T 3 /? "i13Ar?--?ASSk,?__JZIGHT -TUIZNU[G_d? roll ; \ 1 VEHICLES POSITIONS BEFO V[MICL[ N E W RE COLLISION ON STREET OR -*Al NAME 011 NO Ea oT.Km w -.1- vulcM n4)r b,ANO•EO U [! vLI«clE lln4tY P•R•[ K6 EQ .N•ro w.5 D vHCLI OCCISXD K 8 b [ NVCSTKIAi[D DY p? , )pit[ , 1' ' 'I AD now ? ? ? 1 ?o L ? ? ? ? ? ? ?:ouu ?loA°IwRm : nn r ' ) ; KHRLN ? ? 0 0 MOLS'""" ? ? - ? ? ? ? ?w.NEI 1 T•y + "' L P ? ? ? ? EOESTNAH WAS USMEO ALONG 1 ? SpEWALK ! ? WALKWAY D ? cROSwo SHOULDER FROM DIRECTION TO DIRECTION K ? AOS?w ! ? Mypw4+ e ? OTHER N K ' 1 I ' ROAD FAC! "FA w[AMR IKWTCONM10NS TW11CCOTROL XDKCKURI v[r+CEe IYF,Pf OF ROAD CH OF DnIVERMHICIE ACTMXN9 vFHIXt K:R[Ca DV[b11 O 1 f I •; 1 N ? 4 lt•ClE w e l?]p^Y M, cKO cu u 'Z's DAKOHT w I a L ? 1 ? • Ata N r.D a E WAY , 1 ?1 ;,g OGNO SrA.w MEAD 1 4r " 1 Y 1l . A • i ? 2 ? T ?aMNNO ! 2 ? DAwN 2 ? 910R :MN O ` j 1WO wAY .40LE ? 2 ? oVEn1ARIN0 AND RABBINIC _ , y + T , YY 1 ~ ? D ? "c"' ? T (j cc ) ?6AV0WVA6 A ? TOO OIAkR 4w. ] ? WSK A ? DARK IIT0"1ET DMi S1RlT RKILL ? ? YIFLD SIGN ? T ? IL"- RED roQ [j K ? NILNCHAAFLE a + E In R) O ? O [] MAKNO RIGHT TURN X ? MAKAIOLF.F T TURN MAKNOU R 1:1 ? { 4 H . r + J I'` 1 on [n ? n IT cSINIc ! ?A 6 IlAS1w6 AMPLER ? ? AL Y I ? O TU N e 4 ' +I ? S ? 6mc DAR NO 50 6111LFT .HT. ? e ? Rn Tlf AL TWO . ? ! ? LIMWAY1U11N ? e ? %OWIND L M?^ - I Jy, l} # 14ASONFORNOT M[M)ANOIR Cl xWenc«d+rAcI K7••? 1 eC d> 7- OnkR T ?b'LGIY r o ICm nAr.MAN ? ? LANES ? 7 ?810P[b r0 TRAIrC 'IL Oflfil? { 1 v N- r 4, I? t t r 1 0 J • ? ALJLt ry,:FC,r ? J ?OKDTD ? ! ?StWED N ROADWAY ? \ IN" T J WAS J>fYS.%IF•+G H , L? InAl c ? ° NO l El ID O iIA"i cu fl ! ti/! P_T N_ As- j - I aar ` al r7 B ? u dvDED -` r N'A r ' ? Lt IYa !q 5 .t. I '???'??'At ?`??M?d._3?' ,,+'-? -++. , r.M • ra a a?'4.r- n 11 1 ? i r 1 ? I J I'.- b l ? . 1 1 .1 1 }f L .+ ( f / 1 J, 1 I upw Ld{ . 1 rl,a S ?p IF, y f an ' .- 3 ?Jf IvILtJ Vn v L.cv n _ -nI NU.:. ': -.. .., DATE OrF COLLISIO .::_._. -D Y^ CO LLISION TIME OF. COLLISION . L n P l COUNT,,,yyy CITY NO „f}yP % :9Sa ods COUNTY CITY, TOWN NIILES x171 CITY, TOWN .. CJ AUMLI,y n PgcFl% R EITEORSTREETCO SE TION > • OF G r o GI RA/AN OF STflEE7' ROAD OR HIGHWAY . IN TEHSECTING NIT •STREET OR ROAD PREFIX ED [AILEPOST- ' x 9 _7 JC r !'TAE fGC?[` i(/E35 J \ ? JOAN c SECTION•LOCATIONOFC/O LI.ION LOK3U?/L k'p. AMP DIAGRAM DATA d TWEEN ST-TA- Sf EET ` [-? N LJ-??- neu.oeoLrru,s N,nuErosro?oE.r .v nr. L..,?,..4, r. xr, N.N Narr........ .a E 3 ..... j ? ? ?vE" is .... L?O. r Pc'. CODE USE r - :. . ,cLE .+. O OdJCCT STRUCK o oueersr,ut:rl OWNER OF OBJECTS NA115 AND ADDRESS LOC - -1N flOAOWAY O ? ruw ou r OrwE EET s F .° ¢J DRIVERS LAST NAME FIHSTNAME MIDDLE ,yuv"•? I DRIVERELASTNAME FIRSTNAME? ,J. MIDDLE S E ET ADDRESS OUTENO.ANOBO%N STREET ADDRESS - - ROUTE NO. AND BOX NO. '7 / ? •'+o ^ • CITY STATE 21, CODE ? ? DRIVERS OCCUPATION •' A CI TV STATE ZIPCODE DRIVERS OCCUPATION /r? cc t u ?,. ?It D. J W /J, fr 37 DRIVERS LICENSE NUMBER STATE SEX DATE OF BINTH AGE DRIVERS CENSE NUMBER STATE SEX DATE.F.I.TH, AGE - -S, W . Db YEA F G M F M MO DaY R . MAKE -,: ) MODEL' x A,..NN BOOVSTYLE DoRS _ VEHICLEYR, MAKE a«IY._p000 MODEL OvaoeAN E BOOYSTYLE' Z r!7 ATE 010, STATE TRAILER PLATE NO. STATE Si LICENSE PLATE NO. STATE TRAILER PLATE NO.. STATE t VEHICLE IDENTIFICATION NO OtWMETER .. VEHICLE IDENTIFIC REGISTERED OWNER r IRSrY Ow veI :,.- . III, ;..DRIVERS LICENSE NO. REGISTEREOOWNER IUSt rvroo.ew ;? _ _,. OgIV ERS IICENSENO _.. OWNERS ADDRESS ISTREE .CI TATE1.:. - D A TEOFBIRTH 0 NEFSADOREES?,+ -..- ITREEt;CITYA TEI?„?_ ,Yy. .OATEOFO RINI„ 6 a C> X5 (0h O Mw nq.._ rEAp PAHTE OF VEN ICLE OAAAGEO,.. "._.T ... .. ._,,: ,.,?.;? ,,;.-;•_,... Em ueitPC A A : ,..:, .IC:,;;, <srsM •,: LIA ILITY INSURANCE INFORMATION-VEHICLE NO 1 WAS ERE AUTOMOLE L AO .... Y INSURANCE COVERAGE IN EFFECT FORTHIS ACCIDENT ON YOUR CAR ?YES ?NO NAME AND ADDRESS OF LIA8ILITYINSURANCEPOLICYH0LDER --I NAMEOF LIAOILIiY.INSURANCE COMi?N y ,S NAME A.. STATE NAMEA DA F V 1 EAGENT; N ti: zL -?;,- I r` n ^.•+w? LIAB L ,?- IC PoI iL < I I 00 A5 n] 1 ST INJURY - - ` AGE 2N0INJVRY IWE S[I EPEPo T OR AOORNINALINJURIESP•.2-au'pGE+ ?_a_ w-., 1. ME O E ?O SEX,' -,;? OD E I ?y Q - A F 1111 M F ll{fff---sss A. F _ o o? na STATUSOP INJUglD _F- MARK P IFIST ONE THAT APPLIl9 STATUS OF INJURED 1 -' ?'MAgK PIg3TONl THAT ApPL1EZ•]Jl wJ _? . IN VENICE! IN VEHKLE 'T'7 .r In, v KILLED Nv., ur.o.r KI LLEO ievE R 1 s•'. .I •r I . . .ILA-'+il Na. -- -1-11 6? o7.v?ere L:N ? 50 6? u«7r0 T.-'v ? 5? 5 O HORTHEY RRO NCIRCLE _'. OESCg18E,YELOWMHATH,A...O;,IgEFIq,TO VENKLEyS tY?hWAZl11? ,V .•f>btLi -: /N . NeN , O?\ \ E '?? -.. tLYLS..-4Jr, NJS+- cL ie' /=/I?-IJJYJL`CIOSEUll1J ENtcu: c ? 1?an{?cr?d,_al/O_?"r:_cld-rDldjZt?E[! j?.fS?P.N.....:.L.?J4? V 02ry_.leS?nt?e.F-av-?JtLtTi.u_/?.s?ru.{?AC-l6?rJe/ . ;j 2 - \\ Lat, ?_ .. 'armedrG .._fJf ?r_/yhfide /Ltt J.l?-'^y-?J94 ?r' J?. Hy?-Y T d? _ r .JALS-T. ti J K - Q P!»lE S-AM . v L ?Gutr?o?a.Qd j :L..II cQJC?•+_JJalt.s_Tr y_atfap?a?e-Ab-AIG..:' i I I r VEHICLES POSITIONS REFOHE COLLISION IT a ..P VFrwCLE Ife eL10 Ic4 DN tTr•[ET OA HIGHWAYNAM[ OR NO. q"rr r1 e • :: ? O r rh IrDG«I C c6c?t' [? O )i ?,cc... Lt?e.?E+ GGLf/ O O O D ? ? ^ OT111.1 11 T B O ST01 N ? ? 1-1 ? ALONO CID SSINO Fno[A ;R ?dPYy'; TO Fl(' rlfa4Wf l-: [ 1II0 N IUSINEI I [?_ t ? ws. l,J"O_ l J ',..,,. > n ?:vu: A ? no w U O • -F AC! WEATI+lN LIr,,HTCONOITIONI TNAF CCUN)ROL r TV)E OFa ROAD DRIVE RNENN;LE ACTIONS •i 'In,.r.:: L + , , ?...r G«) v. •e M RR,I I SV.YAU [] I ? ONE wAr,: E] 4?GOINO STRAIGHT AHEAD ' («IV ?nuMNO ) AAV ?? ?' C r ?u.. , 0 t ?4Tfr SIGY ? 2 ?TW+)v.Ar ? 2 ?OVERTAKING AND PASTING. f t DNINI: ) V r 1 . F' [" Il :rr:N L.i 'I ?NOAUIiIRLE ? )?YAKIMO RIGHT TUIIN '-1l I'll -.!i • `I ( i. 1 ) I,? A L-, J'1 AIH Vt:NrO ?A ?IL TO(N.HAU'rE C4j? ? MAKING LEFT TURN ,)fns 1rrlrF `7 1'.A4H:Y M.F. ?S?ALLEY ?!?MAKING U•IUMN I :,.r 11 /, r_i NH .rt,YAt ?? ?Iw))•tVxY lA4r1 ? A ?ILOWING ^ ? rY )r;.I 4A1 Sf [IY40 Nf++[ t ?t n /r?cJk l/ 5 I2 w! I ?. p f l_.) )[J -f R.rt. MA.Y ? )?ITOPw(D FOR TRAi FIC ? E f'1??E? wNIGMAL ! II y> ^, A ? U I Sf rA MA1fD LL 1 IrYYp / / -- • ? t ?DIVIDED ? I?JJ STOM[D INN DWAY r 'I I CUM Tq OI I I 1 0 ¢HOIVlO/D nIV T"17TARIINO IN .'?!?137" iY•' `?," ,Y.,...."MeP:,Ap;r[ - _ v {o+y';?? +?YVrn:,7d',: .»....t?c?lnr•.-wre.. :T. 1 Y I,: r? ;a y 40 ?. Y GY ? VEHICLE DAMAGE I CHSCAl CLETHENUMBEROFEACHDAMMEDAHEA. vrly "' 2 s DEAREA OFSE F T P T .? . V RES IM AC . r, INSTRUCTIONS- • 3.OHAY/A HROWISITOSHOWPRINCIPALDIRECTIONOFFORCE. p ? -0AMAOED VEHICLE NO. 1 IUSETMS EI EFOR SKEFCM!NG DAMAGE TO TRAILERS.MOTOHCYCLES, ETC I DAMAGED VEHICLE N0.2 SH- '?-r1nI t0 Rzl 19 11DOJ PO l r 11 "? l t" . O B 9 . ,v " 15. TrMrk rnCrv ?I I D S. Trunk 444 r 18 Untlmcartla ?r e ?F r D ° p t C B. Unawunl.Fa --? x a ? `I Ii.Ovarnun e r t,t Ii OVmtum ` . 0DISASLJN OAGEVEM!CIE NO.1 SEVERITYOF DAMAGE: IOFHER VE I HICIEI sEVERITYO MMAOE'VEHICLEN0.2 []DISABLING AMAOE 300TMERMV. DAMAGE 1[]OISABUNU DAMAGE D[_IOTHEHM.V.DAMAOE ([]DISABLING DAMAGE D(]OTHERM V.DAMAOE p FUNCTIONALDNAAGE 6 NODAMAGE 2 FUNCTIONAL DAMAGE NODAMAGE 2 FUNCTIONALDAMAGE A NODAMAGE A TOWEDBY TO ESi.UAMAGE S EsT.DAMAGE, TO'WEOBY TO $ TOWED BY EST. DAMAGE TO s DIAGRAM OFCOLLISION ao uw.r Ea AE9 ' n DRAW ARROW SHOWING ; i NORrHINCIRCLE ( I ! I W wcss I "orsrR°NUCTroN ARE . " F' I -'_ t _ I ;_? F •-..?r? ? ? TTE ABLEPoINTOF -. ? C-I i __?-l.? I ? L ' 1-... f?l EREDE9r""f'AnMPAm.Q" xosl aN,. osAi ow ABLEVEn ° " .. I , I .I._ \ FOa e ? _ , DESCRIPTION OF . COLLISION ". (INDICATE WHAT PROBABLY HAPPENED DEFORE DURING ANDAFTER TMECRASHNCLUDENFORMATION NOTCH DIAGRAM,E.G. DRIVER D19ABIUTY,REDUCEDl4ABILRY, PEDESTRIAN CLOTHING COLOR,CONSTRUCTION OR REiAIRWOR,LETC) ?.r?_ r/??._ / _J r Ts?rr G ?Nc? iarlLc --_ _- .- .. __ Cc_/S./! l' r ?.•1 ,cr y /' ?`J J 1G.?.L l C.l /O_?U yi?,/ J A< ? ![ ? . ._ _ . f _ Tir L. c!) /U /itrN_jtta c 5 l J OSITIO VEI, HEAGED NO IBEFORE O U MILEPO.T.R. INCREASING OECREASING ONSTREETORHIGHWAYNAMEORNO NO.OF ANES (NONE DIRECTION SPEEDS PQ,rfO BATE VEHC FP K_D VEH. W A S N 9 -".E sl W PARKED 11 ? YES NO O C C UP ED rj YES 17 ^ 21 14 17 NO ---- 1-- PED II _., .._.I I II .ONG _ aTNEEr CNJ95rq Oa"AnwAr prECgwEa r0 9.Et FpIT ETO w.I I PED/DICYCUSTWASU- _ . 1 Al I..I9NQ,I?Ea Cr;ar.- ROAD SURFACE CnG :. WEATHER CNEC Q , :,' CONTRIBU TING CIRCUMSTANCES cJ ,;. wreRrvEHAtY L O G NE FOR I.E. No N. - N6,'] K E FCKK mAq L _.. I // fTIWEPCA9 ? .. l l? EONS nGE a_.. EQ5"OE __?i TOO 1 EPEO E D- WAR" GNIId FNCfa .. 1 I NEaC f, 'I I 7 AsLEinN '... hD? AIM rUra s °N _._? " ...._ ' I J a..ow p - I I iou. [ . L "? .. I - .. _ _L e , caER nON J Ac L,J-1 -1 Wl I L 1 ICC J ff l00 _C , p evE 0 ?' W -: J NPwRO>E ..? I. C _ E._ uAnug 'orHeRlsrECrrri'- o -i,iaxEQrn .. ? eP O LEr I 60WW0 `. [ , PA59 EE" ' p dSPf 0 r, -- .f ?r. J mKQPxENOO FOa LIGHTCONDITIONS ICH[C, Cwel TRAFRC CDNTADL IA. ).. wuE " ;,KCte TYPE OFROAD O I fc"or,s on uoNEl VEHICLE CONDITION clE cnE - SOBRIETY rFN?c E Ne • •.' 4 eraxxEner616NAL I?It J OR9TOr9r0" 6NNt! Lj L, WAY "O. uI CO"OM nU FDI L ,e"EG%o i I rKl f u It r =YM ? nwwA AT I eM"' IN, NfD ,ol. 'rillA""vic EU. }..-., W '.. _ -NG O?Rbt"p L? IN ° E'c 'r e d OCirvE E _f. j'? C Il'? PAPAR— rtl NGH n:Mx I uAKUOR 9 (? 1 sce a lIE?-7 :rE NA (EMFPorA nwFCI J - uuT ... .. • on,', m I. DeFNNOmr.rama I ?s? DACKxA s V ,? rt .e , r IWOW.r lErt uw.owrATUwo Iwo CHEM. TEST L ° Ai^iiaNl r "'MAN xAKITI. w1 - _? ... rf9TO•.EN u . _: DT,rEa ISPFQ rn rA OIiEG I rtTPlNDEO IF OiMRI+KOrEI _ ' x,V o — J? i O,Cmce0 0 . OnKAI!lCNV1 90 % TEST RESULTS I 2 '. .. p. .leeasrvAA.eF:aN. .Ew roEr I.w.rcrr? -' _ nneo F wkoeo IOW W " n CEA9x aNa,a- AO:e W i rut, 4iN Ha' X - AG[NCr rMMr.f pEr W pAit CA [vMi AxxIIOWDer pAIY w 1. E .?N£ ? urJ ) r ?Pn 5 A, r'1 4 M P_, W b 4 !? 1 •a' ? _ A 61 iv 01 A i C VI' NNdL 1? t'IiNU i VIl1_PAGE OF • 140. ? p ni ??` 'LE coMPUINT,wuBEn _ UNIFORM POLICE 7RAFICOLLISION REPORT D UAIE OF COLLISION DAY OF CUWSON TIME COUNTY f.O CITY Iq FHVJA A O DAV Yn SUN 'M. I- EC. IIIUA fPI SAT IUSE:900HOUR M • T 1 z J ?uRBAn / ? ' - ] A 5 e ?F 1V ? E L? 9,5-aoo COU.YTY ?BTATE ROUTE ®COUNTY ROAD ?cir STREET p AD' LS PREFIX ROUTE OiI STREET CODE 5 t1CN JPFFC SON ?OTHEfl ISPECIFYI ELI J C?S ?- ? CITY OII TO'.%N PREFIX EO MI E - L C N S E W ?IN III MILES ? ? ? OF L / //A?(• ' W LL L J L T µ1 - iq A IIAME ANO.OF STRE ORHIG?ryAY INi ISECTIrytG( VV?-'H?-n-TORR AO {y RAMP U TAORAM DATA p?? I p NONINTERSECTION ?,,,,. AC-ENT I NIII %HD CLS INTERSECTII.G STREET ORROAD oRREF. N gE-EEN STREET ANR S nEET MILEAGE LOGE `_,9 "- . ERE IGF,C?OSj?TFF,ETORROAO l1 /Vl G UISTArvCE.WD0IRECT10N FROM REFERENCE RCROSS STREET -,E tH E- NGUSE \V ?AI?LE9 N 6[5 FEET ? OF/"! _, - COLLISION INVOLVED: VEHICLE-VEHICLE ?VEHICLE-BICYCLE ?OTHERIWRITEI ?HRAgUN SEVERITY N OTALNU VEHICLE OBJECT nVEHICLE RR TRAIN ?STOLENVEHICLE ® 0. NILLE NO.-UREO OF VEHICLES ? VEHICLE PEDESTRIAN ?NONCOL4510N ?HAZAROOUSMATERfAL PROPERIYOAMAGEONLY OBJECT STRUCK INAME OF OBJECT STRUCK ANDOMERS NAME) 'I LOCATION OFORIECT STRUCK EGI. DAMAGE . 5 E V! ? FOAD'NAY 111 ?.? ? ? FD EDGE ... S.. DRNERB.-LAST FIRST MIDDLE DHNEH'S NAME LAST FIRST M.OC. OF U CYCIISi OR PECESIPIAN CNECKI R - r e R .-LEN C u ?o s ?- 4 I STREET ADDRE I -Ell ADOPESG V J V C" a 7 / E R CI BTATE ZIP CODE PMONE NO. E CITY TATS ZIP CODE E NO. T?eusA?Jm _ R a Ilir7 CCo/n GUS 32 1v N DRNERB OCERSE NO. 9fAT_ ?E% ATE OF B:fliH N UHIVERS l1EE-E NO. STATE SEX DATE OF BIHTH p• to S ?i /GG W. M 09Y VR. M a 3 p n U4 LAO. DAY YR s ' DRIVERS OCCUPATION FIRM NAME PHONE NO. Z GIVERS DECLINATION FIRM AME PHONE NO. ?adadc? / ? Mein ?r• c CODES > 13I IC S c c u 141 SEATBELT !^. 151 EJECTION CODES > 1]I INL UR L q55 Y TAI SEAT BELT 151 EJECTION TUPEOF INJURIES NAiUREOF INJURIES REMOVE. FR MSCEN-RY. TO E REMOVED FROM SCENE RY- TO VEM.YEAR MAKEIDODGECHEV1 MOOELIDAATNOI'AI STYLE120R:CONY.1 VEH. YEAR M KEI IODGECMEVJ A MODELIOARiNOVA) STYLE I2 DR?CONV.1 V V 757 lb 7- A/ 210 l2 E VEH. COLOR UC. PLATE IW. STATE TRAILER PLATE NO. STATE E VEH. COLOR VC. PLATE NO. STATE TRAILER PLATE NO. GTATE I Will aj/? F:271 C VEHICLE IOENRFICATION NUMtlER ODOMETER C VEHICLE IOENTIFK: ION NUMBcR ODOMETER E CC- 7 V '? 33 E a,'5-' 5 5 P /691..2,3 0 REOISTEREO OWNER-W^f FIRST MIDDLE REGISTERED OWNER-LAST FIRST MIDDLE o. 15 a t - , / N p &P AOpHE54 OF -N ER -A 55 OF 2 s S L-` NAME AND AODRESSOF WSUHANCE GO.OR AGENT NAME AND AODHESSOFINSURAI c .OR AGENT St7 F CO CHARGE G TATIONNO. ENFORCEMENT CHARGE LITATI N-O. 7 ) C2 /7- 3 ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODE$ _ 2 % a , SE% AGE STATUS N EJECT. NAME: 7 C ADDRESS'. C! •?? _ r J? ? 7 U P I NA UREOF REMOVED FROM NNRIEG. BCENEBY TO A NAME: IN T AOUI NA E $ t I T R MOVED FROM NJU IFS' SCFNF RV'. TO W NAME: T ADDRESS } .'?tUY IFF D TIfRo. N R SCENEI? TO S r oue:.-_ S A _?_ DDRESS. E • g Tisf'(f Ia?EiriF3u'---- nrv. st;?NEnr - r o 1 1 U 1 AY PO ... KYI ' IW C ^. I WSEAL DELI Is I LJECT%7N i C ] FAA E40AR (( '0 JUR I` I 6A1 SCENE J S D U O 1lJURV NO- D11111 S 1 NOTIV51AlLFD 11.1 IN NOT FJF.CTED I D 3 OIN R ]T I I ? I - O ED oSIVA ? ? - O I ? ) P 1 ? n % j ] L ry ` PArIt ECT [0 E [ InNF3i 1 ' d ! I A ]._ 1 Oi i ^.•1- <nO WM1 Y . OS U E N fJ 1! l-oll J U PJ10W . t v SEATBELffA LURE UN-0-IF EJECTED 91 NEW= ..Clyk':m:??4 DAMAGED VEHICL'NO. T (USE THIS SPACE FOR SNEICHINp OHMAGE iO TRAILERS,MOTOPCYCLES, ETC. VJ? T 13. HOOD I DAMAGED VEHICLE NO.2 a a '?T1 = ?- ?F 14. Rool wit -T 13.1bop LE ?? IB.UMWCenIpN T la. Tr,nt :E PGYO DAMA IT,OVwtum ' 1 IB. GnC«un,ape . GE VEHICLE NO. CptSABUNGOHMAGE 2 FUNCTICNALOAMAGE - I SEVF.RNYOFDN.IAGE: (O(HERVEHiGLEI SEVERITYOF OHMAGE VEH,CIE Np.2 1)0- 3QOOIERM.V.DAMAOE 10 DSABUNO DAMAGE 3COTH { NODAMAOE FUNCTONAL ER MV. OAMAGE 1CDIAEU SABUN6JAMAGE 3COTHEN M.V.V.OAMAGE 2 DAMAGE NO T. . TOWED By -/21/It S n h) ( 7nr EST-AGE TOWEDBY ' DAMA2 NALOAMAGE F E3T.DAMAOE TOriEON NODANIAGE 1J ,•. EST. DAMAGE TO ? llUlA1C 7 IJ ?J IfI I- TO //Y S 3 DIAGRAM OF.COLLISION ! I I .; TO - PONIWAY . K a rxAa ?? •?-t- ? ~- k f ii >>- , ? I I I a? DRAW ARROW SHOWING ORTHINCIRCLE I Ca cONiRa Aov: Al c?r c H.eMamuer,a110i9i ..._ .. ? 7 _?. ' ? i I ' I ' ? L ?? T--T ?'=: e tt z. -.1. woeAELewwrw _ _ ' . . Irv ,RIOLEVeOEarwANM - EC ro41IC`N9Ai MVA<r. ?I ! I __ ( i ; ? _. -_ ' ! - I I? 7I ? ? Y -' ' ? - I ( ~r I T ? vr,OeA EVEHKLEOR A,,D Airtn DIa, a„°RE ' DES ? I 1 I ? I f- ?_? iT i _i-? - I "T-t1- a?'. 1 I I ? I j ?q 9 'F COLLISION N,O?• ; IINOICATE WHAT PROBABLY HAPPENED BEFORE,OURINO ANDAFTERTHECRASN.INCLUDE INFDPMAigNNOTONDIAGgpM E6.DPIVER DISAB UTY, REOUCEDVISIBIUTY, PEDESTRIANCLOTHINOCOLOR,CONSTRUCTION DRREPAW WOgIL ETGI. ?fnti ' ftlr, h ?fZFlUELI rJc,<J, Of> lC_'L0 ?7`C 110 I.Jr L T '}UIZ 01J4 CO. e,7r`?1'!. -- ??.L sb U r A__? ?iCl!L? ?_?c ( I f.D T J FC7 !i 1_i 1 ? C 74C J 7? J+ E N - r J s /?_?? o ro ' , . ! J CA So-)G 57 0 L rt i . n S r p _ { _ t d A` ..... TI N _ BEFORFC4 L ,.. IEH ?Y HEADED MILEPOST DIR 0119igEEi OR HgHyyAYNAME OF NO \O 'IN ONE OWECTON E H ? = IW M . - ws1 , WC.1 LEO A LLY DECREASING ASV N 5 E W ....... .. .... ..-. - E. D :. ._ OCC D 1 nQ?? _, CoR?..r?12. -C -moo ?sc O? ? Y U E9 i ? ? r 11 E9 N - Y NO . - FED ? n [-. D - n n - A '. . L ND „ , PmrBICYCWTWASUSNA3 - I?-I n r n I?fq ejpa wux Amy (1 s?NA _fnw :: J JC_ v ou ROADSURFACE,?, -r,',-?.WFJITNER. v l 1 ?m"eR ?'I - .,cNL.,aSrlw,wt.. CONTgIBUT1NG CIRCUMSTANCES. cN aNO < _. e ' _ &yC' ' y' ' :; ? ro n I oN l . c.. ?, f c Dmw,cNK[ t Ic oR MaEi Y .,t . ? p yy fi>y,?lf a . z _ WET 2 ? Rliwq '? - NO 2 Y ? ?Q Q"? =CU-LY 03?-mFWBICe OF ? n CDRFA ?n. ENrL - ?a? RgN XN.•- L J }I L _ %? ._. ,1, rr1 ? '7 rI sww V-sNOww ?r--77a? srtiou°iNOM,r°r.rtO ? DonV.R, _ I?,RE _LOCAiIoN rr?? IJ ? L'?i H ? LEFrTU I ao r'j? u a ? a°AFCevEiOP? OaroinvNRnrW ? rWU`«rm°rTn J --- O ` W -----? ?e? Mrt . V' » _ ?V MTCfMlj DrNEA,avCI-I a ,??? . L1GHi CONOIT10N5 :TRAFlRC CGNTRDLR ICntO,r MO M 1.1 AaaiNO "w JTYPEOFF1 AD;, 012,7] 510 .+0 a ;,VEHICLECONDITION;; l 1' v9UI nMaTl 30RRIE7Y ?,? :, -- ] VlHICIt O10 6gNAN ICHECN MEq - !fl Me WAY EI ENIGP y?„pMr?Pleril<rF01 A - ctCi?.7. VTMNIf ICNECNOp ?,I 7 . _-.M. E !! aTOVVmN ? e IA- ?T ? W,y a " __ D6`Eii?' -owl ? ? P ? RMOw ? .,. OHIO ? ;? .. a Dour ET n r? o Ww -1 11-13 ?l - ??a r M< (I.??71 eoewErr 1prTYAND OLIO uE j1O IKHi]pi 0 of n a A. ^p,O 1 f 6 - I r -.. __ W r ___ rmEa wncrul, o mveR 1 `,. ... -„q- ° gNAt - or .. 1 `""E I < c«u e LJ ? Ma,oWN ' ' ` I ro a CHEM. TEST ?- I-} e uoRn . . ? .- 1 -• i_L ?. sE .n o T y ? J L I rtarorveN ranlae+elFn r oTM f ,: ? ,mwEO ... _ ,? ND k, TenPEwseD - Y EMrn(Il? I?_ ? M K ? ray .f] UMmDrO .acEo-,. °`'S ?OM ,-..OVh .. c TEST RESULTS % 2 .1 y 7 ? ' wnaro.-?.aa•.r mar./ uaN.u. a1,..r J tD n.rz .. lr , fir' I'.R+ eAmYno O r.m .IN?r.D,cE RA ,T„'.';° F? Hat X rcr ,^ Mnar rper e< ePVr APVnMeue. n DURiC?tECDPY LgC?I LAW ENiOiKEMF.Nf I -T oiP WC ATOE CGPY. M`ESiI?GATOR 9C?OPY r ? agi?l ? Isry?. . ? f lr I_r rEA; . Ii pEs? I '.Ij.'r r;l; 7,, I hik\} U GATE OF COLLIS,CN DAY OF CO LLISION Pu' C OUNTY NO. GRY NO.. FHWA r..o. pZy Y i 'U1 I MIN2 IDES D WEU INIIN 5 FAI B SAi 1? - AD' NgURI RURX E' / COUNTY Z A .-CLS PREFIX P GUF EET CODE OHSTR U CiiC. ?STATE ROUTE ,M000Ntt ROAD ?CItt STREET O _ . . 7 , Et C('S,') ?OTHEF,SPECIFY, W V 3 q? 5 L W III CITY OR IO'NN N5 E ? ' W P REFIX EO. MILEPOST O C ` CI MILES ?-9 ? ? ®OF 'po IQCQ ! y V A I MEdM10.OF'TREETCRHlGHWAY IIJTERSECTIN'G WITH: STREET OFROAD LL R AMP DIAGRAM DATA T ONe / F • I O I NQ II PSEC ACCIDENT I NTER ON N - NTERSECDNG STREET CR OAO OR REF. O MILEAGE I TER CLS. E RENCECROSS STREBTCRAOAD N BETWEEN STREETAND STREET CODE DSTANCEAND DIRECTION FROM REFERENCE OR CROSS STREET ?, VnG+ET . .PECIAL COOWOUSE ?MILES N S E W- - ?FEEi ? OF -. .• ? VEHICLE BICYCLE ?OTHERIWRREI ?HNSHUN COLLISION ?VEHICLEVEHICLE INYOLVED: SEVEP.Irv NO.KILEO TOTALNO ? VPXICLE-OSJECT ?VEHICLE RR TRAIN ?STOLENVEHICLE ' NO.- RED OF VEHICLES = ? VEHICLE REDESTRIAH NON COLLISION ?HALIRDOUSMATERIAL ? PROPERTY DAMAGE ONLY CBJECT NAME OF OBJECT STRUCK AND OWNERS NAME, LOCTTIONOFOWECTSTRUCK EST.DAMAGE ?ROAOWAY FEET ???? RD. F.CGE '"'" Y DRIVERS NAME LAST -Sr MIDDLE CAIVER'SNAME-1,ASTFIRSTMIDDLE Ilk BICYCLJSTORREOESTRIANCHECKI 5'M //f/ /?/CftR2D H. A R STREET ADDRESS STREET ADDRESS .. v J -/Y/ 414,5 i /,vs's 1 E CITY STAY ZIP CODE PHONE NO. E CITY, STATE ZIP CODE PHONE W. R P "f z/ ;9-w -s E CJ.? , 9f/36,63 R N DRIVERS LICENSE NO STA T E SE % DATE OF DIRT. N DRIVERS LJCENSE NO. STATE, 11 DATE OF BIRTX °' `` MO. l C M0. DAY YR, sly -? r- H - H 'to6 KU 'I /l WN A 3E,'1 DRNERSOCCUPATION FIFMNAME PHONENO. 2 DRIVERS OCCUPATION FIRM NAME -E- CODES CODES > wl jg 01 SEAT BELT ISI EJECPCN CODES > IDI CLASS NI SEAT BELT (51 EJECTION LURE OF /?' INJUR,FS C-'3C-G r? I A L E,IA7frj&j NATURE •WURIES ".-U FROM. NE BV: TO E OvED FAOMSCENEBY: TO VEH. YEAR MAKE, ECHEV.1 MOOEL(DAR- VA) STYLERDALONV.1 VEH.YEAR .-EIOOOGELHEV.1 MODEL IDARTNOVA) SttLE120R`CDNV.1' v lqbq CkeV PI U. v E IS.. COLOR LIG PLATE W.. STATE. TRAILER PUTS W. STATE E VEH. COLOR ... PLATE NO. STATE TB.ULER PLATE NQ - STATE.-, - N SLUE U$12$2 LJA. H _ C VEWC -TIFICATION NUMBER :.: .:. - ?. .;- :.: D D METER ,.:.: .;: C VEXICIE IDENTIFICATI N NUMB R -.:; , DOGMETI. -: E < qjc lsy;-l /a?sG G E P.EGIS- RED OWNER-UST ?.:-; FRST .._?: _,.-. _. MIDDLE PBEWERED OWNER-LAST.:..: FIRST. ,[-MIDDLE ON sXINIC' Rs DQIV ti o- , ADORE OWNEfl ADDRESS OF OWNER. " NAME0,NDADORE590F INS URANCECO.ORAGENT NAMEANDADOPESSOFINSURMKECO. OR AGENT..,, /? CoAV JwG-A t AME2. , ..... CIT CNARO f '• ADON W, ENFORCEMEM CHARGE .:. ?... .:' .. CRA ION - :. _ ..:.. • ACTON IES OF PERSONS INVOLVED U Dopes F _ A s NAME, ADDRESS & INJ R . AGE STATUS W PJECT.; C NAME: ' C ADDRESS. U P NAIUREOF SCE EBV FR M TO IIRIES. naI A NAME: N T ADDRESS . $ ATVXc F EMOVEDFROM WURIES SCENE AI' TO W NAME: T ADDRESS N IEAIUAtES T E NAME S ADDRESS E NA 'U NI STATUS I]15AATAELMDOH C D ; FEES1NL- rCL151 A 1 D E TN' n0v,vNESs D ] I. NO PDURY SOIS1111.1 G Nw- I. NOTCISTALLE0 I. I.OTEJECTED 20EADATSGL%E BNON CISABLP.O ]. NOTINUSE 2.TOTµLV EJECTED T 011-PO^HRON iEtADONAFINVAL EVIDENT, INJUPY OUSED S PARTIALLY EJECTED BUS MOIOFOYCLE, A DIED IN HOSPITAL 1. POSSIBLE -URY A. UNKNOWN AUN,U'01 F B POSFIDN UNKN05yV S. SEAL BELT FAILURE EJECTED RI 1 1 (?4 t Ml1 N 'T A T 1 '+M M°v. JA? 4 T VS 1L 1,1 ! !. I (. ' 1 TI. I L?1??FF J r I. X 1 1 4 - r. Ir I( „k: 4 T 1 ?d. r 1 1 1 _,'? u Y ,1 !t aA r. a j"• v s , '• - L Rl 1 1 / - - ! r! VEHICLE DAMAGE HEAL u.. c E wA lIROE EACn DAMA<.EOAREA. 1 GHADEME O SEVEREST IAPFOT • )E i " INSTRUCTIONS: _ d - 3oR RFOWSI TO..HOW PRINCIPAL DIRECT- OF FORCE. s ?x OAMAGEOVEHICLE NO. 1 11,E PACE FUR Sr.ETCHNGOAMAGETOTRAnERS.Mn,pRpYCLES DAMAGEOV ©CLE N0.2 SPY -la LS ! M1 )E,Y" "! J . yy?-T.I 13.IbW l/'I (1?" 13.Iba0 s ?_ Da FROM 3•, AR la ua y ' 11 ?. , '7`???± a ^?µ li wenlm H Y- 3'f' SR SEVEWiY Ui DA.MAf V4nICI?E lyj1 SEVCWTY OFOAMAGE.IOTHER VEHiCLEI GEVERITYOF?O?AI`!???AA?TTGEj": VEHICLEN0.2 i)'O+aRVn_ 10o-JNG DAMAGE 300THERMV. DAMAGE 1003ABONGDAMAGE a 13 MERM V. OAMAGE 1003 BU GAGE 30UT ERM V.D ItAGE 2?iU++CTIONALOAM.AG A NU DAMAGE 2 NNCi OVAL OAI.IAGE lQNOOAMAGE 2?FU LTIp .AL DAMAGE AtjNODAM GE ,. iowEDBY LrlC'.SOll l trOS E3i DWAAGE TOVIEDBY E9t DAMAGE TOl.ED BY 5 OAM.AGE t - Tp OI' + LO'.ns Rid, T r S A Cr1F L To To 1 DIAGRAM OF COLLISION - - I i3._ _ • t DRAW ARROW SHOWING 1 T i \ \ - - .I?-11L.1 NORTH IN CIRCLE 1 tF. • v 11 I I z _LL LYDE.TN.N?R _ _ ---- I ltXt ? DESCRIPTION OF l l .i T l'hT FRpE.n_v HAPPryrC 9=FORE DUE'. '•DAFTERInE CRA5X 11.t,L D II Or'.MAT ONAOT OA D.4G9AM.EG DRIER la' "' :. :COLLISION J ?.. ',_q DJTY`fi'DULEOYSBI+Tr E[iE3TP ANCLU H'3COLOR,L0N3TRJCTO O P_P .RV.CP.K,ETCi- <- •; D ver °c_,.. in ?/0 f: alcn he acted the ct-v h syei Su 9LniDg cross c y n h .,r:Ea 'eLT. LO s t;.e eb ect and clue to Glle rain On the a..ay To t? colt 1 of the -le icle 7 he t 6h:c e s t adfish _ 9 i1 il1F, and when he. ent ar d - e ct i gertA k y. h? icle rolled over several* ..ies. .._ .." ..._. _ ._ _ -J, I +J.t., F -i 1 JN -,.o or cj oN..,a.w ' _. .. I r ?A. E-?,_?:u .I 's?F oAr' PR D G CU En eTI. y/ " s w ?'?. .. - G 45 / YEL t:p "E3 NO ? EI $i I ? ? -131 A T: V ?, ti ._ ? 3 + i CST IIyI 1 TS ?. I ? 1 N • 1 k I., C LL?J ? A i e C? r i ,0 (G 0 D ',; ? 1 lV J/ C c cvr rr I ? IT rt 1 'y9y r i ? , ' 4 ? ? MR-•1 4 W{-F Ald hHYf . 1n:, +I1?gZ??' F?' MKS 7 M. G }} j IN3 j a - lfy .r I (vri .?:k itl ; + l'?y ?? .r', t l [ I ?? 1 1 ee m _ • Il 71 ¢wMv 1 J ,i 0 c O DATEOFCOWSION BAY OF CIXLSION TIME COUNTYNO CRY NO inW TpE MOB D? AY YR. i SUN 1 MDI 2 IUfS D WL A INUP S FRI B SAT (USE ?AUO HOUPI J .. / /? ? RBNI. RURAL COUNTY ?STATEROUTE ?CCUNTY ROAD ?CITY STREET O ADM.OLS. PREFIX RO UT E OR STREE T CODE SECTION :. ?OTHEHISPECIFYI Ul UT ' - y -/ S / // o L N S E W IN T CITY OR TOWN W PREfI% EO MLCfroST O ? ? [1 ? O C MILES LL NAME 6NO.OFSTREEi NIG YAY INI ER$ECTINGWRH: STREETOR ROAD. flAMP. DI GflAMDATA T ON 1 O .-INTERSECTION -_1 ACC DENT f?lE NON XPO INT NILRStGTING SIAEt Ofl IIOAp Ofl REF. N BETWEEN STREET- STREET IA LEAGE CODE ER IX5. ????\ ERENCE CR SS STREET OR ROAD . '-YY DISTANCE ANDOHE{ITION EPQM REFENDICE ORCROS$STNEEt N u NV -1 ALl-1-Y. SE • / LES NS E W ?M ?FEET O ?VEH EWEHICLE ]VEHICLE BICYCLE E] OTHER (WRITE) ?NTARUN COLLISION INVOLVED: NO PI BEVERRY LL ED -.UE RR II ]STOLEN VEIIICIE OTALNO. O ? . OF VEHICLES ? ?„ONCOLLISKm VEHICIEPEDESTRIAN ?II-RDOUSMATERML ?P- ROPERTYDAMAGEONLY .. OBJECT STRUCK (NAME OF OBJECT STRUCK AND OWNERS NAME) . LOCATION OF OBJECT STRUCK EST.DNMGE. ?POAOWAY FEET o 0 o a O.EDGE S -ERS NAME•LFST : FIRST ,, _ MIDd.E : DRIVER'S NAME-LAST FIRST MIDDLE (IF BICYCUST OR PEDESTRIAN CHECKI D R . .: s . p 1 STREET ADDRESS ..:,;? .,.,. ...... .. A STREET ADDRESS ,_ .,.... ...........:_ .. ..: _._. ._..: .,.., SE GiY , ?. .,. ., ..' STATE, '. ,.... LP CODE ..:.... PHONE NO. SE CITY , . ..,..- STATE / N DRVLAS LICENSE NO.. STATE SE% DATE OF .RTN N DRIVERS ""'BE NO._,,, . .. STATE SE% DATE OF 811TH Q. M0. DAY YR O,. . . MO. DAY YR 9 DRIVERS E, __. _.,. .. P NEA S 1--AME P N NO. = CODES ?i 1Dl ` UcY IA1 SEAT BELT 1EJECTION CODES 131 CUUSS IA1 SEAT BELT ISI EJECTION : NATURE OF E ..S UV E:C -.Es V WES NA INJTURE- URIES FROM NE BY: TO FROMSCERE BY' TO VEFI-l q MAKE(DODGECNEVJ. MDDEL( ART1101A) STYLEI2DR-CONVJ VEM. YEAR MAKE kDODGEwCHEVJ MODEL IDAflT•NOVA1 STYLE I2 DRCONY.) V " '. . I (I..' V E VEH. COLOR UC. 111E NO. STATE TRNLER -1E NO. STATE E VEH.COLOR UC. PLATE N0. STATE T-IE fl PLATE NO. STATE N 1 ... I H 1 O V(111CLE tptMIFICATKJN N'JMdEH .,._. ODOMETEfl , ,. .. VEHICLE IOENTIFICATI?NUMBEfl L L _ , _ . E E REGISIERED OWNCI-LAST FIRST MIDDLE REGISTERED OWNER-UST FIRST MIDDLE N N O 0 DURESS OF OWNER ' 2 14111E AND hODRESS OF I-RANCE CO OR f.GENT AMEA14DADDRE580FI145URANCECO.ORAGEM - CRAROE A RRO NO. ENFORCEMENT CHARGE rCiiA7 ON NO. I ACNON J _ a D s ADDRESS & INJURIES OF PERSONS INVOLVED Goofs 1 NAME ' , SEX AGE STATUS EJECT. 6 NAME' C ADORFSS' D NAIJREOF??-?-i T- RkMOVED FROM -- P INJURIES. _ SCENE DY- TO A N NAME T ATONE Of R 1 E NSA---- i? J 11 N By E)UR'CS c BY TO 111111E ?f W 1 S A" T"" Di' o' N .PA ... $ L. 'tom- f 'i 1 ---._._---_ 1O , 1 JB '1..lAi 'i?ON C 'S ?? REL7 ( fJEC110N (` 2 q J Y D 1 RY 1 OT 'SIAUFO 1OTf FC1ED 2 OT NOSE 210TALLYf FLI FD O ST 5) T I 11 L V 10 J I'AHit L FLIED ?f..3 6 tl (+ L .r ?• AL ! ::C N,JRY )1!4 U': NIF .I Ai If[Lf iA fIE FJT.CIEO L1JL ti I ? I ! {' 7 fir[' 1 ? ? ? t VL J 1 ti ?' k r;7 1 (fhi J 4 I; I? I ? I 1! F ? y r ,, '7Y"?"h 1 i F lil ? I F fk 1 z V r 1 Y M b. ^ iID4R p DAMAGED VCHIC LE N O. 1 s YALE IDR fKrtCH Nc uAMAGe rD TRAIL f, oTRC STC., DAMAGED VEHICLE N0.2 r ] m T rF"' a. T ? C C a f _.._ ^'H ?{ I]OUr•Iwn I. U_ U ? C'IV _ EEVERIT O d GENE CCE NOfI SEVERITY Of DAMAGE-IOTHfR VEH CLEI EE RIlYOFOAMAGEVENICLFNO•,i » - 1 DIE tl GO ] ? OTNERMV.DAMAGE ] L-1 FUNCTIONAL D M1uGE . Q NO DAMAGE 1? J7 OISABLINGDAMAGE 0 OTHER M.V DAMAGE r}'?1 DISABLING DAMAGE O ? D V MAGE ] lJ FUNCTIONAL DAMAGE . H NO DAMAGE ] LI FUN ? MAOE t IP F TOWEDSI'l ! DAMAGE O foe DAMAGE O EO 4. ET OMnAOE .. F TO DIAGRAM OF COLLISION A ArF 1I TO f l o ! ?????? 1I71 I ,1 f' ... y'DRAW ARROWSHOWING RTH IN CIRCLE _ x. »DA Y[»IEIt .[D[,.A.N DA DM[Dr.D, D , r Tr , e0esrquNr,r»fe[fON AxO Ar,[R COLLRION S ., 1 h \ L .: 1 j - 1l _?_ ?, I .. __ DESCRIPTION OF COLLISIOf?f a 1 DCATE OBAB pErv ED OEFOR N AND AFTER THE CRASH. INCLUDE INFOTION N IL CED VIER - EOESTq C OT INGL R CO TTAUCTION OR HEIAIRV IGE CI OT ON DIAGRAM. E IV ER _ I. T 1 I1.? _ - ' / ( + - / ? i ?[ , yr -i ?•, '/ut c ? .?Y) Fy,, ;. 'I ,t•••?• ?l? y ?_?.1 E .' . v E`"_-_"--'•-rT--_.T/'1f.-1-_..G? L ti •. +iy5 IT EN. V EADED 0. - NBE ORECOLLISION MILE POE C NC SING DEC EAS ND -- - R. 0 E T OR N G Y NAME Oq O - W. OF LANES ECTION HOME CHR f E E CGALL ARKEO - .1 -FED E CCUP1 ED f? Pi I 1 1 ?3 - I u " O _ l_ E : ED C G.. O D F ^ -Y " s LO ? I CYCI TWAS USING. eR .-. r " p S EW ] ] IEHOU R ED S KED E G TE.- lf- LK INALAWAY l 'C OSSwa FRUTE .)OTHER L • OAD SURFACE ECKONEI WEATMEfl ICHECKONEI _ ., .. CONTRIBU C TIN CIRCUMSTANCES. HECKONEORMOREI R ERNSHCLE ACTIONS ?NO ]v[ Cl[ NMR d O L t . [xL1 R DER ]? ^ CRIVEN O, ] IVE ..... N] r ! ? „J G qA G T AMEAO _ 1r I DRY _ _ 1 L?10VEBCASrD : ??_1?CCOH06?_.CE I ?,,.J ]..?-!QQGL419,Ek'L_ ANN t 1 ^ L ltl ??ND PAKING ' [1•)f ? -T ) i ING I URVOS MI E <E ? L l? -1 O F CE Eq I- . _1 ABLEEP NiLY ( 7 L-.J ]I-. MIGHT TURN v -??] WOw _ WOW 3 I`f I 1•( ` 1'Ll Y [O f ET iE O .-r f G L 11 E? ? LOC TIDNPA G , 1 I_JA? .. fr i C[ - !J t OP'•- f ( E EE fFD RE Al I DE - ? _ I_,EI I 0 ".29m .fiFO LI.PT TURN •-t1 KING ?1(.TURN , y n LLL Y C111 THER T JD E iC E N. q ' - I L. DTS 6000LG I I_.1 1 . SLOW NO ?EI ? 1 O I NLR ISrtClYI O I e." MpgOPFR A 'I]? DISR CGNgl Stop BIG S 10. OTHER ISrfCIFYI rIEO FOR I STO TRAFFIC • 1 ONDITION N:HLCK ONtI TRAFFIC CONTROL I O E CLE CLE TYPEOF OAD N0.] ICHfCK ONE OR ORE VEHICLE CONDITION ? SOBRIETY I STOIrE0AY914NAL I JfO . I f GNL J f 1 ,I ONE wAY r VEHICLE I4 L} Q INO'] j??`If115T01 VEHICLE CHECK ONE) INO.) .. dl`} _ .11-111GN rl Y f? STOIPEDIN . _.___ -LG-N ._......__... ,I.1J TNO-MA? L ?lw.a%BHAKtS Vl _ BUPAVI ILIA I?- J u L-l J ROAMAY I IO? J THATfiC6A.9 DA I] __ _ F T]r I YIELD I .SIGN ]I 1 -R[V[REISLE t ?.J RO D . Ef[ TI I]I D C VF L. EADLGNT9 ---- 7.- _ INO ?]?I -MAIM I TY NOT ABUD I-1 IIIC, BAR KTIM.F T10N ]? Wl .. -' REDS G I ?? I 1[ C NC[ LOO PA lJr DE EC E 1 1- USO [iY 'MERGINGIINTEPINGI TRAFFIC) CMINK G T90N EE - f L _U ?f 1_FLAf G AMBEII fly AL [ _ L-1, Ef 0 tl.9Y0pJN O e E ONINKING S?CKIxO. e, DARK-11.1E1 . ...,. LroN7fo}L? I e._ I IIG R N ?e iuBui tiielr I?f _I y,u .:.. - I'. I I. .?... DARK-NO f ? ltlllET LIGHTf OFFIC[ I ftruCi A,fp '? ^7 refrGWfN I Onlc I IEL IN.' 1 , . . TI i M ILA" N e rNf ?._ ?' ) 0 [O . _.. I I f NO OEF ECTS ___. _. _._. ...._. .. •. - 4• 1 I I TCSTREFUSfD 1 . k CII Ur[C FYI .OT E CRNINH I 1 UNOIV TOED MIM IY[CIf YI % TEST RESULTS Z Nv117 GA,ING01ICiMSNAU9 SHANK 0AU01 NO rOLICIDIYAICIII. ULICI ANINVLD NCl ow 1 A AMR HIUS MO[OlO rl +< ?? I I 1 _,_1 ll 1 -.•. f N00 ..A ]EGO M Hg X INVIfTIGwiING OIIICINI NAM) ).AMA INGOT NO Inky UNIT ON OIfi,1011. OAT-n-Ill, ,-BvIUeY OAiL ?d k I DVILICATC COPYV LOCAL LAWCNI DIIC[M[IIT AGINCV?S COPY ?TlIIPLICAIE CGPV?tINVFSNGA7UR'StCOPY 1 ,. I I ':?'?kfYl. RYA '1711,11, "151117m 4 tCKi I 4 sum ??Y lv "2 L6 ?? A 77, [' N ?C 4 " OATS OF COLLISION - DAYOFCOLUSCN IIII 111 SAI III(5 WE TIME (USE 2400 OUR) LO"" TYNO : /? ' CI - ,fMWA; NBAN YI A E1r• u ° t /1 T M DAY f SUIT MDN ) 1 t 3 5 0 Y J _ URA, . 1 iJ A E COLA TY NrSTATE ROUTE COUNTY ROAD ?CITY STREET Q ADMC S PREFI% ROUTEORSTREET CODE. CTCN ,X l??, f TI / (/313,4 ? OTHERISPECIFYI L 5 E W ?IN. CITY Ofl TOWN N W PRE I% EO M ILE-51 .D MILES ? ? ? ? Q LL C - NAMEA NO. Of Si RE' ORH NWAY -' IN1E SECTING WITH'. SiRCETOfl flOAD flAMP DIAGNAM DATA -- - - --- ' t T ON C! Z I . I' NONINTERSECTLOi. CC DE T NTE NON RD INTERS CTING STREET CH ROAD ORNEF. ? Q. MILEAGE TER CLS. kRENCE CPO STPCOR ROAD S , `- ,- N BETWEEN _.-__--_.____.... ..STREET DLS LODE '•. )ANCEANUDIRECTCN FPOM DEFERENCE OR CPO55 STREET Mx LS.1N KuHMrt SPECIAL COOING USE r - OES, ?. - ?MILEB N B E W J. __". VEHCLEWEN CLE ?VEHCLE BICYCLE ?OTHER(WRITE) COLLISION INVOLVED: ? IT ARUN SEVERITY NO KILLED SIO ENYE CLE OELECi ?VENIGCE RN 1nA1N _ ? L NCLE No INJUflED IoTAINO OFVEHCLES D ?VEHICLE PEDESTRIAN ?NON COLLISION' ?HAZAPDOVS MATERIAL PROPERTY DAMAGE ONLY OUJECT STPUCK INAME OF OBJECT STPULK ANDOWNERSNAME) _ ., .. .: LOCATION Oi ......... KS': E ,,.,;, .,.. EST . DAMAGE + MIOULE - --- ± : ?POADWAY FEET ? ? ? ? NO EDGE S FIRST MI?L E - III UICYCL D DRIVERS NAME LAST S ON FLRESTHIAN U:: - •? - D - FIRST ; DRIVERS NAME LAST--- ---" nai£tSO?I v FST- ,, D.. ;. , . _ I - t . vv, XG' PL 1 [?vh rT 1'Y??v??-.. d g _R STNEETAOORESS - I 2? 1.J2??ILL u P 1, G v .o , ti3x 8i C? 33 w:??u 1. r. R E CRy - STATE - ZIP CODE . PHONE NO. E CRY STATE :. :. .. ZIP CODE..: .- PHONE NO. ; R , R P4 ?'Ow?S? t..?w 83?L ?'SI- I t " Ir a.' nI N + D VEPS LICE IS NO. SLATE S E % DATE OF BIPTH N DRIVERS LICENSE NO. STATE SE% OAIE Of &HRH O. qQ O (07 7 1 V? ?c- ? , , J S \ Mo OT O r, S80P7 6..J11A I_' lO. •2oAr R LL 1 I 000PARoNl 1IR1A NAME - . .. - PHONE NO. OPNER 0 S rj ION i1NM NAME -11H. C1 000 PA I -' _ P EN :? {_ TMt ? S . G '- t P 1 ( c 1 ? . } JE 1C C?`1 ?O ? - I?l• 7A v S M c \[ef CODES J IJI CLASS- I41 SEAT BELT _.__ 151 EJECTION _ ? CODES 11, CIAU- IAN SEAT BELT. _ I EJECTION- n r -J 1 TUUREOF - - N E U - JUKES F IF\1G OLL NI' ' '? Vr TO E EBY R HMSLENEBY TO , O SC F VEH.YEAfl . MAKE IDODGECHEN.1 id MODE (DART NOVA) ?s STYLE IZ DR CONV.1 ' - v E YEAR mss- MA EIOODGE CHEVI ?d z MODEL (DART NOVAI STY LE IZDRCCNVI ap z?? b E. VEH. Caoa LTC. PLATE NO. . STATE. . TRA14EJ1 PURE NO BTATE ` .. E... " VEH COIAR UC PLATE NO- STATE TRAILER PLATE O STATE ??L R 1 iUE Flf3(oZ t Gie v? . YAL92 c,,c? 4 VEH lF I IIFCATCN NUMBER. '-? ODOMETER .. C VEHCIE IpENTIFCATI N NUMBEN : ?..: "-? OlX1METFA " E E REGISTERED OWNER - LAST ..: F.I .... ..: AaDOLE ' LAST - ; I iWST .. .. 1.. .. MDOIE RE.SlEREDOOV4NEERR- r , • >a 0. - ApOPE53 OWNER .:. - ::. .?. ... 1 - .. .. .._. .; '. ADOHESS OF OVINER ..:... 'I .: ':: ....: .. ... .. '?e.P - NAME ANDAOORESS OF M511R CE A • NAME ANDADDRE55Of MSURMNCELO. OPAGENT o ?..J? CITATKA O? O+ CITALIONN CHARGE : N- + ( ,. . ,EIN IAxE. FORCEME .. _.. . . NT - 7 P AcTron NAMEI ADDRESS & INJURIES OF PERSONS INVOLVED co SE% ots AGE ""' T STATVS _ u. t _r T s EJECT. _ y 1 C NAME- { S 4 C A; E55' n U NATUREOF SCE OE nYD'FROM - TO Wmm[s I p A NAME: T S AOdLE53 REp VI:D FnOM O SCENE BY j TO 't I „ URIf 441 NAME: .1 1:1 I ADDRESS - O, v!'DTHOM--- Nf N N TO nL S N l NAUNIr - / p E S. ... _ .? NAME.' I j .• , S 5, ADRuPESS iTv2-DTRSM IINiURI SCI I+E nr To 55 TAI S[Ai O[LT 151EJEC11ON r F J F C p 11151•IUS ZPAsu-n SF[pISTHIAN A BSYC IST 1)IS[ATPCSIICN F-1 eOTHER oMt- I IJHNJURYcLA INOWJURY ZDEAD AT SCENE GDEAUON FRR VAL I SIIISAD NG INJURY 0[IONDSAUUNG I[VIDf NTHNJURY POSSINTIR INJURY NOT 1151ALLED NOtIH USE. 1USCO ` [H01 EJECTED JFCI[D Z IOIALI rI DPARIIALLY CJCCICO A - f ? L 5 D E f OTN[n a e [NTN[..5 - nu^ olnncrcln 63 epOSiI ON UNKIgvrt! Ap[DCN HOSPITAL -+ EAT ST DELI FMLUnE 5S [JCCET I I + !' 1, A 1 '?Y7 C `? r - 1 A 11, ? ?xa Il[, E Ter „ rY II ,I, 4 , TL? I A C . . 1 ?. L ' I i f r N f A E DATE OF COLLISION. q ./)' / C AY OF COLLISION T E- ! uN i I4- J €P q E1 E Flil E EAT W. OG17., ?• n.t O Y N i _ / C TY NO YPfl _ ?'-- U {/• ?? E F1 l: /? CI??J Z [JR STATE ROUTE COUNTY ROAD CITY STREET O OTHER ISPECIF YI W q PREFIX R OHS E ODE. SE UNA OUTE CTION N•/J.?? O L N ? I CITY OR TOWN N F W Lm''T IN II,, ll S 4 f M E5 ?N? L:l ? ? OF T • ?j WiU- C U l PHE I% ER .. R. OST - ? C P1 O'lflEE q _ IN FL:[CIING WIT :]T J R EETO M / (p V T \ ?F I ?I 0 1tl /y 1 L(i I../ O ?. V RflOA LL / / O RAMP RAM I NON INTEH]ECTION '" - IO; ClLS. D ERSCCTRI 5 EC IIH EFFnEN C N -.E. T EETANtl STREET EC 5 • ? OIS T A N CEO ?O O I gEC ION FgOC REFS NCF..OR CROSS STRECT r ZQ L E S ` // 11 // '?Y E ?____ OUING USE J' U?l ]FEET ff Tdw^ 1 ;:' - R6 ?y r Y i I VOLVED: 1I11i?'-?'-T'11 VEHICLE-VEHICLE CLE COLLISION I- VEHICLE V -BICYCLE < TOTAL NO. EHICLE-DEJE OTHER IWRITEI ? IT N EgITY llp LLE C . : OF V "'. CT nV NICLE -TRAIN E CLES C? yEHILLE-PE (-1 OES -IAN U N ? STOLEN ? , D VEHICLE ?/'D'J AFD 7 ??????}}},yyy??i i J 1 N L' COLLISION IDF.CT STgUCK INATIE,pO TLTRU NEfl M 1 r HAZAR DOUS M AL LOCATION ON OF OgJE<T ]TRU CK PAOPERT EpAMgOE ONLY Si I }? i y (p? ' b k 1 Y E f) ( i C I 1 l II I VEfy Nq E L ^ //1 L?-?1 T N DWAY 1;2-E . "AMAOE ??1r IJL?? EOO }j +'? 4 O . rtr t /J /r. ,'.: LE + /-T-?-. t Ii/.?? ?1 •? "'IM: S T SN D . S AIDDLE,- IIF PEOE IAN CIIECKID ,5 R / - , _ STNEETAODR .' 4 ? ,. GTATE P -, OOE 1131111__ 4 R b C, T ?rJ 1 (.J lJ " 1 .. .. ST ..., R r . .. .-0.. . ,,•, _. H p F O ' r y ?p . IVERS LICENSE nO 1 6 7?J? l a 3 4?1 N . ?E E R50<C AT O N R qME. GJN " \ SE% qTE OF GIRTH 1 ERS LICENSE NO. :.. x N .. [STATE E RTT" IN " ' . - ua/]' /' ?:. P, INE,NO. ORIVERL,OC UPAi10 / Z IIC%IL/?u. III ACC F/ CJ /CF'G ,111"MA ME ... .. r-.... .,.. .. HONE NO. . I /V ,u,..e_ ?a&[43FU ma 1. ?e •R \.. ?'1 r /, ?^ /? - - °••, ^"•. EIUQDUE-LNEy. N DELIDAn T_NDYA STYLE.IO DR: EGNy.L.: }? LI .PLR E0.: STATE ILERPI NO STATE. .. :.: N.COLOq PLATk . o E STATE t . . LEO PLATE O. ._ ,... O e IE IDENTIFICATIO N Efl;., •; ._,, CE Ij( r J2.-',7 O O E En ,,, ?., C' NICLE IOENTIFICgTIONN MUER ., ODO k HEOISTEREO jER-LAST .. ., .FI .... T ............. :-DOLE '. E. nEGIETERE00wNEfl-LAST .. FIRST -RP OLE::::.r. ,. O; AODnE o ,J, N NAME ANOAOONE55 OF INSURA NCE CO.Oq AGENT N AME AND ADDgE55OF Irv5uNANCE CO.OR NT.., '.%i7,'•"?.? /I,;, -... N//, ` CITATION NO. .., 27772 ENFORCEMENT CHARGE - CITnT10N N". r //7 5$ Y ' ACTION _ NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ' CODES _ U C AME• SEX AGE STATUS No, C T FJECT. ' C DDges]: U IN, . . IIII ES HEMOYEO FRoM A wME: N N RA, T rAiDD of W I oNl ss: n pF E S S Eelc S. ?IJ?srATUS ul rcAT ro]nON ' C Asugnen . s ffpnsTHlnN , ? 1 ' a MuT, CLISi s T.OTIIFR P091TIOH n IL A WITNETNI IRD]_MOTONCYLLE) E LR G ] p, POST TIONUNKNOWN D S UL NOI Uq I 8T?N?YnLTLED I&SftDJFF#p Fp 11 . NON-DISAGNtNO ?. Nor' NUSE T. TOTALLY EJECTED L VIDE NTI INJUgYr O,u+KN ]. uAIi TIAIIY lJ[CTEO L ]. POS]IOLC INJUgY J "' OWN NKNOWN If < ` • E. EEATUELTFAILUAS ' ..Crc. DTI J C \i 1\ r ii X41 ?I i?4vG fli v? ? d II~ rb,., 4'}` „? 77 5 - ;p. fit. 1 I+rI ILA` rb'jacJ a?1 .? , Y" 'h JYiI y 1 11 ?1h fr \ S ? L? I I ' T I?