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HomeMy WebLinkAboutCrash Report08/24/2007 13:16 3054165444 , C.011 DA TRAFFIC CRASH REPORT MIAMI FIRE RESCUE PAGE 05/05 DO NOT WRITE IN THIS SPACE S c t 0 2 LONG FORM MNLTO DEPT. OFHIGNWAYSAFETY 6. MOTOR VEHICLES, TRAFFIC CRASH RECORDS, N1:1 KIRKMAN BUILDING, TALLAHASSEE. Fl 32399-0537 O'70S1( Location I DATE OF CRASH (1 �� 1 IE Of St{ 1 (�J-7 ❑ AM PM 711v1E (OM A NOTIFIED I Q AM PM TIME OEPICE I c 10- _ AAAtvE7ti AM ^ % PM SWEET. AGENCY REPORT NVMBE 1.� SSW CRASH REPORT NUMBER q{ 3 V 7 5 7 1 COUNTY/ CODE 01 4 {o FEET of MILE(s) N $ E W CITY OR TOWN El 7 III 1 M (Check N In Cey or Term) t'n c Any l C Nt r am i o m E AT NODE a FEET a MILE (S) FROM NODE NO, NEXT NODE NO. NO. OF LANES 2_ f. 0 2. UNDIVIDED DED TT+EEr, ROAD QR HLGNwA � f• AT THE INTERSECTION OF (sestet road or higtn ayl a FEET MILE(S) N S E W FROM INTTION OF (greet odd or Nghway) 1, 'Thom ORrvER f 2 ACTION 3.N/A Run ✓ YEAR 66 WJIE f� "� TYPE (� p f USE O? V. UCENSE NUMBER STATE VD{ 1 LE TMn1AAM771447tio17 IDENTIFICATION NUMBER 2 eft ,;�. 5 6 I � T 1A Undermine 'M.d 21.rrow TRAILER OR TOWED VEFdCLE TRAILER TYPE lYt)7 B POW FIRST POINT INFORMATION 14 13 12 11 10f 9 0! Anneu VEHICLE TRAVELLING PI -0 E {-w-L Su) I 1 411 ON AT - Est MPH 2c Posie0 Spaod Zd EST. '10, VEHICLE DAMAAGG OCC3 1. Drsablrn0 FtnICITOMal 3. Dsrleoe Z. E EST, TRAILER DAMAGE °PAtAOE LY.6l.W ARFAMI 3 L Pedestrian ❑ Vehicle C MOTOR VEHICLE INSURANCE COMPANY (LIABILITY OR PffP) &� bk.. S (DFO• .( Si.c POUCY NUMBER M VEHICLE REMOVED BY: 1. TON ROleeon L1st 2 Tow Owners Regum1 3, Driver COM& 3 OF V6BCLE OWNER (amok Dort Tut OF P 11 Same As Duvet) t A M 1 CURRENT ADDRESS 3 ^ end $ 1 t cQAa3 CITY TATE . 1(J€ (—cCcDOL.3-r-Gack.� ➢P NAME GF OWNER 4 T,ak% it Towed Vo O0) CURRENT ADDRESS (Amber and Street) CITY AND STATE DPP COM NAME OF MOTOR came ICamerrea vel0cle 01tly) CURRENT ADDRESS (7Abiber and Sweet) CITY , STATE AND ZIP COPE US DOT a CC MC IDENTIFICATION NUMBERS IE OF DRIER ( uP,� pee From Driver Lkancn) .N�2� / PEOESIS{AeA— l clARENr ADDRESS Av ',— (Humber Ind Ito" Street)) ,...)1 CITY, STAIR B ZIP COPE } t E L �3tiz rg 4 TIE OF WIM 0 DR LICENSE NumBER STATE DL RED. ALCARUGTEST TYPE RESULTS ALC/DRUG PHYS.OEF RES RACE SD( INJ S.EOUIP. EJECT. .7 4 Z22c el-t C. 1` (� TY 1 Blood 3 Ulrtw S Nona En* 4ReNeed 1 f 1 l HAZARDOUS er01EMA&S 13E1140 TRANOPORTBD n ACAw1E0 tF YE2. INOIC1010 Ow IAADvm Ar01 OP Dicta aGIT IIUI/BER Fs�M F{y TAANt OH OJt J .TON 0i DO,Ma0O. Box WAS sumnuu, NALAl0ler OFILE 09 RECOM 0VSR *TES EXPLAIN IN MAASAATE 1 DRIVER'S PMCNE N0, 1 Ted 2 No L. . Tat Me I z-4 I 1�.. I rem 2 No �()' Ir L` 'Peet 2 Ne ( ) DRIVER 1, Phardarrl H 2 s Run YEAR MAKE TYPE USE VEN. LICENSE NUMBER STATE VEHICLE IDENTIFICATION NUMBER 2 3 4 6 �.��� te, 19.OYerbAn ACTION �' 1 17 8 2.77 TRAILER OR TOWED VEHICLE TRAILER TYPE "AM p Po1wt INFORMATION 14 13 12 1 I 10 9 oat j w VEHICLE TRAVELLING N S E W rF j1 ON AT Est MPH Posted Speecl EST. VEHICLE DAMAGE t. Do . 2• eel Na Dma9O EST. TRALER DAMAGE 0561100E AND CIRCLE Wawa] ARENS) a U _FZO MOTOR VEHICLE INSURANCE COMPANY (LIABILITY OR PIP) POLICY HEMMER 7- REMOVED BY: 1. Tow Ronda. Us-1 2. Taw 0wnett Request 3, Dnver 4.00 et ❑ > NAME OF VEHICLE OWNER (Check Box K Sarr.1 Ad Orfnel CURRENT ADDRESS (Number and Svs001 CITY AND STATE DP CODE 0 NAME OF OWNER) Trader or Towed Vetdc4) CURRENT ADDRESS (Amber ;, :. CITY AND STATE ZIP CODE C 00 NAME CF MOTOR CARRIE7i (C10Th l VeHcb Onhl CURRENT • : • SS (Number and Sheet) CITY , STATE AND VP CODE U6 a 00 MC IDENTIFICATION MOMS to IDOT ED d o- NAME OF DRIVER (TOra From WeerUvonse) / PEDESTRIAN CURRENT ADDRESS (Number bed Street)) CITY , ST ATE B ZIP CQDE DATE CF BIRTH DRIVER LICENSE NUMBER 1 STATE OL R£O. ALCIDRUG MT TYPE RESULTS A4C45RUG PHYS.DEF. RES. RACE SFX MJ, Si EQUIP. EJECT. TYPE END. { Blood 3 Urine 5 None 2 0o t RoA,eed wAs HAZARDOUS MATE. BEING - _• 1 Wm 2 Ne • ..•• • I Yw2114 CI e TCS. ar0ICATE MAME OR FOUR Oldi RUTARCP 1,40m (A MON7 OR BOX AN0 LDSSIT NUMBER FROM BOTTOM OF buxom, r WAd, Wr2AR7VU5 RE0OMIENO DRIER R5-Ex5M, IP YES EXPLAIN or NARRATIVE If�1I 1 Y« 2 he I 1 DRIVER'S PHONE N0. ( ) ICode Information Y£HiCLE TYPE VEJTj(J E.17SE TRMLER TYPE �ro cE (Drlvec l Petl) PMvslcAt DRFEG7s ALCOHOL / DRLICOSE LOCATION IN vEHICLE 01 /u ronoben 02 Van 03 OOP TEL0A 1 P,U: 2 or t Ms tint 04 NB6uf1 Truck • 4 rer tires 05 Heavy Truck - 2 or more roar ale. 0a lex /- traga (Cab-000000 07 Mora Norte (RV) 08 Bus IOmer - seals Ia0-15) 09 Bus ( dinar r subs for new 151 10 Mork 1t Uoro.cycb Moped IT TM ercekr VONok 14 Iron 15 La. Epeed VoNde 77 Omer 01 Prvate Tr. r,„ rAt.rdurr 02 Cerrmcralal Paawrlgom 03 Commrdal Cargo 04 PM* Trer/opdrgtion OS Fut*A: School Bus 0B Private &rod Big 07 Am2Uanea 08 Law0rM,e.rrem 09 Fire ! Rescue 10 Anew 11 OtMrCronCaersem 12 Coe Concrete M6xer 13 14 0a bage or Refude IS Cargo Van 77 Other __ 01 Songfe SerN Wet' 02 T ones Sens hula. 03 Tare Trader 04 Sande Mount) Need 05 Dom Trader 06 U6sh Tra1k, 07 Horne Tracer DE Pole Trade 09 Towed Vehicle 10 Auto Transport T7 Other 1 Coady of Cretin 2 Elearnera In Stele 3 NOD-Reeftk x Out d St ie 4 Foreitn S UAlknoem 1 No Dckc: Known 2 Eyegge:0abcl 3 Fagot / Askeo 4 Hewing Defect 5 Inners 6 Se-:ztre, EPlkvey, Bmckou 7 Omer Pryelcel DH eel 1 Not Orbiting or wing moo 2 AVOhDI - Under Induerce 3 Drubs - Under inAven35 4 Akohoi d Drags - Under IMluenre 5 Had Bean Odnking 6 Pending ALDORVO Test Remit 1 Front Lan 2 from Center 3 Front Right Rea Leg 5 Reel Career 6 ResRght 7 9 B Body Of r or utPatwnwr 9 Ow DI_ TYPE SAGE I A 2 B 3 C d DI O vslls.. 5 E/OPeresx 6 E/ Deer. -Rest 7 None 1 WN1r 2 Eese.S 3 HL5OB0Mc 4 Olher INJURYJEWRITY 1RAEEILEQ 0 M NTALUS I None 2 Fusel* 3 0540-1 TSMA• aaAi 4 5 (WINn9 (VA1Nn 30 DeTa) 6 Nan-TrA. rook - 1 Not In use 2 Seal Bad / Shoulder Habeas 3 CM4dRoss-due 4 Afr Bog - Nre Dwpd 5 PA' MB0 - Na Dapbyetl 6 Solely Hormel 7 Eye Prow -don REQUIRED SEX RSEMET�j 12 Male I Yes 7. No a No Eaooraemel6 Renuihl Female EJECTED 1 N0 2 Yes 3 Pala RBMIV-40003 (REV. 01IO2) Pepe Of _--. 08/24/2007 13:17 3054165444 MIAMI FIRE RESCUE PAGE 01/02 ofitiER 1' PPa font l � MAKE TYPE USE VEH. LICENSE NUMBER STATE VEHICLE IDENTIFICATION NL.Ps4ER 3 4 5 6 7 18. Undercm6e2e 2 Fat B Ron AL'TION 3.N/A �J ......me- 20. puritan 20. VJMdslhkl (3O�. B ., VEHICLE TRAILER TYPE 27. 7ralbr TRAILER OR TOWED INFc4MA11ON - � tn..- wow RIM POnt1 14 (3 12 ll TO 9 pA ELE VEHICLE TRAVELLINGON N 3 E W I" 1 n AT Est MPH Ponied Speed EST. VEHICLE DAMAGE ng 2 flmcdonal J. No Cimino EST. TRAILER DAMAGE DAMAGE O AND CIRVL6 Witmer, AREA([) n . C> ■ . L MOTOR VelICLEIRISVFLOICE COMPANY (UA.BILITY OR PIP) POLICY NUMBER E REMOVED BY: 1, Tar Rotalan List 3. skiver 2. Tow Canes Request 4.0dkr m NAME OF VEHICLE OWNER (Check Bps 8 Same ANDfMn) CURRENT ADDRESS (Weber end boors)) CITY AND STATE ZIP GORE Q NAME OF OWNER ( Duller R Tatted Ve$) CURRENT ADDRESS Number and ... , CRY AND STATE ZIP CODE C NAME OF MOTOR CARRIER (CannoUal VeneJe Only) CURRENT AOORESS a , • end sVeet) CRY , STATE AND ZIP CODE LIS DOT a ICC MC IDENTIFICATION NUMBERS 1 I 1 1 1 6 3 10 0J NAME OF DRIVER ( Trice Awn Diver Limnos) l PEDESTRIAN GURR,. • s • - ESS (Norte. and Steed) —. CITY , STATE d ZIP 000E DATE OF BIRTH DRIVER LICENSE MAkiOER a RE() ALC/DRt73TESTTYPE RESLLTS A1.CIDAUG PHy5.OEF, RES. RACE SIX INJ, S.EQIAP, EJECT. END. , 1 Blood 3 lJrk+e 5 Nam i B,aaM 4 Rehired n -•• i - -- AL8 Kato TRrw6PORTEO 7rd,• YE2, procA7 w gN FLAOARp kg) , 7nrT OR4 CM n...3- -. 00.47.• •••: ' NJYaF Atle180Trou Of 01A1100D. -r, MATERIAL DOW miter_ -• r•.r. ND.- •' srw. IF rue EXPLAIN IN NMRATNE DRIERS PHONE N4. , 1 Oa ?No I as 2 No ( ) 1 - • PROPERTY DAMADE0-0 '3' VEHICLES _,•_ EST. AMOUNT $ OWNER'S NAME ADDRESS CRY STATE ZIP # 2 PROPERTY • •a. D•OTHER TWWVEHICLES EST.AMOLINT 5 OWNERS NAIVE ADDRESS CITY BTATE DP VINO n7FR R PIsnFSTR eN V H(C E eFr.T VEHIC) F MEIVFMF14T VEHICLE S PFCIALBRICZIONS 01 No temper DiVelf I Anon Wang In Nr cs E 2 Q 91 No Defects I� O2 Del. Brakes. 01 M Mead 0 © 3 Slapped f Stalled 1 None Fatm 1 © 3 02 CUERen (Evooln module) 003 F RgJ9M - of - War » r % [ 03 Warn r Smooth Tie 04koproper Delecdra 1lprooer 0 22 02 Slowing 1 03 Making ten Tel a Backlog I r Jl/ I / 2 3 Pagoe Pond( + Rb6r4 l r// 05 Improper Lane Clings LigFa + 05 n9 RIVETim 11 Passing ng 5 Emergency D8 Tun // %� 05 Punting T Biewotd r II 06 Ural 12 Ddverteae or 8 Construction IMehoanance R 07 PJedtd - Under IMuenCe / / 06 Sleeting Mech. I/ 07 Eniminp / Letting 1 PPddng Spare Runaway Vehicle SOURCF DF CARRrF INFORMATION oB Drvge - Under Inform 0f Apo&0 Under lMuante 07 WFndssael6 Wtpas 08 VoNtie 77 AN Des D8 Properly Parked 77 An Ocher poi.* Parked 1 NO1 P09400ble j 1 i x D a Drugs • 10 Followed Tao Comely EQUpwrenl ( Defect (Ecplrvn In Narad^eL 09 8TCrVpply In Na adve) 10 Mddng UT oo 2 SreppIng 3 vehicle Papas Side r t i Disnowded Para Signal POINT OF QQLUS)ON _ 4 Oliver 12 Ennead Sae Speed LAna 19 Improper Ions 01 O. Road ID 2 n/ J U S Other 13 Olsregmded Sep Sign 20 Dtgagr<ded OOtiv Trams Dame 02 Not On Roe4 „-2EDESTRIAN AQ30,,y 14 Fared To MAntoln Equip. /Vence 21 Diving Wrong Side / Way 15 0i rcpn Passing 22 Fink*" 03 Shoulder 04 Median / 01 Crowing NO at htla+secion 07 wailing 0 02 Crossing Mid In Road 2 © 1 Remaly 16 lk0+a Lett Of Center 23 Vatitle hewed / 05 Tan Lane at block Crosswalk 03 Crossing et trtesrnecion OD SleengrPteying Buo(nefa 2 Primly 77 Exceeded Staled Speed LkM 24 Driver I iPic1 n (E�Idn WORK AREA 04 Wearing Aipng Road WIG, Traffic in Rood Reddendal 18 Obslnc9n0Tratec In Narrate) ��� 01 None R:J [17] jJ 05 Waadng Along Road NOV 'hank 09 0•.i&. In Peden.. Island 3 Open Country 77 M Other (WON In Narradre! 02 _Jae by 03 Entered D I / f / 00 WOAdnp on Vehicle In Road 77 AO Oder (E.p n k, Nara6ve) Be Unknown F3J T)&1lBSE9U T QJLE1! NIf51 ROAD SYSTEM IDENTIFIES f�UGHTINACONDITN7N . iblo 01 Coa 1Wd1 MV 1083 0kt( Rau Etc) 1�1 S-t= ' Wen News 29 My Ran Into 1NtaM:uverl 02 CUNWith win WIn Transport( Heed On) 113 welt Sign 1 Sign Rem 30 Ran Off Road Into Wamr 0 d a 01 drowsed* 07 Forest Road 02 U.S. I 08 PrietoRonde-Ay02 03 Slats 77 Al Other (EwpIain 01 Day5ght Dusk 03 Dawn / J_ Q 03 Cai0shn Wet MY I Transport( Angie) 17 MV He diary Pcie / Ught Pole 31 OrerMned 04 Onielon Nth MY Trarep it a1t Lea Turn, 16 WV fat 0w.arat 32 Ocau8ant FM From Vehicle 05 Dawn MAW NV al Transmit Right Turn) 19 MV NI Fence 33 Trackar/Tralm Jackknifed 06 CoRakin Wit MV In Tmmpoll Sideswipe) 20 5t8 ND Concrete Sankt War 34 Foe 07 Wade, WM MY is Trenspon) B oked 040 21 MV Nb BidpehTErer/AbormarlRaa 35 ploelon / ' / 1 / a County In Na reiNel 05 LOore 06 TunIPike / Tail 04 DOA (SOW LigND 6S Dan (No Street UgIQ 88 Oritn0wn _ROAD SURFAC y jJQN WEATHFR ROAD SURFACE TYPE 01 Dry 02 Wet 01 Dear 01 Sla9K,nveiralone 08 Caation WA.0okedCa 22 UVMalTree 0S0ruttber/ 36 D0'wn01Rwway 09 Cotbbn Wtl, MV on Roadway 23 Collelan Wen Carettic00n Barricade Sign 37 Cayo Lou or SINK 1 (0 Coition Wlli Pedlar* 24 Colston VAd, Ttal6e Gale 38 11 eoisiat wro, Bicycle 25 Co61 m Welt dash Adenomas Median C}osgow f�f' / L G/JI I /f IL /� / IL /mil 0l lei 77 Al Date (Eynon) in Nxaeve) 0 ] ! 02 Wudy 03 Rain 04 F T7 3ak1 (Explein Narrdeve) �0 J! In 02 ElectaM9 04 Comets 05 080 77 AY Other (Erytein Naradvel 0 2_ in (8ace Larol 24 C0I.y7on WIg1 Fixed 0tr$ef0 Afore Read 77 A9 Other (E�lyn In 12 DoYrkn With Mooed 13 Down WO k100ed 27 AIV lit Colter fixed Oblect Nrcelvne) / / / 14 COlelon Wan Train 28 Coasion Won Moveable Otged 0n Road jQARG0MIWr 1 ALTTME OF CRASH VISION OBSTRUGTFO SITE LOCATION ItRAFFICWAY C216B6aFR 01 No Delo= 02 Obsouclon WM Warrkq CO Gbs 'uafon wo .t Wan:no D4 pool Dr,der' Reprk / COnettceon 05 Loos. Waco Maerhts 08 Shoulders • 044 r Lee f Hgh 07 Hoke / Koh f Unmet Paved Edgy 01 0 01 Vlslp, Not obscured 02 InGemenl Weadw• 03 Panted 1 Sapped Vehicle 04 Tim r Crops 7 Buayea 05 toed On Vehicle 08 Buadm0l Flaed 00800 07 she.; (Dlbaadt 01' _I+EEIGSD.Efia wh.1 v --^ U-Tum Zane In OS Not N Intersection I RR X•tn0 I B Repo 01. Simian - Lade 02 At hkeraeo9on tI Al Influenced By u+easao6on �'� 71 04 Drrvew.y Aooex 05 Ra4read 11 Private Pro uoty 06 Bridge 12 Toe Booth D2 argM - llpy.4. r DawnOiede 03- 07pvo - Lew! 04. Crave • Worm I Oowngrede I LP/ 07 EMzwee Ramp 13 Pudic Bus Step Zone mplataill f FE 08 MI Ramp 77 AN Oder (Esplaln In 09 Renato Lot • PVb9C Narra6ve) 10 Perking lot • Private 01, Paved � � 02. Llnp eved 03. CO 08 Sterwont / P tche 09 Intro /Poached Road Sur/aca n M Other n Nar:aveJ / / Ott Fog 09 Smoke 77 Al Olt a (6kposn t 0 Cana In Natra8vel 08 FhrMng Light Na,-arva) 09 Retrosd ti(paai (0 bmaer / Owed / Flagpersan OD O r tea _o > SECTION N NAME OF VIOLATOR FL STATUTE NUMBER CHARGE cJTA71ON NU/ABER SECTION 8 NAME OF VIOLATOR FL STAT MBEs CHARGE GrTATNTN M.ALBER SECTION it NAME OF VIOLATOR FL STATUTE hk7MBSR CHARGE J�t� CITATION NUMBER • SECTION 0 row CIF VIOLATOR FL STATIRt; M B ( \ CHARGE CrraTIDN M1e1DER Page —2— Of 08/24/2007 13:17 3054165444 MIAMI FIRE RESCUE PAGE 02/02 rLk.;mum 1 rvlrrit, urv-.Or1 mcr�rC I NARRATIVE/DIAGRAM MAIL TO: DEPARTMENT OF HIGMAY SAFETY a MOTOR vEFACLES, TRAFFIC CRASH RECORDS SECTION. NEE KIRKMAN BUIDINa. TALLAHASSEE, FL 32399.O5O0 DO NOT WRITE IN THIS SPACE 0 7 0s I f TIME EMS NUIVIED (FATALITIES ONLY) AM EN TIME EMS ARRIVED (FATALmEs DNt?) Om GPM DATE OF c CRASH I I 101 COUNTY I C CODE 0 t (cce) MUT. AGENCY REPORT NUMBER l' 2 HSMV CRASH REPORT NUMBER '72'3B-75-1J (NARRATIVEJ VE.,4_1 t cLe 4 1 L-FeE.P9G...z,► __. 1 RA V 1 Q (,,e 1G TP \VEL___t%U(. _Sc i -4 60OtJ A iI T'4. sIl o-Ac. M C . `174 S-r -r . t-7 l Ad E S N cs T L € L_ L tTE /\ N3 !b I .S F r(--4 C-e_l_ SNP JS -{ Exr` f \1E € C3\/ , A LARGE. Pc Trpo or A i E. L 4PPeoy I--.c f f- 4 r e`! 2 -s7- c 5_-r- I C3 5:11 C. s OLDS' I r-ci „I L r- r 11-4 c -r fir,. o &y f T 15 t -tom, s r A At ( t, -ro -n-\ E. L► Gi-k- ( 13G c0 - r m -5tC._ ` 1'EC ee. t I�C. cx{& ... E NCB T r(ct 4 tC.,.L. IC#-4 i Ct4460 J--i c. fS T Ycfr___ - 00 C)�. i � oV&aNG ; . a e- 113 SECA PASSIPirrb\f j�{ E CURRENT ADDRESS c t c0- _ CfrY STATE DP COOS --r - DA OF 81 T5/ 52 RACE ( SEX L3 LOC INJ 1 6, EbUIP. EJECT. ISEC!FASSI Z 5 1 2 P N'6 N OER CURRENT ADDRESS � CRY & STATE ZIP CODE r 1I03 k`7ST DATE OF RTH 1 1 RACE 1 SEJI 15 LOC INJ a- S !:QUIP. .J CT, P IL'S NAME CURRENT ADDRESS CITY & STATE DP CODE DA OF BfrITH RACE SEX IOC INJ S. EOUW. EJECT. OCA PASS* SEC* PAS PASSENGER S NAME CURRENT ADDRESS CITY & STATE ZIP CODE DATE OF BIRTH RACE SEX LOC INJ S. ECVIP, EJECT, SEC/1 PASSI PASSENGERS NAME CURRENT ADDRESS CITY a STATE ZIP CODE DATE DF BIRTH RACE SEX LDC INJ S. EOUIP. EJECT. SETS PASS', PAS°,.EN6ER S NAME CURRENT ADORE53 CITY d STATE ZIP CODE DATE OF BIRTH RACE SDI LOC INJ S. EQUIP, E.K:CT, ^y 0 `.8 > SECTION'S NAME OF VIOLATOR FL STATUTE NUMBER CKARGE CITATION NUMBER SECTION A NAME OF VIOLATOR FL STATUTE NUMBER CHAR CT ON NUMBER �._. l ( e-J J t- lk t- wuNESS NAME (1) CURRENT ADDRESS CRY &STATE DP CODE WITNESS NAME (2) CURRENT ADDRESS CITY . STATE DP CODE ST ND 9Y •NAM: T. Physkian or Nurse 2 Paramedic or EMT 3. Ponce A. Certified ls1 Alder 5.00Ter Olc, INJURED TAKEN TO + u A BY • NAME HAS NVE$'f1OATI0N 22. YENO R , ` f l IF NO, THEN WHERE? IS IpNESTIGATIOCOMPLETE? N 1. Z N06 IF NO , TNEN WHY? DATE OF 05 REPORT 1 ( I C 7 PHOTOS IF YES. BY WHOM? IGATkIG N3ENCY TAKEN 2. S r ► { 2. OTHER — a ID/BAD � �� D T reeNT i�(a ! t l ��� ^�I C J+_ FHP El SO PI PD -' fiER NS 5 (Rev.1,02 Page .. Of