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PRR 17-2616
To. Page 1 of 4 2017-12-1517:38:01 (GMT) 15615941838 From: Brett Steinberg FAX COVER SHEET TO COMPANY FAXNUMBER 15617370188 FROM Brett Steinberg DATE 2017-12-15 17:37:38 GMT RE Michaelle Louis, DOA: 12/08/17, Crash Report No:: 17-2398 COVER MESSAGE Thank you! WE'VE MOVED! PLEASE NOTE OUR NEW ADDRESS Laurie Levy Legal Assistant to Brett Steinberg, Esquire 10 S.E. I st Ave., Ste. C Delray Beach, FL 33444 Ph: 561 630-0053 Fax: 561 594-1838 Email: lauric@brettsteinberglaw.com www.brettsteinberglaw.com 4400 PGA Blvd. Ste. 600 Palm Beach Gardens, FL 33410 Ph: 561 630-0053 Fax: 561594-1838 Email: laurie@brettsteinberglaw.com www.brettsteinberglaw.com E-MAIL CONFIDENTIALITY NOTICE: This e-mail transmission, which includes its attachments, if any, is intended for a particular addressee(s) and may contain confidential and/or attorney-client or work product privileged material. If you are not the named addressee, or if this e-mail transmission has been addressed to you in error, or it is otherwise not clear that you are the intended recipient (or his or her authorized agent), you are hereby notified that you have received this e-mail transmission in error and that any review, disclosure, distribution, dissemination, copying, printing, maintaining, saving, or other use of this e- mail transmission is strictly prohibited. Delivery of this e-mail transmission to any person other than the intended recipient(s) is not intended in any way to waive privilege or confidentiality. If you have received this e-mail transmission in error, please notify WWW.METROFAX.COM To: Page 2 of 4 2017-12-15 17:38:01 (GMT) 15615941838 From: Brett Steinberg Steinberg Law, P.A., immediately by reply e-mail to the sender and permanently delete the e-mail transmission and its attachments, if any. Thank you. WWW.METROFAX.COM To: Page 3 of 4 2017-12-15 17:38:01 (GMT) 15615941838 From: Brett Steinberg VIA FACSIMILE: 561-737-0188 Gulf Stream Police Department 100 Sca Road Gulf Stream, FL 33483 RP: My Client: Rep ort A'umber: Date of Accident: To Whom It May Concert): STEIN a3Iou X" LnW iiiorney December 15, 2017 Michaelle Louis 17-2398 12/08/2017 At your convenience, please forward my office a copy of the crash report for the above - referenced incident. Enclosed please find a completed Sworn Statement for Crash Report Information. Thank you for your prompt attention to this request and please do not hesitate to contact me should you have any questions or concerns. Very truly yours, Brett M. Steinberg BMS/11 Attachment: as stated Delray Beach Office: 151 NW 1st Ave, Delray Beach, FL 33444 Palm Boach Gardens Office: 4440 PGA Blvd #600, Palm Beach Gardens, FL 33410 TPI:5G1.630.0053 1 Fax:561.594.1838 I Www.brettsteinberylaw.con To: Page 4 of 4 2017-12-15 17:38:01 (GMT) 15615941838 From: Brett Steinberg SWORN STATEMENT FOR TRAFFIC CRASH REPORT INFORMATION Motor vehicle crash information Is confidential and exempt from disclosure for a period of 60 days after the elate the crash report is filed. §316.066(3) (c) Fla. Stats. (2003). Obtaining confidential information by someone who IGIOWS they tare not entitled to (lo so is a felony violation. The undersigned requests the following crash report (date/locatiotn/parties): !x/08 Aa -7 13 R6 Q n OCDlI n QI�L' VFs(r�c AAM ichuelle kouis 6 ISI JJk, The undersigned states that he/she or the organization they represent qualify for(Y& immediate disclosure of the crash report according to the exemption checked below an does swear or affirm that information contained in a crash report made confidential by statute will not be used for any commercial solicitntion of accident victims, or knowhngly disclosed to any third party for the purpose of such solicitation, (hiring the period of time that tine information remains confidential, ❑ I am a party involved in the crash, 91 1 nm it legal representative to a party involved in the crash: Fla. Bar No 11677 OR Immediate Relative (relation) • . OR Written Authority from immediate relative, copy attached. ❑ I am a licensed insurance agent to a party involved lin the crash, their insurer or insurers to which they applied for insurance coverage, Fla. License No. ❑ I air a person under contract to provide claims or underwriting information to a qualifying insurance company, identified as: ❑ I un R prosecuting authority, Fla. Bar No. ❑ I represent a radio or television station licensed by the FCC or newspaper qualified to publish legal notices or a free newspaper of general circulation, which qualifies tinder the statute Name of Raclio/Televisiou Sf ttion, Newspaper ❑ I represent a local, state or federal agency flint is authorized by law to have access to these reports. ❑ I represent a Victim Service Program, as defined in §316.003(84), Florida Statutes. Name of program: Brett. M. Steinberg Steinberg Law Printed Nanne Agency/Business Represented 15 l N W 1" Avenue Address (561) 630-0053 Delmy Beach, FL, 33444 (Area Code) Telephone Number City, State, Zip Code state of Florida, Comely of Palm Beach Sworn to (or affirmed) nod subscribed before me Ibis day of , 201_, by Brett. I41 Steinberg known a or Produced Identiricatioi_Typeofl.d. produced: Prrnl,Typc, or Stamp, Couunirslmled uaoieumoiw7y ziptiftin of 'Notary P icor Ccrtlficd Lmr Enfmrocment m• rrecliomd Ofaccr Driver's license or other photographic identification, proof of status or identification that demonstrates qualifications to Recess this information were reviewed by day of 2p1_. agency employee, on this . — YOVANARICOLESANTILLANA MYCOMMISSIONpGGlF10509 EXPIRES: February 19, 2021 •. •�,.' Owsw Tem fiotaty Pow ualoftr*m TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via e-mail December 15, 2017 Laurie Levy [mail to: laurie@brettsteinberglaw.com] Re: GS #2616 (Crash Report 17-2398) At your convenience, please forward my office a copy of the crash report for the above- referenced incident. Dear Laurie Levy [mail to: laurie@brettsteinberglaw.com] : The Town of Gulf Stream has received your public records request dated December 15, 2017. I have attached the report to the e-mail for your convenience, as Motor Vehicle Crash Reports are confidential for a period of 60 days after the report is filed and they are not available to the general public during this time. On February 15, 2018, after expiration of the 60-day period, per Florida Statute 316.066(2)(a), you should also be able to view your original request and response at the following link: http://www2.gulf-stream.org/weblink/0/doc/116147/Page1.aspx We consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records This TrBffc Crash RePM can be pSCMAo ante .INmlr.wyuwl..w111 I WAS DOT PROPERTY INVOLVED IN THIS CRASH? FLORIDA TRAFFIC CRASH REPORT LUNG FORM ❑ 5RUKT FORK[ ❑V OPDATti ❑ 113 I AC F OF vERICEE ,StV lI IOR(5) 2 Itttwa.d Mmj TOTAL * OF PERSON SECTION(S) 2 MAIC TO: MPAR I MEA 1 Or RIUMV rAT 5AFt I T & MO i OK vtRICEE5 TRAFFIC CRASH RECORDS, REIC KIRKMA196UICOING l U I AL * OF IQAKRR l fvt_ SEC t IONIS) T TACLAMASSEE, FL 32399-9537 LASH DATE TImE OF CRASH DATE OF REPORT REFUR-"1110 ...1 Cal• NUMBER HSMT CRASR R1111015" R<llfren UVW2YT! I 1V:35*%n I I zrumzu I I , ih'64ya I urur4tvr CRASH IDENTIFIERS W.athhr CondMon Ra-dw.y Sorfsoa Cenditim; Sahael 6a: R.I..ted COUNTY CODs C PLACE OR CITY OF CRASH CHEC; CK IF WITHIN TI -E REPORTED esS� TCRED ICJNCO13E 06 �-....., veto- GULF STREAM LIMITS �V I'nME Tu:3a Am Iu:as RIII TIME ON SCENE ME CLEARED SCENE CHECK IF COMPLETED ❑� REASON in urveeog0011 NOT I..0 ipelel 6 Blowing M Sena. So 6 y�Mor El NOON 8y:1 Motorist I e I 70:37 AM '1'1:03 AM 4 wu MNy.W 77 Other, raFfIR11 1 pat („e.,...e......y} r ROADWAY INFORMATION D `• I 7 V 7 Rear Y. roe., Narrative Be Unlanwrm 1 Clear 7 Severe Croaawk 2 Claud; CRASH OCCURRED ON STREET, ROAD. HIGHWAY Indirectly Involved AT STREET ADDRESS k © AT LATITUDE AND LONGITUDE NORTH OCEAN BLVD (&R. A1Ay 9R7a � Ornatotm AT FEET MILL R to F -© ni.rnolaimnMe4nVn.n.Ra...ecr,Rpam.r.I�rRn: 3 Awe �acFROM-,=—F 200 El El PELICAN LH Flout Harmful E..nt 1 vrvrmnvrsasaver 18 Fwaes 19 ROW Atiom tar 7.Corltxale 2 FEReWslon 11 Pedlwjva "MOR v, t7Eler W..Mc ewior Road System Identifier 7 Fawn. Rowe 3 Iran” m 12 REWEY vehicle (train, 20 am Overhead Strucllaa 32 Tran (ItarWinp) Type of ehouloer Tn =F lumnl1 on Traft Circler B Pd -ate Roadway sn Wm 4 Carly a �a� m 3 2 U.S. 5 Local 77 in 3Shoulder » Mewa. El 1 P_ved T 2 Unpaved 2 i 3 Four -Way Intanecoon T-Intereactio n ewwul 7 FMe-Print. or Mora 77 Othws Explain in Narrative Otter. Explain Z.. =,-- v - urnplkelTol - ,oEla 7 Separow 3Curb 4Y4nteraoctlon a In Parking [arse or CRASH INFORMATION ICHE RE TAKEN)^ Zone Objet Equlprtlene 27 Guardrail F;---- 36 Manoax Light CendMu . W.athhr CondMon Ra-dw.y Sorfsoa Cenditim; Sahael 6a: R.I..ted OWNER'S NAME ❑ Manner of Cglliaienllrnp ct 1 Down b Dado-Nol DpIWEgoo ❑ ? 5 Si emallf Rain El a Mud. OIL Grovel 7 Sand 1 No 2 Yas. Slam es: I 7 4 Sideswipe, acme d rection I 6 Opposite Oincllan 1 L19h�q 6 Blowing M Sena. So 6 y�Mor El � p so u Row to Side 4 wu MNy.W 77 Other, raFfIR11 1 pat („e.,...e......y} drool 3 Yes, 5rtnod But 3 Yes, 7 Rear Y. roe., Narrative Be Unlanwrm 1 Clear 7 Severe Croaawk 2 Claud; n 1 Dry 77 OthExpExplExplain Indirectly Involved 1 Front b Roar 77 Othaw Explain Narrative h Frere w Fnsw 77 Other MWY5n erraer 2 Wet Nti- _ � Ornatotm R—Ere II WMVI so e„R>o..., 3 Awe FII.: n.rm1a. t',=m N„n-C.dllalo.. Collision Non -Fred Object�l.n with Fi-od Objost Flout Harmful E..nt 1 vrvrmnvrsasaver 18 Fwaes 19 ROW Atiom tar 7.Corltxale 2 FEReWslon 11 Pedlwjva "MOR v, t7Eler W..Mc ewior LocstIan on Rveuwey 3 Iran” m 12 REWEY vehicle (train, 20 am Overhead Strucllaa 32 Tran (ItarWinp) 2 On Roadway ervi-) 21 &lupe Pim or Support 33 UN-, Polalught Serpem 6 CWUa=gWnerd 13ANmal &idpe Rol 5:;..... S.yn 5upporl 3Shoulder » Mewa. El First Harmful Event Loo: m Shift 14 Motor Vehicle N 23 Cuw 35 Tragic Std Support 6 Gore a FUN. -..FM From .., .. 24 Curb 35 Ohler Pos; Pole or 7 Separow within Interehango Mater Vehicle 15 Parked Motor Vehicle w elan aoppon a In Parking [arse or 7 Thrown se Failing 16 Work ZonelMaintainance 26 Embanlanard 37 Fence Zone Objet Equlprtlene 27 Guardrail F;---- 36 Manoax 9 Ouftlde Rf R -d--, El 2 Yes 6 Ran int WalerrAnal 17 Smock oy Fem ry, a, siul.yPW 2.. Guudrali End -.a =or FRIG vo,e.1 tae,. -'a Ros swo 88 Unknown 9 O1er Collision CNIF 29 Cable Harrier conk n9, turobet, ate) Other 88 Unknown First Hprovfol E -;--M R.I_ti■m to Contributing Circumstances: Road 9 Won. Travei-Pollhod Sulam Contributing Circumstances: fsnviranment Junction 6 Rainey Grade Crusting El14 ErcanralEdt R. ❑❑❑Ic Road Surfs . wou) Ntlen (weL I �oBl.— In Roadway LLJ Ro..aenL7lert -e re ren Reeled Sha or or Irml 16 Stlarotl-Use raw, 12 Debris t Nuns 13 Tra1Ec Central Device ; „a„e a - ll.,oedrray 2lmenec im 17 AccsleratioNOcolsiation Lane 4 Work Zone;Cansblrcllonf Inopero Missing er--cmea 2 Waathar Condtacn. 77 Oher: Explain in a ERRAEBER-..e 1B h Roadwe- ' m�"®'an � 14 Non -Highway Work a Wisamanjej R.nawe 4 DdvewaylAley Artane - p w Explain A Renta-� 8 Shoulder mews. law, IoE. ROIL) 77 Other Explain in Narrative Giant a Glare BO Unlvwwn R -s— eo OrlRilomm i RIrL Roles. 3=rwx tib Unknomn Work Zone Related o1 ih In �. roc ZOI s lYinl �mv gyps or Ts .m woos ;-rmsrs In ;rami wns � Enfore—■m In Work. Sig rmalwly Sign Lane Closure ZONE 1 No Yea 2 Advartm WamYng Area I k 3 Trattsitlom Ara- 21.ane StWUCroalover I = Work en Shoulder.. Madsen • Inmrnme+u W min y ..w. � Ll no ❑ 2 Yee 1 Ru 2 Officer e BB lknkrrowrtb u w nwr.q ruao u 77 Other Ell= In Narrative BS Unknown 3 Law Erdarmmntl Vehida Enforcement 5 Temtlr efilan Area Only Proaattl rril.rCQv NAME ADDRESS CITY & STATE ZIP CODE NAME —Elm urr'r o ori.+ .- -;:: covE NAME ADDRESS CITY STATE ZIP CODE VEHICLEER DAMAGE VEH. 0 PER N PROPERTY DAMAGE - OTHER THAN VEH. EST AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE n. v FeR.:.—Rt3 mm"im-arreR . nrur N.R. w...vn.. OWNERS NAME 17771 ;CHECK IF BUSINESS) ADDRESS CITY& STATE ZIP CODE VER11%CE 1 Check if Commercial ❑ R•�,•-Wtiamu..",rmokromoer HSMVCraahReport Number rr-23sa 3707310, �erYoe IM Trsntport ❑ VEHICLE LICENSE NUMBER STATE 2 Parked Motor V■hkN T o>=ORi+f PC REGISTRATION EXPIRES Check N Peru.■nt, ,.rr�n9 v� 0613012018 Regi.,,— [I1;D"7Hji-%e6R835i103fi3 1 N ■rw Raw ;EAR MAKE MODEL STYLE COLOR DAMAGE EST AMOUIF" 2YCmoram IT] Z008 190tJe RM itRIG PICKUP WHITE- 2FunWo�rw1 ggUn■known a 3 N— M $300.00 INSURANCE COMPANY (DRIVERI In3e POLICY NUMBER Towed due VEHICLE REMOVES s7 Rear AMP.RMSRi5Ilr3alp�laeram CA -.;= No 2Yea F]ERen Req�el r .. wamr, explain In Narrative Jam.! NAM£OF—mwvnnee(GnI�RrPSU51NI:S5} ❑y CURRENTADORE55 CITY ■.,...T` ZIP PHILIP THewlis m Rma 416 NE 6TH AVE BEMW BEACH FC �3+;a3-oossA Treler LICENSE NUMBER STATE ReGlu.r.n. k. EXPIRES CIRIM.Pemtenerd VIN .-R MAKE On: Ri0MMM LENGTH AXLES ❑ 'neer LICENSE NUMBER 57,;Tv Room...;,. v.. EXPIRES Crrack ii Permenant VIN . -- MAKE LENGTH AXLES 11,ro: Rg3trati n ❑ VEHICLE R , E r: Off -Road Unknown ON STREET, ROAD, HIGHWAY .,T e3T SPEED POSTED SPEED ITOTALLANES TRAVELING 91 El ❑ ❑ ❑ ❑ STA, E RORD Al 25 135 2 1NoWz m. RELEASED HAZ MAT PLACARD R�IIIacR CLASS -- M -Impact ea;vtsnapetl... El hio El- v' ul 3 R 5 fi .Yea 121 Yea 2 3 4 5 6 7 19 Ur,darcerrlege 2 7 Ba Unknown 8B Unknown �e Overturn 19 1 15 18 17 6 MOTOR v-uaSla-M IpppB US DOT NUMBER t 15WI; 20 �aRlele �o13 21 •Tralw 21 14 13 1Z 11 0 . MOTOR arlreRlen.,..,.m CITY -k_- LP CODE PHONE NUMBER Vehi■1■ Body i3rp. 15 Low SF---- Vehicle Trafll■..■y Cmwnen:i.l Morar ■Rich configuration ,., 1tr (Spm) U,Yioy Vehicle1 T�W.l Na Divkw : • �-.. 5 vov Es v, RA! PtacaMed B TraeodTrlple 3 17 Cargo-_ ( ;.,ape M ' ...vr,■y, Rvk Divided, with a Lar R—rdous Melenal. - 7ruin more man -w.voo Da (4,539 (4.539 kg) or leas) Contin mm Len Tum Large � 2 SIrgb-one : rook (7 w o v rrk. kg}. Cama Classify 1P_ �- Car ;a Ill- CCREM u rw vmy. DIvded. Unprotected more Qia11 iv.lXX) ME 14 Safi kg)) ;p tabu arye WWI (aoa. Por 9.15 2 Passenger Van 10 Otho Light Trucks (1(11,1X%) ib-- (painted �4 feel) Medan a Single -Unit TP ick 13 or more wd■_v) occupants. including aR08!] 3 Pickup {.,oap Rq) ur less) 4 Two-Wey, Divided. Positive 4 Truck Pueng Trsler(e) 11 Bus (seats ran _finer 1 S 7 Motor Home 20 Medlurn"* , Trucks (mars Median Berner 5 Truck Tractor (bobta) 1 Bus (sisFr ) �- oux awn 10.000 lbs 14,536 Ra)) v t711FWay Traakwsy a Truk Tnw:sn.,errs•Tkmer 77 Otho, En�n Including drivo . 11 Molomyd. 2: F- eealir :ansae 7 Truck Trador)Oouble Truck 12Maped n - Snnkwwr, 13 AR Tenaln Vehicle IA I Vl ap Sn Namatlye T;aleT TWer v 2 Tandem Sam! TraW 0 Towed Vehlc. Cargo B■dy Type Cemm/Nan-Gammen!.! TRAILER 7--MR2 7ssw 0M T,10Auto Transport 13 Intermodal etreretate Carrier 4 Saddle MounUT._isr 77 Othe.. Explain in �'�•� em! CordahwrChasels ❑ 21nineshta Carrier 5 BoatTreuer N -s- 4 FFWPw .� :■IIIS.�y 3 Nan a Utinly .-rarer w Unknown 5 Pa1e-TMHN Another Vel,kla Not n Oprafflff=e1R , nick 7 H■se■ Tral■, ; kry �� a cargo T..., 15 Not rhe 2 B■= 7 Fletbad (-hitle p,aaa BI Most H..-ful Evan: 1 10,U0097s 4.639 ..les Comm { a uwk,. (4_939 kg) or lace rot 1 Overuunpolovar :e,ee;•�. ,00a ma (,.vao 11,793kg1 9 ConQate MWf - G■rrkvaacWR 3Mer.then28.000lbs 11, i rraraleoslen ( kg) 10 Auto Transport 77 Other. Explain in 31mm■ k)n +Rolm .; c.rbagalR-se Rrr,r■ra 4 Jackknife cattle on WIM N■n.Rx.d Oel.■Y �va.■lan RR■■ 99)aet 12 Lag 59 Unknown 7 4 5 CergofE ,..lpmem !pee a 3ra! 1v Peaeshlen Vehi.p..y..w.uwrnr 1C_?ashCkutkIon is Cable Barrier F.rnena■,ler, a Few From Moor VeVehicle,1 ; Pod=,-- Va 30 Concrete ,-rams MW Vehicle Use 7 ThrThrowna P.�y nun..., 12 RailW6y cle (halo. ■r�ri■] 20 Bridge Ovshead 5 wmra 31 06ksr Trellc Berdw Sequence of Events a Ran inm W.1alCanel ; �,,,�,,w1 zt BI1�e Pier a Skasrport , . ree (standing) ❑ e Olhw Norl.Cdpsior 14 Magor VsMde 1n Transport 22 Bridge R_1:1 2nd 33 lldll- Po , 1a F-1 15 Parked Motor Wehkie 23 Culvert _ _ F. - Si' 14W6 s7gBeneo of E vents 24 corn �- • rare Sy.. �..0 f v„ 35 Traffic: Signs Zappor ...y..0 ....rn Favre Equipment 3a Other PaeR Pale, : Support 1 No brake hllu■, .la).7 Somer my n =M &W" koaryo a 26 EmbanknMl V Fence as �v 4n ; 3.pentim yr OrnArlywfp S=t In Motion Dy Motor 27 Guardrail! F... 30 Mailbox N Unknown - R„ Off R59M-my, :er■ae 29 Guardrai End M: oY.■r hep -w rurrOI Roavey, -Fbsd Ob bluitl 0 nnel etr-44 C1°'° M°�nVehicle MaR■ebr ACUan Trtimr. contra! Device For Vehicle Dafacte 45 Crow GanlartlrwE7 5halgh: Left . :; Sou, .,. m TruThi: V.hl..larRe:dwayG..d■ .. SpRre®..0 ...q3 r ken", Left 14 SImm i dol ee—y ,.egkmaing ■Curve _ 8 Fl■� Sgnd 2 Hitde-, Rvadw-y Aligement T 5 Turrmg Rghi 15Lagv nig Traffic Lans 9 Rerway Crosslrq 2 Brakes ;� a y � Traffic Lan- 1 No Controls 1 3 UPS a e.� 4 Lanes t7 Sa11rII11 1 SoaNta a Parked - am. cwj..� fir Rw.■ave """g aw 0t v'oe ( 3 Tire: 14 VNndowsr 3 S-5 (notlom} Crave R. .t 10 MMM U -Tum 68 Untamrm Devlss + wr+A (head Windshield Plrgnwn, Officer, El 3 Glrvs Loh . ; un� assn a Tretla Control = gniwn, Wl; Sig Guard, .=) El a Steering 19 Truck C3WPV S ectal FeRctlen 1 No 5 77 ou,a, Eden n ❑P � Function ! Ambnmsm 14 Inrero,y Bus 8 Stop 5gn R.raove 7 ..Y.... � react RitclV of Motor Vehicle ` Pa . rersae 10 FVs Truk 15 Chartern- Bus . �..o Sryrr a Exh:■si System Safely Chalna T 3 Poles .. P.rm MWTranspori 10 Shuttle Bus 96 Uolvmwrk 10 Body, Doan 77 Oewr, EMIllim in 7 Ta>d 12 School Bus : , Pd... eaaar Sm -tomer Tri R....'uvo 8 M ; Z Tromoconmmror Bus 88 Unknown 12 Sus $Ion a8 Unknown RvtSfTION9 PERSON 6 I NAME OF VIOLATOR FL5T .. y . c. c nURIaER I Pre n3M7 90010 S 2 7 ftge a„ PERSON # T M.1'" 1 No CWtubidon...uon Rspavrgxzvnc7Case Number 17-2398 0 ❑ HS MV Crash R.p...111 r 87073107 1 Driver NonA 2NonMotodst E VEHICLENR1;111! 69 Unknown r•• •Rc•Y17lgEcR 70 0BI11 jiiuw Otter Read Recommend ❑ MEOW R cn Req, .wavrrranl 1 EU .03QR ETl�R Sraonrg j 1 J 869.7660 eR118r Ram CURRENT ADDRESS (Nullba and Street) 30 Swerved orAvoided Dug CRY 8 STATE lon ZP CODE 4711 FRANWOOD ;;R (outside the Vrattldv, explahr 00 -RAY BEACH Da1ta5R (cox phone, or. I7 rmravre, i WronQ Side of vleoreQ Way 3 Other Electronic Oavke B T64V 77 Other Ccmnwarg Action FIL OTHER 73 5 DATE OF BIRTH t*Jl! DRIVERS LICENSE NUMBER STATE EXPIRf!S 3�RiTY (iNJ) 1 NuL7q=bls (non richt) Suet 1 Male Z Female El 1 'RAIRT 2 Possible 4 Irma atug ❑ a..ts (wittirt .h,.ays) T 031 611 8 8 8 w erg E -324210-98-.r96-0 rG 071612023 3 Nwr•lncapeata•„a a :om.rentc Felaltty let DrIvM Actions .a —g of Crass M.1'" 1 No CWtubidon...uon Wgolmd End■nam .eats 0 ❑ 1ACh 3a 4 3 ❑ 1 yes N=.Igera M—w �� parow 69 Unknown 2 Na 70 0BI11 jiiuw Otter Read � -Rest MEOW R cn Req, .wavrrranl .a CRar meUkrplOver 7 Sraonrg 2nd 10 Followed loo C10307 Driver Distracted B,- 4 OtterWide the Vehicle 30 Swerved orAvoided Dug Z Efeeaonic lon a ..- _, coppery Nomm, ...., Camnkrrhkatbn (outside the Vrattldv, explahr ot)ocknon-Motorist in Da1ta5R (cox phone, or. I7 rmravre, i WronQ Side of vleoreQ Way 3 Other Electronic Oavke B T64V 77 Other Ccmnwarg Action jF411FOodon d°ree. DVD pkyer) 7 InaltenW. .. OiIBAIIR let DrIvM Actions .a —g of Crass i;;7 Weather a [.au on r.rwe 9 Smoke e *dObject 1 No CWtubidon...uon 25 Ran off R.aarrey an.Yvw.r—as 3 tnlenleckn-Other4 Mldblock - M.rked Crosswalk 11 Shared -Use path or Tral 2 Operated MV In Carelss or 27 DMINMa otter Traft 3 Ym.w —° � TrwseCr.parauanN 7 7 r r,s Otter, Explain N=.Igera M—w Sign 69 Unknown 3 Fall. w YloldRy ....•fit 70 0BI11 jiiuw Otter Read 4 improper Birwg MEOW 6IR*Rrfa.rTan .a CRar meUkrplOver Sraonrg 2nd 10 Followed loo C10307 DRIVER OR PASSENGER 11 R—. Red Light 30 Swerved orAvoided Dug ROW .; Drove sae r.r. tier COntiuww a ..- _, coppery Nomm, ...., ❑ ; .3 Ran Stop aqn 151mpttpr P :ser ot)ocknon-Motorist in amveaeo I'Mmu opfd Roadwe;, etr: 31 Operated M7 in Errebe, i WronQ Side of vleoreQ Way Rua exx or. Qrs"vrs Mousier 25 Failed to Keep in PMR, Lang 77 Other Ccmnwarg Action SM Candid■R At ..mer crasx d h 1 Appi--nty Normal Z; asp w Fawged 51 nick) up F_�_ led 4 Seltrae, Eplespsy..1ack ut 7"CM ImplBred 4th 8 Emotional (deprowFun, angrydi od etch do B Under the hteuancoe of MadicationsoMpg __ , vmar, vsin In Narrative as Unknown ❑1 i� her. Dowcrejsson 2 Other pedestrian (wheelchal, person in . y, armor; pedaanm conveyance, etc. 3 arc�.t 4 Other Cyy - —.-wo..l or Maw Verne■ Not In Transport (parked. e1cc-) ucwpani of _ Narh MUldf VaNcl. Transports.— owI78 Drumm .fp. 0 NWMowst a..nr 6 Lighog merrier o NWnppaww° Pratecbve Pad= Used 77 Qetei; ERP& ears. knws, velli! ) in N r= RanawY■ cwuuwr0 {JeOket, .a uraahown ALCOHOL USE: m tarar 1 No El 2 Tart Refrhaed L 2 Wv 3 Test (awn 88 Unknahm e8 Unknown, 8 Ts-= Waite Cr•..,....acv... i a Illearc.7R rACILITY a L nor .,parted r Z 04 Law Erdoroernwt 1 77 Otutl Expleln In N—tivw Be Unknown W 1 YcnICLE N S w .----a ® a era C A—.d» cue,. r�r+.. .uRwreraree� .... tan..r wson I lntmed on - Marked Cma— i;;7 Weather a [.au on r.rwe 9 Smoke e *dObject . 1116......e- O.Y..anuu Croarwalk 9 MediarYCrosalrg I...... -E an.Yvw.r—as 3 tnlenleckn-Other4 Mldblock - M.rked Crosswalk 11 Shared -Use path or Tral 4 Mkbl)dr - Merited Cro«.... 12 Nw Trask way Aro. 3 Ym.w —° � TrwseCr.parauanN 7 7 r r,s Otter, Explain - cmver, r�aaxr■r I1 NemaWo 8 nwya° Lane 69 Unknown DRIVER OR PASSENGER (blcklard responsai Roadway Against... apn w'cliaCeml m Gare! tare) 4 • of In Narrative Helmet Uwe (HU) pe( Ey. PiOlBc sun (EF) S Romatnt Systema ❑ (RS) DRIVER OR PASSENGER ROW ❑ ; ❑ 1 Ye- Z,•o MotorWh1ct.dv.ungPosition: ER7�R: 5c`nr OTHER 2GM-1000HeimW a Notnppg®ae 1 NuL7q=bls (non richt) Suet Rong Oth.r tL�) r R. Rwnm 2 Nwv Used - Motor :...av 1 Les 1N.tAppliceble - or area � BBI Usaa 2 M� 3 R 1 Pront 2 Sleeper Section of Track Cob 2 Second ver Bug DapIBJ'ed ;, ,goner 4 Lae; Belt Ben Use Used s Lai Ban txay used 77 Other 3 Other Endosed Cargo Area 3 Third 9 coon EJECT k 7 Not E ► ad (knee pen 8 Ro:anhh: E.-- .rp. C1881aR1 (� h risYfstive) 1 Fourth + IJ..OrlaOaarJ Carpo Area 5 Trailing Unit 77 Otho. R..,. 1 2 Ejected Tolaly a 1 Nat Ap*.bk e 2 Nat a ysd la�aon 7 Child Restraint System - Forward F-�g B Child Restraint S, stem - Rear F..dng as n Un kn-.-.. 8 Riding on Motor Vehicle Exieri■r (Ron- 21!p—,% Ply D°p-1ga� 7 Dep 'Af�1 B Bao Scor BB oW;,Q q,.led4 NotAppilwble � v`r�iie 68 88 Unknown Y,. Brtr xmn mn 77 0111.. Elpoln in NamgM ❑1 i� her. Dowcrejsson 2 Other pedestrian (wheelchal, person in . y, armor; pedaanm conveyance, etc. 3 arc�.t 4 Other Cyy - —.-wo..l or Maw Verne■ Not In Transport (parked. e1cc-) ucwpani of _ Narh MUldf VaNcl. Transports.— owI78 Drumm .fp. 0 NWMowst a..nr 6 Lighog merrier o NWnppaww° Pratecbve Pad= Used 77 Qetei; ERP& ears. knws, velli! ) in N r= RanawY■ cwuuwr0 {JeOket, .a uraahown ALCOHOL USE: m tarar 1 No El 2 Tart Refrhaed L 2 Wv 3 Test (awn 88 Unknahm e8 Unknown, 8 Ts-= Waite Cr•..,....acv... i a Illearc.7R rACILITY a L nor .,parted r Z 04 Law Erdoroernwt 1 77 Otutl Expleln In N—tivw Be Unknown W 1 YcnICLE N S w .----a ® a era C A—.d» cue,. r�r+.. .uRwreraree� .... tan..r wson I lntmed on - Marked Cma— 8 Ski Mlk . 1116......e- O.Y..anuu Croarwalk 9 MediarYCrosalrg I...... -E an.Yvw.r—as 3 tnlenleckn-Other4 Mldblock - M.rked Crosswalk 11 Shared -Use path or Tral 4 Mkbl)dr - Merited Cro«.... 12 Nw Trask way Aro. 5 revs came - timer Location - cmver, r�aaxr■r I1 NemaWo 8 nwya° Lane 69 Unknown 7 ahoulderAtoadslde (blcklard responsai ❑ 2�lDartlDesh AtUon '^ w 3 Fssun—VENA Rlgt:-o.-�y ❑.. axtau w ver �ramc 3; .a !rd ..Ep.as,aOlAcar ❑ l In Rw3FSy fr-rTy (-terhNrhg, yirg.........y. offiIxR) a Elsamed Vehida RWOW (worici g on, pusrwg, b nEti t� ! a Q) ALCOHOL)DRt LCOHOL TE COH e �T..l.--..--- rintl 2 Braath ❑ ST REULT❑rkhe 1 PENDtNU Othar, E,xplwr 2 COMPLETED IIB UNKNOWN 3 7 Papa orf_ ❑ rwx.rt rn.rro crash b Welk'kip7Cyroiag a- 5idewaill e In noadway -- caasenq naeaway 2 VftMM to Cross Rw1Trr3y 77U�7u4i• mf M to ori (e.0.. Along rrraetan R��yfflre0 s wan or o Gwiry to or tram School -'K. 12) vramel nlir 9 Wo InTreftlerr: ��n�yaing AbmO (blcklard responsai Roadway Against... apn w'cliaCeml m Gare! tare) ;a.:mry 77 Other ExphM in NerraWe 68 Unkronw 7Er11ertnolEtdbrrQPSlkedlS _—.ry ;EImproper TUMWgrge a 11 Improper Pasaa v g inattentive (IBM, e_Rip, .tic) 12 Wrong -Way Riding ar ,,—.v 9 Not Visible (data clothing, no 77 winch r:.j.. M In NameWe a•�y. gel as Uf9W~ GMS AC a133FECTED DRUG TESTED• DRUG TEST TYPE,r2lNeoffilve UE__,,Z3Z.lr DRUG USE 1 Tvet Not C,Nen BIBBB aslWe 1 N■ ev ,mosso 3 Udne1:1 a +..orf Given 77 Other. thrhdhhg 88 Unknown. 8 resod E kin Nemseve Unknown ❑ R ..�ale2R ME61C.4r. Fn[`.li I7V iaen7ConvTcn m 00I3 "'OR ROtaam EMS RUN NUMBER I MEDICAL FACILRY TRAN7,-r._e c y l l 1 1 J N A 1 . V I V L A I I U N ` f R I l S O N s L N A M E O F V K ) L A T O R P E R S O N 0 1 M M C T r N a n O R R E P O R T I N G O F F I C E R I D l a A O G E # R A N K I W O F C K S M V 9 O O W 5 R O E M F M H E . R R . ! ' J ! R R m C I R T Y P E O F 1 7 D D = 3 u l t a n I G U L F 5 1 K E M M M U C I E U E P A R T m ! N o ; HSMV—:ez S 7 pegs of vi=rIICCE ;F = Check if Commercial M :moue in Transport ❑ VEHICLE LICENSE NUMBER STATE Motor 2 Parked Mar V_7 361.�F0 FL 3 Wo—INNVehicle NendR� YEAR MAKE MODEL 2Yes oa Unknown 2015 TOYT CaFrUUCQX INSURANCE COMP RT taR10lRr INSURANCE POLICY I, a. n. c FARM MUTUAL AUTOM D225i88a94 RePerillp Agency Case Number T7-2388 REGISTRATION I!WR!3 121`0512018 STYLE aoaRaEDAN BER Towed■= R Damage. R. !Tot RRL! OF VEHICLE OWN BR [CHECK IF BUSINESS) ❑ CURRENT AMR=; MICHAELLE LOUIS 238' UI11TOR RIDGE CIR C7 T mier LICENSE RaImBER STATE REGISTRATION EXPIRES Chick 9 Pe1n-1 011e. R.ywueiaR ;t;gBer UCE..3R..amBER STATE REGISTRATION EXPIRES Check If Permenem Two. Rryvumon ❑ VEHICLE N S E W Off -head Unikowa ON 5 Ell r. ROW.. HIGHWAY TRAVELING r 1`1 El r]❑ ❑ a I A I t ROAD AIA Z=MAT RELEASED 1N HAZ MAT PLACAR= .fW NUMBER CLASS ..e 2 Yes0 98 Unknown 58 Unknown I .,i -.OR CARRIER NAME U3 BUT immeest ..... c3a -ielit ADDRESS or" VIN VIN R3f114 Crash Report Number 870!3107 CIRM. 1`1111111onefd YIN R .Islreeon ❑ 2T113URH81FC283234 COLOR DAMAGE: EST AMOUNT 1 D4tebsllp 4 Mki r WHITE - 11"1 2 FkatcWW ; 3 None BB Unknown ❑ VEHICLE REMOVED BY 1 Ree,oe., 2. Owner R nnICAAEGCE LOUIS 4,� Explain � >ns CITY d STATE ZIP �.....-usma rC 3s -a1c8 YEAR I WKE ILENCITH I AXLES YEAR I MAKE I LENGTH I AXLES a.,, 3F!1I7 POSTED SPEED TOTAL LANES 0 35 1 A 08 3 4 5 6 2 3 4 5 6 7 18 Undercarrl_� 1a V8 Z 7 1 15 .0 17 8 '� vyertan a9 1 15 18 17 8 20 Windehiekl 14 _3 12 11 0 9 21 l Tra�er� 21 14 113112 11 0 8 STATE ZIP, PHONE NUMBER V.hl■lw Body Type '_ M=p@ed-m.ca ; ra.�.cway Ctammerclel Motor Vwhlala C■ffflgarepon El 1a (SPQR) Utlkry Vatdce 1 Rol Divided 1Vehicle10000Ib:=1e-Pl4eme■e .7 wiry ier, [10,000 Ibs 2 Two -Weir, Not Divided, — « Ear HaiaP[lou:. a�nsls 9 Trudk..-. c .o,vvo a gr SW (4,63a kg) er lets) Cone Worn !aR — 11010 1:12 EN16-Unit Tnrck (2— gnu WvWR .y), V,...kt Clsssay Passenger aen 18 Motor Coad! 31Mo way. Divided. t711pmt.� Toa � :O,voo 01 { ,.63t1 aqA 10 6u—rg■ T. (loom for 11+15 2 PU95q-W Vm 7 v LWr 7moos (.0,avo rbs (P• — a. Isa1) Median a Single -Ursa � am (a .w more arias) romm driven 3 (WIMP (4,538 kg) =lei _y .14ro oy, Ddv dK Mills" 4 Truck PuNna Trailer _) 7 Motor Hume 20 ....... rrorry Tnrdn (mare 11111 n Barrier a . rami : rA= (bkbisil) 11 Bus (seats dor aaae than 15 6 BUN then 10,000 b. (4,530 _;,)) s one•w. 8 Truck TraclbrlSomkTraler �_ts. Ing did 1; M..M..r... 21 Farm Labor Vehicle 7 . moy 7 Truk Track dowbie Tnrdk 77 baa E$lain In Nor,..,,, 12 Moped vtnar, Opalm In NartaWe 40 Unkr~ Trailer fq PI N Unknown AN terrain sono (A, ., 96 Unknown 1 Ships ?= Trailer B Pda semen eommlHon-Commarcla! TRAILER 1 TRAILER 2 ` ' wf 1mn Saint Trap 9 Towed Vehicle Cargo Body Type 3 Tw* Tmhw .0 ren T rensport 131nteonodal 1 Interstate Carter ❑ ❑ 4 Saddle MmnUTnsiler 77 Other, Eggh in Va-W— am Container Chassis ❑ Illee3f! Verner 5 Barn ;,wen Narrative 4 .' VMW om—y 3 Not kk CmarcejUmummem a Utlflty Trench dib Unknown - FWr. aler Another 7. Hol n Commares/Other Tnxk 7 Rowe -. ew 1 No Cargo 6 Gargo Tank 7.0 Ro. Fwpi :nam Moat H.rmful E -vont Rww.nlalon . 7a,voo ae (.,»c kg) kx lett 2 Bus B F7etf>ed {vehicle 10,000 bs E13=GCWR Dump 1+,538 kgf or lets not 1 OverUrNRono.er 4 210.001-211000 1bs {4.536-:..; 9 Concrete M7s:r dls 2 Fi[lE l 3 wv,a Then 25,000 bt (11.;91k91 .e now T PteYk19 ��� 3 akaltelllaR 4 Not rsntpen 77 Other, Eladn b 4 Jecldknie t 1 Gar4agerRne:■ ,..,,.tRe El emt.slF wan R.n+Uad Object Collision FL:w vajecr '2 9a Unknown o+..s.I-cquiprranlLoss orShift :aFeaes— 0 FeWumped F_.. vror : elNJa 11 P}MWM 19 impact _11onoatmterM Voshlon °_- UWE Barrie EmerN■n■y 7 Thrown or FaikV object .� R....y Tante ;!heir drone) 20 Benoit overhead Stftluk ro 30 Concrete :nano sorrier Vehicle Use Sequent. _f E. writs 9 Ran into Wa. — 13 An 21 86d",-, or support �• V WW Traft Semler 9 09ler Nan-CoNsion ..rnar V. — In T 2211W Rai 32 Trow (=tack ftl El 17. 15 Parked M V..� � c■R!!1 34 Tea FS Sgport [4114e Sequ.ao er kerne vmyj O°r "� 34 TrelRc Sign Support 16 Work Zona/mahlermum 35T..fac S genie Support e •r 40 i4Gpmerlt Fakes (bl ww ire Equipment 25 pt41 i Ru breka -,.M. r) 17 Struck B F w warn Post Pula. or SOW Y a9, Shatlq C_n. ar �.. ln,o■r.arar¢ 37 F_— 2 Yv: 41 Saparaion of Univ w sasbox 3rd o. afllelowrl 4th 3.. n Itloow, Iry ,nafGr 27 Gkardrai F... ❑ ❑ 42R , Off R02d"7 Right Velnirle -o Vkarcrm End 39 Other Fixed l'Japa (wee. 43 Ran Olr Roadwa; Loll oe,er m.rru.sv O tafidYn Hamel eta 45 Crus CaneeRle IS■101Ah1VIvr..lreuverAction TfaftiraC.ntrolDemeFor Vehicle Defects frelghl Ahead 13 Stopped in T..IAc Thi= Vehld. Rmedwsy Grao. 45 Downhill! Runewe,- 3 Taer�rg hn 7.. .�,y 1 Level 4 Backing d 5 Neseiatirq . Cane E a Flesnaip SUM ❑ D Roadway Allgnmewt pffl: ly 6 T...o,e RW, 16 Leavog Traatc Lane a ...,..y caossnp ' FErM E 4 D B CRFii-g 1�9 Lane= :. r , .,. y ...: , w . 7 M. OOIklfQls Device 2 &ekes . C -eels ❑ I S v Parked 77 Oihar, Explain In No,.,,.. 4 Schad Zon. S; . 10 Parson 3 Ties 14 VAndaAW �-9 I r 2 Clava RpM 10 Making I'Jram as Unknown Davka , fry %—,—, WMltlshdeld 3 Curve Len 11 a:- a - w■rrsal ��w" a"� Nang tell) 15 Mirrors Gwkd, eta) 9 ael.l Fanctlar no 3 ! 141hw — N �>o P P� Fkncson 9 Ambulance rsky !e! o Signal ay.. , , amer, cxpmin in f ms's 18 rlsmry ❑ of motor V.hiot. 2 Form Vehicle 10 Fie Tnlck 13 ClmrtedTour Bus 7 row S n N^,..0- 11 Farm Labor T. 86 Unknown 9 Exha■-A Siem Salty Chairs 7 Taxi - tPort 18 S.-,ema Boll .0 ter, Doan 77 Other rspsin in ...,*. aka .. Farm Labor Bus eefNtery toren-wr............-o. 11 Power Train R..,...e rin50N M NAME OF OF HSMV90010S 0 7 Paps of 19cRt0Ill 9 z 10river �c!!s NAME 2 No"olorlst El 3 P assin er A MICHAELLE CURRENT ADDRESS (Number and Savvy 2187 LINTON RIDGE CIR APT C7 Ion— or Din In tim 1 Mala Female 72!0511994 e 1 U -known Rq,nwy FW, y Case Number 17-239'03 LOUIS CRY 8 STATE DELRAY BEACH FL 17. a. cra■I1 Report Number 37073107 IMonE NUMBER ;/64)8664456 DRIVERS LtcEf7.e ntYMBER STATE EXPIRES IR;10n, SI a 1 None 0-100-540.94.845-0 2 Poaibls F[ T�rOer�OzO uR.,..-..-- DL Type R"Wred Endorsements $ � wperRla[ ❑ 211113 8 FJOper-Rest 3 No Req. Endmemwd l molar nee UOacUraa 5 Load an Vehkle - e1eAllem Weather 6 Bulldlrwrixed o:q.... 10 Glare 3 Parkedlbtnpped Vehids 17r 5nW&Abads 77 036 ]dter, :n:P=. -CpBWoo 8Fq InRowo Motor Vehicle SeaUnq Pa=kin_:LOCATION: 7 Nona ..„/ or Crash -ow 1 N. Con-5ee5R......... DrttrarDlstraet/R ay y Down h9ide me VeNcle 2 Opem^ er. n arena ar 1 Net Distracted In RonatIve) 5 External --aamon Magog" Mannar VIM= Com unicatlon an ve1YcN, axplaln 3 Failed to Yleld Ri-pht-0I-Way Davin: jwl �, aim in in °} 4 improper BalSlg 3 Olhw Electronic ISefls eating Tin 6 unproper Town tl..:ye�n devin, DVD Peyer} 7 �a 5 TrafNnp Unit Steering 88 Unknown l molar nee UOacUraa 5 Load an Vehkle - e1eAllem Weather 6 Bulldlrwrixed o:q.... 10 Glare 3 Parkedlbtnpped Vehids 17r 5nW&Abads 77 036 ]dter, :n:P=. -CpBWoo 8Fq InRowo Motor Vehicle SeaUnq Pa=kin_:LOCATION: DRIVER ,,...r ..„/ or Crash -ow 1 N. Con-5ee5R......... ... R... on Ra ov T 2 Opem^ er. n arena ar 27 DIZHIM l� otherTref6c c 1 Front Magog" Mannar 3 RIpRI 2 Second 3 Failed to Yleld Ri-pht-0I-Way Sp.,,,, Oster Road 3 Thlm 4 improper BalSlg MUM:MY°a 4 Firth 6 unproper Town 29 Over......,,,,,,,y,,,,,er 77 Other R- 5 TrafNnp Unit Steering :n- .0 I=-. or, tRSly trailing ani) 11 Ran Red MW 12 De, too F.1 for Conditionsto 30 Swerved orAveided Du. ❑ •� A— Stop .71 Wind, Slippery Same/ els, 1 S Improper Paseip Corea Reraeotodst to Roadway, eta 17 Excaaded Fos- Speed 31 Operated MV In Erratic, Be Unkn■anjll9ln OF rwu„y Way za �Reea m Keep in Proper Lane Rvcnwaa srAg=eaNve mmRef yr 15 ; ,, oe10r w,w,uuunp Aotlon l molar nee UOacUraa 5 Load an Vehkle - e1eAllem Weather 6 Bulldlrwrixed o:q.... 10 Glare 3 Parkedlbtnpped Vehids 17r 5nW&Abads 77 036 ]dter, :n:P=. -CpBWoo 8Fq InRowo Motor Vehicle SeaUnq Pa=kin_:LOCATION: SEAT. . -,cm So.t -ow Omer (LOC' 1 3 Tea Given .... e111sleal! a -ems 7 Left 2Mldde 1 Front 1Notxpplirrable 3 RIpRI 2 Second 2-IEEPer Section of Truck Cab 77 Other 3 Thlm 3 Othr:r Enclosed Cargo rvwa jet In 4 Firth 4 Unendosed Cargo Arra.. MMMMr 77 Other R- 5 TrafNnp Unit 88 Unknown 88 Unknown a Rlding on Motor Vehicle Exterior [non. (wed. _k-) 6 Oxuparr M _ Ilel}IRomr :lase trailing ani) .... ervirmo t Roadway With -rvmc i n ar a v.—y M yr from School (K-12) 5 " °1v'% TraRkwR; 68 Unknown Rewnenela 9,J Driver Re-exam 33444 VNJ► o j=30 330 daysl i 6 Non-TraBlt F_tany 11;ra 4th Cendltlen... El crash 1 Appare„.r Raman 3 AsMM Or Fanged 510 (sick) c Fa4ttee o—.. Epetpsy, Blackout 7PMioo�n�Ffip-a .cion. angry, disturbed. eiar 9 Under the ierttrenee of Medi6aw.w.,..yar wv _ 77 ovler, c:p eh it Narrative B8 Unkrwvm DRIVER OR PASSENGER Helmet Use (HU) ❑ EyePromanon (Irr Restraint System= 1 Ys_ 3 )Rut Motorcycle Helmet NR; 2 Othw Helmet, Not Rpj>SCSble 1 NotApplic" (n.n�.wmrwr 31-oetwr 2 N Used M014r J 1 Test Not Given ❑ 2 T■st ReMsed Rorty o CtMaflon At Time of Crash 1 Intarsecdon - Marked Crosswa 9t B Sidewalk www - .o.. -4-1 1 �-11acuour +d t-ep Be11 Used Perron . 51111101-M. 3 Tea Given .... e111sleal! a -ems Deployed 4 Shoukler Be6 r11y — used 1U le5q Elowar,sa zNot E Total � 7 e z , NbtlIPP11 Leola (know, p�y� - I ❑ 5 WP Bob Only oil euro - , Unknown 7 Chid Restraint System - Forward Facing 7❑ - E 2 Mot Combination B Child Rectrairn; Sy:—.Rem Paueey � eaployed•Fronl 7 y rtaln t1 noot�. 4 4 Not Applicable 4 DaP695d-Skie as „�,,,,riiienl 10 CNId Rest vJntTymvUnknowwsl ofZ;r Unknown 77 Other, E pie ri in R«... w 1 PW=anie u/senPa■n < w m ��� (wheeldtari, in 1 Test Not Given ❑ 2 T■st ReMsed Rorty o CtMaflon At Time of Crash 1 Intarsecdon - Marked Crosswa 9t B Sidewalk L -.on Frtor to Crash 5 Perron . 51111101-M. 3 Tea Given .... e111sleal! a -ems 21"lamecaon • Urenan■o eaaeeasse 9 MedlenrCroulne I"_— wendnyCyeJirq as, les+reA! skater, ped■_MW —7=--. a! 3 �M TO MEDICAL FACILITY r�'1 . oawr4 MidWbrk- Marked Crosswalk -e.,...eway,..,..... 11 Sherad•Uke Path or Trail e,., Roadway - Omer (working. - playing, etG) Osler Cyclist , Midbladl - Marked Croeswael 5 Travel Lary - Other Lew6on 12 Non•Tn dhcw$7Ara: Wa/e°.a Roadway 7 Ad txeq ro Raodwa• e 2 YVe oig to Cron Roadway , { g.. a uuylwlu of Motor Vellkk Not it Tnw:pon 6 t� LRrre ri Olhv. Explain k ,...,-.,e A 3 MINUCyaong mong :houktar nmlen) (wed. _k-) 6 Oxuparr M _ Ilel}IRomr :lase - . Rla Canna== .... ervirmo t Roadway With -rvmc i n ar a v.—y M yr from School (K-12) 5 " °1v'% TraRkwR; I CefRfJ 7 Unknown no of tIRIMMPiCAS( urn•_ on renin W. ❑ DaeliOaeh -.pecan: of naval !ells} 4 vvaw%vLyakAknq ((—nt-,-.a) R�wa galhol Trask i IR r rr Other Ex in Nar=livv w eOJO�n>fl nava } 1 Nona Safety Equipment 2H~ 6 ughtiegr74 6 Nn Appk.W 3 Folk= to Yleld RlJld-0f_way, Fila/ to Obey Signals, -niter yr 7 Entedri EiFnp P_..eaelarld Be Unkn■anjll9ln ft IM TumfMe 3 P. ...nava �..a O..v yr 15 r I I ( ■, knee/, chins. etc • • amer GFNIe.I is Narrative 4 Rsd*cWo D7onq Om*, In R;aUM improperly (ctan�, IPQiO. 9, playlnq} • »-a■ p roper P� o Inattentive (lae,ing, eating, etc) 12 uwroleg-way RWing a....0 . y . BB UNawwn DecapacK �} 6 Disables ..Rlee R...ma 9 Not Vlelble dark clothWig. !A �vR�r narrative on,PUSNnq.lea-vapprcecrn>4)� (`9 W�1( ALCOHOL e..e: ❑ No 1 1 Test Not Given ❑ 2 T■st ReMsed -wrx,L ltSi IYf'E« LcpNOI 1 Blood Z else/! ST RESOC — FEnelna ❑ BACVUl Eurccl DRUG TESTED' RUG USE 1 T■:t Nat Giver Tb:t Rsfucaa NoPending 111� DRUOTESTTYPE RUG ,w Re„ve Blood ems ❑ Negative 2 Yec 88 Urn 3 Tea Given .... e111sleal! a -ems r r www. CVRIFR. cv In Ner=evs oo UNKNOWN 12 Unknown ❑ w. ❑ ID OF �r.nR.' OF TRANSPORT ..N4 .ransported TO MEDICAL FACILITY r�'1 EMS AGENC:...,...E OR Ip EMS ee 15, .vim. a To RUN NUMBER e1e171Giu Explain ur menatNs 68 V rl rnC1UiYTRANSPORi'ED TO 2 EMS 3 Law Errorcemerd 77 Other, Expletn in R-..-efa . -, Unmown I..+ 1 41M twAurcLe a. ,,w,uFQn o MEDICAL FACILRY❑EMS AGENCY NAME OR ID EMS RUN NUMBER e1Mka¢ 95111aUR a IVEHICLE li rAME DATE OF BIRTH I INJ I SEX I R 10 1EJECT CURRENT .....!!u., (..mnper aro St=et) I up" /Tata -- ...., rnw.,u, r I 11emC..eenerr lame are ID I EMS Re.. Reme�R t Ila ...�.�: PI■ ora.. ew.� n ■emw Mer..' w wanes HSMV 90010 S 7 7 rug/ of