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HomeMy Public PortalAboutPRR 19-2687TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered in person February 5, 2019 Bonnie Erbstein (Police Report 87073111) Verbal Request for a copy of the Police Report #87073111) Bonnie Erbstein: The Town of Gulf Stream has received your verbal public records request. The requested documents were delivered by hand to you on 4/5/2019. We consider this request closed. Sincerely, Renee Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records Sworn Statement for Traffic Crash Report Information Motor Vehicle mash information is confidential and exempt from disclosure for a period of 60 days after the crash report is filed. §316.066(2)(a) Florkia Statutes (2014). Obtaining confidential information by someone who knows they are not entitled to do so Is a felony violation. The undersigned requests the following crash report (date/location/parties: The undersigned states that he/she or the organization represented qualify for immediate disclosure of the crash report according to the exemption checked below and does swear or affirm that the information contained in a crash report made caMidentiai by statute will not be used for any commercial solicitation of accident victims, or knowingly be disclosed to any third party for the purpose of such solicitation, during the period of time that the information remains confidential. am a party involved in the crash 1 am a legal representative to a party involved in the crash: Florida Bar Number (J') )�P i _„ i am a licensed Insurance agent to a party involved in the crash, their insurer or insurers to which they applied for Insurance coverage, Florida License Number _ I am a person under contract to provide claims or underwriting in formation to a qualifying insurance company, Identified as: — I am a prosecuting authority, Florida Bar Number — 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, as defined in 316.066(2)(b) Florida Statutes. Name of Radio/Television/Newspaper I represent a local, state or federal agency that is authorized by law to have access to these reports. Name of local/state/federal agency i represent a Victim Services Program, as defined in 6316.003(85), Florida Statutes (2014). Name of Program: / 1 /V t r iz.r -PIA S /flr3 /_( Printed,Name (Area e) T ephor,/Number AgencyrBusiness/Represented 7 Address ^� City, State, Zip Code State of Florida, County of � Ci! 13 � /nn Sworn (or affirmed) and subscribed before me this) day of V -W__, 20 by rr� Personally known_or Produced IdentcationType of Identification Produced: Print Type or Stamp, Commissioned Name of Notary KSMV-34010 (Rev.12/14) 7 I a e Z' ,r Signature of Not#t1 Public or Certffied Law Enforcement or Coional Officer This Traffic Crash Report can be purchased online at: www.buycrash.com WAS DOT PROPERTY INVOLVED IN THIS CRASH? FLORIDA TRAFFIC CRASH REPORT LONG FORM ❑ SHORT FORM ❑W UPDATE ❑ TOTAL # OF VEHICLE SECTION(S) 2 (Shaded Areas) 2 MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TOTAL # OF PERSON SECTION(S) TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TOTAL # OF NARRATIVE SECTION(S) 1 TALLAHASSEE, FL 32399-0537 CRASH DATE TIME OF CRASH DATE OF REPORT, REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 02/01/2019 3:15 PM 02/01/2019 19-0192 87073111 CRASH IDENTIFIERS COUNTY CODE Weather Condition COUNTYOF CRASH PLACE OR CITY OF CRASH CHECK IF I I IME REPORTED TIME DISPATCHED 0$ ICITYCODE 44 PALM BEACH GULF STREAM CRY LIMITS Q 3:17 PM 3:17 PM TIME ON SCENE S E W© AT/FROM INTERSECTION WITH STREET, ROAD,HIGHWAY IME CLEARED SCENE I CHECK IF COMPLETED REASON (If Investigation NOT Complete) 187 Notified By: 1 Motorist 3:19 PM 88 Unknown 4:05 PM 1 Dry 77 Other, Explain in Road System Identifier 7 Forest Road 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY Weather Condition AT STREET ADDRESS # al School Bus Related AT LATITUDE AND LONGITUDE GULFSTREAM RD 4 Flog, Smog, Smoke 5 Sleet/Hail/ 2 Freezing Rain 5011 6 Mud, Dirt, Gravel 7 Sand 32$$ I 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction © 26.495135 -80.054925 AT FEET MILES S E W© AT/FROM INTERSECTION WITH STREET, ROAD,HIGHWAY 6 Rear to Side Narrative OR FROM MILEPOST # 187 hN R] 11 ElLAKEVIEW DR 88 Unknown 2 Cloud 7 Severe Crosswinds y 1 Dry 77 Other, Explain in Road System Identifier 7 Forest Road Type of Shoulder 77 Other, Explain in 3 Rain Tvpe of intersection 5 Traffic Circle 1 Interstate 4 County 5 2 U.S. 5 Local 8 Private Roadway 9 Parking Lot 1 Paved 2 ❑ 2 Unpaved 1 1 Nof at Intersection 2 Four-Wa Intersection Y 3 T -Intersection 6 Roundabout 7 Five -Point, or More 77 Other, Explain in Narrative 3 State 6 Tumpikelfoll 77 Other, Explain in Narrative 3 Curb First Harmful Event 4 Y -Intersection CRASH INFORMATION (CHECK W PICTURES TAKEN) 2 Fire/Explosion 11 Pecialcycle Cusion 31 Other Traffic Barrier Location 1 On Roadway Light Condition Weather Condition Roadway Surface Condition School Bus Related NAME NON VEHICLE PROPERTY DAMAGE Manner of Collision/impact 1 Daylight 5 Dark -Not Lighted 9 1 2 Dusk 6Dark-Unknown 4 Flog, Smog, Smoke 5 Sleet/Hail/ 2 Freezing Rain 5011 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction 3 Dawn Lighting 4 Dario -Lighted 77 Other, Explain in 6 Blowing Sand, Soil 2 ❑ 8 Water 1 ❑ Directly Involved 6 Rear to Side Narrative Dirt 1 Clear (standing/moving) 3 Yes, School Bus 7 Rear to Rear 1 Front to Rear 88 Unknown 2 Cloud 7 Severe Crosswinds y 1 Dry 77 Other, Explain in Indirectly Involved 77 Other, Explain in Narrative 2 Front to Front 77 Other, Explain in 3 Rain 2 Wet Narrative 88 Unknown Narrative 4 Ice/Frost 88 Unknown 3 Angle First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 1 Overtum/Rollover 10 Pedestrian 19 Impact Attenuator/Crash 30 Concrete 2 Fire/Explosion 11 Pecialcycle Cusion 31 Other Traffic Barrier Location 1 On Roadway 14 3 Immersion 12 Raitway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Off Roadway 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 3 Shoulder 5 CargoiEquipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 1 4 Median First Harmful Event Loss or Shift 14 Motor Vehicle in 23 Culvert 35 Traffic Signal Support 6 Gore 6 Fell,Jumped From Transport 24 Curb 36 Ohter Post, Pole or 7 Separator within Interchange Motor Vehicle 15 Parked Motor Vehicle 25 Ditch Support 8 In Parking Lane or 1 No 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 2 Yes Object Equipment 27 Guardrail Face 38 Mailbox 1 8 Ran int Water/Canal 17 Struck By Falling, Shifting 28 Guardrail End 39 Other Fixed Object 9 Outside Right-of-way (wall, 88 Unknown 9 Other Collision Cargo 29 Cable Barrier buildinq, tunnel, etc.) 10 Roadside 88 Unknown 18 Other Non -Fixed Object First Harmful Event Relation to Contributing Circumstances: Road 9 Wom, Travel -Polished Surface Contributing Circumstances: Environment Junction 4 5 Railway Grade Crossing ❑ ❑ 10 Rod Surface Condition (wet, ]] 1 icy, snow, slush, etc.) 14 Entrance/Exit Ramp 11 Obstruction in Roadway F3� ❑ 1 Non -Junction 15 Crossover - Related 1 N 12 Debris None 16 Shared -Use of Path or Trail 2 Intersection 17 Acceleration/Dceleration Lane 13 Traffic Control Device 4 Work Zone construction/ ( Inoperative, Missing or Obscured 1 None 5 Animal(s) in Roadway 2 Weather Conditions 77 Other, Explain in 3Intersection-Related 18 Through Roadway maintenance/utility 14 Non -Highway Work 3 Physical Obstruction(s) Narrative 4 Driveway/Alley Access 77 Other, Explain in Narrative 6 Shoulders (none, low, soft, high) 77 Other, Explain in Narrative 4 Glare 88 Unknown Related 88 Unknown 7 Rut, Holes, Bumps 88 Unknown Work Zone Related Crash in Work Zone Type of Work Zone Workers in Work Zone Law Enforcement in Work 1 Before the First Work Zone 1 Lane Closure Zone 1 No 1 2 Yes Warning Sign 2 Advance Warning Area 3 Transition Area 2 Lane Shift/Crossover 3 Work on Shoulder or Median 4 Intermittent or Moving Work 1 No 2 Yes ❑ 1 No 2 Officer Present ❑ 88 Unknown 4 ActivityArea 77 Other, Explain in Narrative 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area Only Present WITNESSES NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NAME NON VEHICLE PROPERTY DAMAGE ADDRESS CITY & STATE ZIP CODE VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE HSMV 90010 S 1 7 Page of _ 1 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number VEHICLE # ❑ 19-0192 1 87073111 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check g Permanent VIN 2 Parked Motor VehiGe 1 3 Working VehicleRMA391 FL 111/16/2020 Registration ❑ JTMHXOSJ885001070 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 1 Disabling 4 Minor 2Y s ❑ 2008 TOYT LAND CRUISER SUV GRAY - GRY 2 Functional 88 Unknown $200.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due VEHICLE REMOVED BY 1. Rotation to Damage: 1 2. Owner Request PROGRESS 914459146 914459145 GERALDERBSTEIN 3. Driver 1 No 2 Yes 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE ZIP BONITA ERBSTEIN 3288 GULF STREAM RD GULF STREAM FL 33483 Trager LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES One: Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN' - - YEAR MAKE LENGTH AXLES Two: Registration E] VEHICLE N S E W Off -Road Unknown I ON STREET, ROAD, HIGHWAY AT EST. SPEED I POSTED SPEED TOTAL LANES TRAVELING ❑ ❑ 0 ❑ ❑ ❑ GULF STREAM RD 5 20 2 HAZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area of Initial Impact Most Damaged Area 1 No ❑ 1 No ❑ 02 02 3 4 5 2 Yes 2 Yes 2 3 4 5 6 18 Undercarriage 18 2 6 88 Unknown 88 Unknown 19 Overturn 19 1 15 16 17 S 1 15 16 17 8 MOTOR CARRIER NAME US DOT NUMBER 20 Windshield 20 149 21 Trailer 21 14 9 13 12 11 0 13 12 11 10 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Traffrcway Commercial Motor Vehicle ConfiguraUon ❑ 16 (Sport) Utility Vehicle ❑ 1 Two -Way, Not Divided 1 Vehicle 10,000 lbs or less Placarded 8 Traclor'nple 16 1 for Hazardous Materials 9 Truck more than 10,000 IDs (4,536 17 Cargo Van (10,000 lbs 2 Two -Way, Not Divided, with a ❑ 2 Single -Unit Truck (2 -axle and GVWR kg), Cannot Classify (4,536 kg) or less) Continuous Left Tum Lane more than 10,000 lbs 4,536 k 1 Passenger Car 18 Motor Coach 3 Two -Way, Divided, Unprotected ( 9)) 10 Bus/Large van (seats for 9-15 2 Passenger Van 19 Other Light Trucks (10,000 lbs (painted >4 feet) Median 3 Single -Unit Truck (3 or more axles) occupants, including driver) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 4 Truck Pulling Trailer(s) 11 Bus (seats for more than 15 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier Truck Tractor (bobtail) ier occupants, including driver) 6 Bus than 10,000 lbs (4,536 kg)) 5 One -Way Trafficway 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 11 Motorcycle 21 Farts Labor Vehicle 88 Unknown 7 Truck Tractor/Double Truck 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Comm/Non-Commercial TRAILER 1 TRAILER 2 13 Intermodal 3 Tank Trailer 10 Auto Transport 3 Van/Enclosed Box Container Chassis 4 Saddle Mount/Trailer 77 Other, Explain in ❑ 1 Interstate CarrierF] El ❑LCargo 4 Hopper 14 Vehicle Towing 5 Boat Trailer Narrative 2 Intrastate Cartier SPole-Trailer Another Vehicle 3 Not in Commerce/Govemment 6 Utility Trailer 88 Unknown 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 7 House Trailer Flatbed (vehicle pplica lbs 1 10,000 lbs 4,536 k or less DumMost Harmful Event Non -Collision Comm ( g) P displa kg) or less not 1 Overturn/Rollover GVWR/GCWR 4 2 10,001-26,0001bs (4,536-11,793kg) Concrete Mixer displaying HM placard 2 Fire/Explosion 3 More than 26,000 lbs (11,793kg)0 Auto Transport 77 Other, Explain in 3 Immersion4 NotA licable 1 Garbage/Refuse Narative 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object2 Log 66 Unknown 14 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 19 Impact Attenuator/Crash Cushion 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 20 Bridge Overhead Structure 31 Other Traffic Barrier ❑ Sequence of Events 8 Ran into Water/Canal 13 Animal 21 Bridge Pier or Support 32 Tree (standing) 1 9 Other Non -Collision 14 Motor Vehicle in Transport 22 Bridge Rail 33 U61iry PolelLight Support 1st 2nd 15 Parked Motor Vehicle 23 Culvert 34 Traffic Sign Support 14 ❑ [40.46 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 1 No brake failure, etc.) 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 2 Yes 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 88 Unknown 3� 4th 42 Ran Off Roadway, Right Vehicle 28 Guardrail End 39 Other Fixed Object (wall, ❑ 43 Ran Off Roadway, Left 18 Other Non -Fixed Object buildin , tunnel etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline 1 Straight Ahead 13 Stopped in Traffic This Vehicle ❑ ❑ Roadway Grade 46 Downhill Runaway 3 Turning Left 14 Slovdng 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 2 Hillcrest 17 5 Tuming Right 16 Leaving Traffic Lane 9 Railway Crossing 1 None Roadway Alignment 1 No Controls 2 Brakes 13 Wheels 1 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill ❑ 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including Device 4 Lights (head. Windshield 5 Sag (bottom) 1 2 Curve Right 10 Making U -Tum 88 Unknown Flagman, Officer, 3 Curve Left 11 OvertakingIPassing 5 Traffic Control Guard, etc.) signal, tail) 15 Mirrors Signal 77 Other, Explain in 6 Steering 16 Truck Coupling Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ 2 Farm Vehicle 10 Fire Truck 15 Charter/Tour Bus 7 Yield Sign Narrative Exhaust System Safety Chains 1 of Motor Vehicle 88 Unknown 3 Police 11 Farm Labor Transport 16 Shuttle Bus 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farts Labor Bus 11 Power Train Narrative8 Military 13 Transit/Commuter Bus 88 Unknown 12 Suspension 88 Unknown VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 2 7 Page of _ PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 19-0192 87073111 1 Driver VEHICLE # NAME PHONE NUMBER Check d Recommend ❑ 2 Non -Motorist 1 1 - 3 Passenger GERALD ERBSTEIN (614) 999-1809 Driver Re-exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 1466 RUE SHERBROOKE 0 #707 7MONTREAL (QC H3G1 L-2 DATE OF BIRTH SEX: 1 Male 1 DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incepacitating 1 None 5 Fatal 30 ❑ 03/24/1938 2 Female 88 Unknown E612424033809 QC 03/24/2022 2 Possible (within days) 3Non-Incapacitating 6 Non -Traffic Fatality DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd Condition At 1A 2B 3C—No Contribution Action 26 Ran off Roadway Time of 1 4 D/Chauffeur 3] 1 Yes 2 Operated MV in Carelss or 27 Disregarded other Traffic ❑ Crash ❑ 5 E/Operator 2 No Negligent Manner Sign 6 E/Oper-Rest 3 No Req. Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 1 Apparently Normal 7 None 4 Improper Backing Markings 3 Asleep or Fatiuged 6 Improper Tum 29 Over-Correcting/Over 5 III (sick) or Fainted Driver Distracted B By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 2nd 1 Not Distracted 8 Emotional (depression, $$ 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided : Due ( p 4th 2 Electronic Communication (outside the vehicle, explain 12 Drove too Fast for Conditions to Wind, Slippery Surface, MV, angry, disturbed, etc.) Devices (cell phone, etc. in narrative 13 Ran StopSin 9 Under the Influence of 9 Object, Non -Motorist in 3 Other Electronic Device 6 Textin 15 Improper Passin Medicetions/Drugs/Alwhol gcg Roadway, etc. (navigation device, DVD player) 77 Other, Explain in Narrative 17 Exceeded Posted Speed 31 Operated MV in Erratic, 88 Unknow 88 Unknownp 88 Unknown 21 Wrong Side of Wrong Way Reckless orAgreessive Manner DRIVER VISION OBSTRUCTIONS --I 25 Failed to Keep in Proper Lane 77 Other Contributing Action 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 4 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER ❑ 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems DRIVER OR PASSENGER ❑ 1 DOT Compliant ❑ 1 Yes [3 (RS) SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: LOCATION. 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) Seat Row Other (LOC) 1 1 3 No Helmet 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Air Bag Deployed 2 Midde 2 Sleeper Section of Truck Cab 5 La Belt Only Used 2 Second p 5 Deployed -Other P Y 3 Right 3 Other Enclosed Cargo Area Ejection (EJECT) 6 Restraint Used -Type Unknown 3 Third g (knee, air belt, etc.) YP 77 Other 4 Unenclosed Cargo Area E1 Not Ejected ❑1 Not Applicable 6 Deployed- 7 Child Restraint System - Forward Facing (explain in 4 Fourth 2 Ejected, Totally 1 2 Not De to ed 8 Child Restraint S stem - Rear Facin5 Trailin Unit g Y Combination Y 9 narrative) 77 Other Row 3 Ejected, 3 Deployed -Front 7 Deployed -Curtain 9 Booster Seat e 88 Unknown 6 Riding on Motor Vehicle Exterior (non- Partial)Deployed-Side88 Deployment YP 88 Unknown Y 4 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown N n -Motorist Description Non -Motorist Location At Time of Crash g Sidewalk Action Prior to Crash ❑ 1 Pedestrian ❑ 1 Intersection - Marked Crosswalk ❑ 5 Walking/Cyclingon Sidewalk 9 Median/Crossing Island 2 Other Pedestrian (wheelchan, person in a 2 Intersection - Unmarked Crosswalk 10 Drivewa Access 6 In Roadway – Other (working, building, skater, pedestrian conveyance, etc. Y 3 Intersection - Other4 Midbiock -Marked Crosswalk 11 Shared -Use Path or Trail playing, etc.) 3 Bicyclist 1 Crossing y 4 Midbiock -Marked Crosswalk 12 Non-Trafficwa Area 7 Adjacent to Raodway (e.g., Cross 4 Other Cyclist Y 2 Waiting to Cross Roadway 5 Travel Lane -Other Location shoulder, median) 5 Occupant of Motor Vehicle Not in Transport 77 Other, Explain in Narrative 3 Walking/Cycling Along (parked, etc.) 6 Bicycle Lane 88 Unknown Roadway with Traffic (in or 8 Going to or from School (K-12) 6 Occupant of a Non -Motor Vehicle 7 shoulder/Roadside adjacent to travel lane) 9 Working in Trafficway Transportation Device on- o ons c ions rcums antes 4 Walking/Cycling Along (incident response) 10 None 10 7 Unknown Type of Non -Motorist No Improper Action Roadway Against Traffic (in 1stEl 77 Other, Explain in Narrative 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way 1 None Safety Equipment 5 Lighting 4 Failure to Obey Traffic Signs 2 Helmet 6 Not Applicable ❑ Signals, or Oficer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 3 Protective Pads Used sod 5 In Roadway Improperly Vehicle 11 Improper Passing 77 Other, Explain (standing, (elbows, knees, shins, etc.) g, g, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking in Narrative /yin working, 4 Reflective Clothing (jacket, 88 Unknown 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL USE F 1 1 No 1 1 Test Not Given 2 Test Refused 1 Blood 2 Breath 3 Urine EST RESULT 1 PENDING ❑ DRUG USE. 1 1 No 2 Test Not Given Test Refused ❑ 1 Blood 3 Urine ❑ 1 Positive 2 Negative 2 Yes 3 Test Given 77 Other, Explain 2 COMPLETED Yes 3 Test Given 77 Other, 3 Pending ❑ 88 Unknown 88 Unknown, rf Tested in Narrative 88 UNKNOWN 8 Unknown 88 Unknown, if Tested Explain in Narrative 88 Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 1 Law ❑ 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE OF BIRTH INJ SEX I LOC: S I R O 1 EJECT I HU EP J ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nd Tanapo 2 EMS 3 Law EI«— 77 quer, E.., in N-- SS Uni m ❑J PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX LOC: S I R O EJECT I HU 1EP I ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID _T EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NO TraiwPa 2 EMS 3 lar Enla O—O 77 q , E>ml h Na:nirve BB UnMown ❑ HSMV 90010 S 3 7 Page of _ ADDITIONAL VIOLATIONS PERSON # Reporting Agericy Case Number HSMV Crash Report Number NARRATIVE 19-0192 87073111 Vehicle 1 was exiting driveway of 3288 Gulf Stream Rd, heading east. Vehicle 2 was driving north on Gulf Stream Rd, low speed. V1 struck V2 with the front bumper while exiting driveway, causing minor damage to the left rear door of V2. Driver of V1 admitted fault. ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE 57 71 INJ SEX I LOC: S I R O 1 EJECT I HU I EP I ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NA Tntmp— 2 EMS S law Ela.cemmt 770t- Eqq h h DIEMSAGENCY Ne.rn'rve M U� PERSON ]VEHICLE # AME DATE OF BIRTH I INJ I SEX I LOCS IR O EJECT I HU I EP I ABD I RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY 2, EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NOT. rspoN. 2 EMS 3 Lav Elmaement I] E '— In N.— SS U— ❑ ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 750 OFC TODD E. SUTTON GULF STREAM POLICE DEPARTM POLCE DEPARTMENT 1IPD)1 HSMV 90010 S 4 7 Page of _ DIAGRAM REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 19-0192 87073111 IAGRAM NOT REQUIRED HSMV 90010 S 5 7 Page of VEHICLE # 2 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 19-0192 1 87073111 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE P REGISTRATION EXPIRES I Check if Permanent VIN 2 Parked Motor Vehicle 1 3 Working VehicleJBNI88 FL 04/27/2019 Registration ❑ 4S3BNBF63F3026066 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 Disabling 4 Minor 2 Yes 1 2015 SUBA LEGACY 4 DOOR SEDAN GRAY - GRY 2 Functional 4 88 Unknown 3 None Unknown $500.00 INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Fo wed due VEHICLE REMOVED BY 1. Rotation ALLSTATE FIRE AND CASUA 9419736741109 Damage: 1 2 Owner Request 3 2 Yes LIDIA DEL DACOSTA L 3 Driver 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY& STATE ZIP LIDIA DEL LOUTEIRO 563 COVERED BRIDGE BLVD LAKE WORTH FL 33467 nArORTATrailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES One: Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES Two: - Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED]POSTED SPEED TOTAL LANES TRAVELING R El El EJ ❑ GULFSTREAM RD 15 20 2 HAZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area of Initial Impact Most Damaged Area 1N ❑ 1 No ❑ 11 11 2 Yes 2 Yes 23045 6 7 18 Undercarriage t8 2 3 4 5 6 7 B8 Unknown 88 Unknown 116 17 8 19 Overturn 19 1 15 H111 17 8 MOTOR CARRIER NAME US DOT NUMBER 20 Windshield 20 14 9 21 Trailer 21 14 9 2 11 0 13 10 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration ❑ 16 (Sport) Utility Vehicle 1 Two-Way, Not Divided 1 Vehicle 10,000 lbs or less Placarded 8 Tractor/rnple 1 for Hazardous Materials 9 Truck more than 10,000 lbs (4,536 1 17 Cargo Van (10,000 lbs 2 Two-Way, Not Divided, with a (4,536 kg) or less) Continuous Left Tum Lane ❑2 Single-Unit Truck (2-axle and GVWR kg), Cannot Classify more than 10,000 lbs (4,536 kg)) 10 Bus/Large van (seats for 9-15 1 Passenger Car 18 Motor Coach 3 Two-Way, Divided, Unprotected 3 Single-Unit Truck 3 or more axles occupants, including driver 2 Passenger Van 19 Other Light Trucks (10,000 lbs (painted >4 feet) Median 9 ( ) 9 ) 3 Pickup (4,536 kg) or less) 4 Two-Way, Divided, Positive 4 Truck Pulling Trailer(s) 11 Bus (seats for more than 15 7 Motor Home 20 MediumfHeavy Trucks (more Median Barrer 5 Truck Tractor (bobtail) occupants, including driver) ( 9)) 5 One-Way Trafficway 8 Bus than 10,000 lbs 4,536 k 6 Tru7 Truck Tractor/Double Truck Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer B Pole Trailer TRAILER 1 TRAILER 2 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type 13 Intermodal Comm/Non-Commercial 3 Tank Trailer 10 Auto Transport 3 Van/Enclosed Box Container Chassis ❑ 1 Interstate Carrier Saddle Mount/rrailer 77 Other, Explain iner ❑ ❑ ❑ 4 Hopper A Vehicle Towing 5 Boat Trailer Narrative 2 Intrastate Carrier 5Pole-Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 6 Cargo Tank 15 Not Applicable 4 Not inCommerce/Other Truck 7 House Trailer 1 No Cargo 7 Flatbed (vehicle 10,000 lbs 1 10,000 lbs (4,536 kg) or less 2 Bus 8 Dump (4,536 kg) or less not Most Harmful Event Non-Collision Comm 2 10,001-26,000 lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 1 Overtuplosioover GVWR/GCWR 3 More than 26,000 lbs It 1,793kg) 10 Auto Transport 77 Other, Explain in 2 Immersion osion 4 Not Applicable 11 Garbage/Refuse Narrative 3 Immersion 4 Jackknife Colliston with Non-Fixed Object Collision Fixed Object 12 Log 88 Unknown 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 14 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 19 Impact Attenuator/Crash Cushion 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 20 Bridge Overhead Structure 31 Other Traffic Barrier 21 Bridge Pier or Support ❑ Sequence of Events 8 Ran into Water/Canal 13 Animal 22 Bridge Rail 32 Tree (standing) 1 9 Other Non-Collision 14 Motor Vehicle in Transport 23 Culvert 33 Utility Pole/Light Support 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support 14 ❑ [40-46 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 1 No brake failure, etc.) 17 Stack By Falling, Shifting Cargo or 26 Embankment 37 Fence 2 Yes 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 88 Unknown 3rd 4th 42 Ran Off Roadway, Right Vehicle 28 Guardrail End 39 Other Fixed Object (wall, ❑ ❑ 43 Ran Off Roadway, Left 18 Other Non-Fixed Object building, tunnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline 1 Straight Ahead 13 Stopped in Traffic This Vehicle ❑ ❑ Roadway Grade 46 Downhill Runaway 3 Turning Left 14 Slowing 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None ❑ 2 Hillcrest 1 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing Roadway Alignment 1 No Controls 2 Brakes 13 Wheels 1 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sign/ 3 Tires 14 Windows/ 5 Sag (bottom) 2 Curve Right 10 Making U-Tum 88 Unknown Device 4 Downhill ❑ 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including 1 Flagman, Officer, 4 Lights (head, Windshield 5 Traffic Control signal, tail) 15 Mirrors 3 Curve Left 11 Overtaking/Passing Guard, etc.) Signal 6 Steering 16 Truck Coupling 77 Other, Explain in ❑ Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ Narrative 1 2 Farts Vehicle 10 Fire Truck 15 Charter/rour Bus 7 Yield Sign 9 Exhaust System Safety Chains of Motor Vehicle Ba Unknown 3 Police 11 Farts Labor Transport 16 Shuttle Bus 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 Transil/Commuter Bus 88 Unknown 12 Suspension 88 Unknown VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 6 7 Page of _ PERSON # 2 Reporting Agency Case Number HSMV Crash Report Number 19-0192 87073111 1 Driver❑ VEHICLE # NAME PHONE NUMBER Check if El3 2 Non-Motorist 1 2 Recommend Passenger UDIA DEL DACOSTA LOUTEIRO (661) 459.7006 Driver Re-exam CURRENT ADDRESS (Number and Street) CITY 8 STATE ZIP CODE 663 COVERED BRIDGE BLVD 7 LAKE WORTH FL 33467 DATE OF BIRTH SEXY 1 Male ❑ DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) ❑ 06/25/1946 2 Female 68 unknown L360524467250 FL 06/25/2019 2 Possible 6 Non-Traffic Fatality 3Non-Incapacitating DL Type Required Endorsements list Drivers Actions at Time of Crash 3rd Condition At 1A 28 3C—No Contribution Action 26 Ran off Roadway Time of 1 5 4 D/Chauffeur $ 1 Yes 1 2 Operated MV in Carelss or 27 Disregarded other Traffic Crash F ❑ 5 E/Operator 2 No Negligent Manner Sign 1 Apparently Normal 6 E/Oper-Rest 3 No Req. Endorsement 3 Failed to Yield Right-of-Way 28 Disregarded Other Road 3 Asleep or Fatiuged 7 None 4 Improper Backing Markings 5 III (sick) or Fainted 6 Improper Tum 29 Over-Correcting/Over Driver Distracted By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 2nd 1 Not Distracted 5 External Distraction 11 Ran Red Light 8 Emotional (depression, 1 9 30 Swerved or Avoided . Due 4th 2 Electronic Communication outside the vehicle, ex Iain 12 Drove too Fast for Conditions angry, disturbed, ecce ( P to Wind, Slippery Surtace, MV, Devices (cell phone, etc. in narrative 13 Ran Stop Sin 9 Under the Influence of 9 Object, Non-Motorist in 3 Other Electronic Device 6 Textin 15 Improper PassingMedications/Drugs/Alcohol r Roadway, etc. (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted S eed 77 Other, Explain in Narrative P 31 Operated MV in Erratic, 88 Unknown 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 88 Unknown 25 Failed to Keep in Proper Lane 77 Other Contributing Action DRIVER VISION OBSTRUCTl67NS___1 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 1 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain ❑ 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems 1 DOT-Compliant ❑ 1 Yes 3 (RS) DRIVER OR PASSENGER 1:1 SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: TION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non-motorist) PLOOCCI Seat Row Other ) 1 3 No Helmet 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Air Ba Deployed 9 2 Midde 2 Sleeper Section of Truck Cab 5 Deployed-Other 5 Lap Belt Only Used 2 Second 3 Right E ection EJECT 9 3 Other Enclosed Cargo Area 1 ( ) (knee, air belt, etc.) 6 Restraint Used -Type Unknown 77 Other 3 Third 1 Not Ejected 1 Not Applicable 7 Child Restraint System - Forward Facing 4 Unenclosed Cargo Area 1 PP 6 Combination in 4 Fourth ❑ 2 Ejected, Totally 2 Not Deployed Combination 8 Child Restraint System -Rear Facing 5 Trailing Unit 1 narrative 3 Ejected, 9 Booster Seat 77 Other Row 6 Ridingon Motor Vehicle Exterior non- I 3 Deployed-Front 7 Deployed-Curtain 88 Unknown 88 Unknown ( Partially q Deployed-Side 88 Deployment 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown ❑N n•Motorist Description ❑ Non-Motorist Location At Time of Crash g Sidewalk ❑ Action Prior to Crash 1 Per�estnan 1 Intersection - Marked Crosswalk 5 Walking/Cyclingon Sidewalk 2 Other Pedestrian (wheelchari, person in a 9 Median/Crossing Islandd 2 Intersection - Unmarked Crosswalk 10 Driveway Access 6 In Roadway —Other (working, an (wheal building, skater, conveyance, etc 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared-Use Path Trail playing, etc.) se or 1 Crossing Roadway 3 Bicyclist 4 Midbiock -Marked Crosswalk7 Adjacent to Raotlway (e.g., 4 Other Cyclist 12 Non Area 2 Waiting to Cross Roadway 5 Travel Lane -Other Location 77 etherr,, Explain in Narrative 3 Walking/Cyclingshoulder, median) 5 Occupant of Motor Vehicle Not in Transport 6 Bicycle Lane Along 8 Going to or from School (K-12) y (parked, etc.) 88 Unknown Roadway with Traffic(inor 7 shoulder/Roadside 9 Working in Trafficway adjacent 6 Occupant of a Non-Motor Vehicle I cent to travel lane) (incident response) Transportation Device Non-MboTonst Actionsicircumstances, 4 Walking/Cycling Along 10 None 7 Unknown Type of Non-Motorist tst ❑ 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right-of-Way 1 None Safety Equipment 5 Lighting 4 Failure to Obey Traffic Signs 2 Helmet ❑ Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Passing e 6 Not Applicable 3 Protective Pads Used zrNl ❑ 5 In Roadway Improperly Vehicle 11 Improper Passing 77 OtherExplain (Standing, (elbows, knees, shins, etc.) in Narrative lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong-Way Riding or Walking 4 Reflective Clothing (jacket,88 Unknown ❑ 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT. ALCOHOL USE: ❑ 1 No 1 t Test Not Given ❑ 2 Test Refused 1 Blood 2 Breath 0[2 3 Urine EST RESULT: ❑ PENDING DRUG USE: 1 1 No 2 Test Not Given ❑ Test Refused 1 Blood ❑ 3 Urine 1 Positive 2 Negative 2 Yes 3 Test Given 77 Other, Explain COMPLETED Yes 3 Test Given 77 Other, 3 Pendinga88 Unknown 88 Unknown, it Tested in Narrative 8 UNKNOWN 8 Unknown 88 Unknown, if Tested Explain in Narrative 88 Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 1 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX I LOCS I R O EJECT 1HU J I EP I ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nd TnmparlW 2 EMS 3 La Ensco M 77 01-, EU ,i in Nanetrve M U­ ❑ PERSON # VEHICLE # AME DATE OF BIRTH I INJ I SEX I LOC: S I R 1 O EJECT 1HU J I EP I ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO ,n 1 No Tran i—W 2 EMS 31 EnracemaM 770. ,, E,­,n Nv,atne W U,1 p ❑ F I HSMV 90010 S 7 7 Page of _