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HomeMy Public PortalAboutPRR 21-2860LAW OFFICE OF TODD C. PASSMAN, P.A. 200 S. Indian River Dr., Suite 306 Todd C. Passman Fort Pierce, Florida 34950 Tel (772) 465-9806 todd@passmanlawoffice.com www.passmanlawoffice.com Fax (772) 465-9868 November 22, 2021 Certified Return Receipt Requested No.: 7021 0950 0000 6005 7622 Gulf Stream Police Department Records Department 246 Sea Road Delray Beach, Florida 33483 Re: Date of Accident: 08/27/2021 Agency Report No.: 21-1728 HSMV Crash Report No.: 87073133 Our File No. 90.4-21-130 Dear Sir / Madam, The undersigned hereby makes a request for public records pursuant to Chapter 119, Florida Statutes. Request is made for any and all records regarding the above accident, including but not limited to: 01A 3. it/p 4. Nln 5. l/6. 4 /j4 7. p131? P 8. 4/ 9. Any and all Reports (Long Form, Short Form, Updates, etc.) Witness Statements, written and recorded Photographs All Video, including audio Dash cam videos, including audio Body cam videos, including audio Accident Scene technical reports and measurements 911 / dispatch audio, radio communications, and CAD related to said incident Any correspondence, emails, text messages, or other communications which reference or concern the subject accident. Demand is hereby made for access within five (5) working days of receipt of this request. If there are any questions about this Request for Information, please contact our office. Your cooperation is appreciated. We thank you in advance for your prompt response. Sincerely, LAW OFFICE OF TODD C. PASSMAN, P.A. Todd C. Passman TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via e-mail December 8, 2021 Todd Passman [mail to: todd@passmanlawoffice.com] Re: GS #2860 (Police Report 21-1728) Request for any and all records regarding the accident on 8/27/2021, including but not limited to: any and all reports, witness statements (written and recorded), photographs, all video (including audio), dash cam videos (including audio), body cam videos (including audio), accident scene technical reports and measurements, 911/dispatch audio, radio communications, and CAD related to said incident, any correspondence e-mails, text messages, or other communications which reference or concern the subject accident. Dear Todd Passman [mail to: todd@passmanlawoffice.com]: The Town of Gulf Stream has received your public records request dated November 22, 2021. You should be able to view your original request and a partial response at the following link: https://portal.laserfiche.com/Portal/DocView.aspx?id=177812&repo=r-430100cc The City of Delray Beach serves as the Town’s Dispatch. The Town has submitted your request to the City of Delray Beach to provide these records, resulting in an answer from Delray Beach stating that 911 Audio is retained for 90 days pursuant to the State of Florida Record Retention laws and is purged after 90 days. Therefore the 911 audio no longer exists. The Town now estimates that to fully respond to your request will require $4.50 for the thumb drive of the BWC Video. The Town of Gulf Stream does not have any crash scene photographs, video, dash cam, accident scene technical reports and measurements, correspondence, e-mails, text messages or other communications which reference or concern the accident. If the costs of producing these documents will exceed your deposit, the Town will provide you with an initial production of responsive records and an estimate to produce any additional responsive records. If the costs of production are less than the deposit, the Town will provide you with the responsive records and a refund. (4.50 for thumb drive) Deposit Due: $4.50 in cash or check. The thumb drive can be picked up between the office hours of 9:00 AM – 4:00 PM Monday through Friday. If we do not hear back from you within 30 days of this letter, we will consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records VEHICLE # 1 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 21-1728 1 87073133 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES VIN 2 Parked Motor VehiGe 1 Check tt Permanent 3 Working Vehicle HHRH74 FL 06/30/2022 Registration ❑ 1GNSCGKC5GR416428 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 Disabling 4 Minor 2 Yes 2016 CHEV UT UTILITY WHITE - WHI 2 Functional I $25,000.00 88 Unknown 3 None 88 Unknown ll INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due VEHICLE REMOVED BY 1. Rotation TRAVELERS CASUALTY INS. �N910atS1BA to Damage: 2 3. 2. Owner Request 1 1 No 2 Yes ❑ ZUCCALA 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY 6 STATE ZIP OCEAN LEASING LLC 101 PUGLIESE WAY DELRAY BEACH FL 33444 Trailer 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 ❑ ❑ ❑ ❑ ISRAIA NORTH OCEAN BLVD. 35 35 1 2 HAZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area of Initial Impact Most Damaged Area 1 No ❑ 1 Nc ❑ 3 4 5 6 01 02 3 4 5 6 2 Yes 2 Yes 2 7 18 Undercarriage 18 2 7 88 Unknown 88 Unknown 1 15 16 17 8 19 Overturn 19 1 15 16 17 8 MOTOR CARRIER NAME US DOT NUMBER 20 Windshield 20 14 13 121110 9 21 Trailer 21 14 13 1211 0 9 MOTOR CARRIER ADDRESS CITY STATE I 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 Ibs or less Placarded 8 Tractor/Triple 16 I for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 17 Cargo Van (10,000 Ibs 2 Two -Way, Not Divided, with a 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify Continuous Left Turn Lane (4,536 k 9) or less) more than 10,000 Ibs (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 Ibs (painted >4 feet) Median 4 Truck Pulling Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier 5 Truck Tractor (bobtail) occupants, including driver) 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 8 Bus than 10,000 Ibs (4,536 kg)) 5 One -Way Traf sway 7 Truck Tractor/Double Truck 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 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Comm/Non-Commercial TRAILER 1 TRAILER 2 dal 3 Tank Trailer 10 Auto Transport 13 tame Chassis 4 Saddle Mount/rrailer 77 Other, Explain in 3 HopperVantEn Box Container Chassis ❑ 1 Interstate Carrier ❑ ❑ ❑ 4 Hopper An Vehicle Towing 5 Boat Trailer Narrative 2 Intrastate Cartier 5Poie-Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 7 House Trailer 1 No Cargo 7 Flatbed (vehicle 10,000 Ibs 1 10,000 Ibs (4,536 kg) or less 2 Bus 8 Dump (4,536 kg) or less not Most Harmful Event Non -Collision Comm 2 10,001-26,000lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 1 Overturn/Rollover GVWR/GCWR I3 More than 26,000 Ibs (11,793kg) 10 Auto Transport 77 Other, Explain in 2 Fire/Explosion osion 4 Not Applicable 11 Garbage/Refuse Narrative 3 Immersion 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 12 Log 88 Unknown 14 5 Cargo/Equipment Loss or Shift 10 Pedestrian 19 Impact Attenuator/Crash Cushion 29 Cable Barrier Emergency 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 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) 9 Other Non -Collision 14 Motor Vehicle in Transport 23 Culvert I 22 Bridge Rail 33 Utility Polei fight Support 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support 14 ❑ 14046 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 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 VehlCla ❑ ❑ Roadway Grade 46 Downhill Runaway 3 Tuming Left 14 Slowing 1 Level 14 Backing 15 Negotiating a Curve I 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 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 1 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-Turn 88 Unknown Flagman, Officer, 3 Curve Left 11 Overtaking/Passing5 Traffic Control Guard, etc.) signal, tail) 15 Mirrors Signal 6 Steering 16 Truck Coupling Explain in Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 77 Other, 7 Wipers Trailer Hitch/ of Motor Vehicle 2 Farm Vehicle 10 Fire Lab S88 Unknown 15 harter/Tour Bus 7 Yield Sign Narrative 9 Exhaust System Safety Chains I 3 Police 11 Farm 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 Transit/Commuter Bus 88 Unknown 12 Suspension 88 Unknown VIOLATION PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER I PHILIP ANDREW PIKE 316.1925(1) CARELESS DRIVING Al PKOTP PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 5 VALENTIN IIANOVIC NOVIK 316.1946(1)(A)3 IMPROPERSTOP WITHIN INTERSECTION AIPKOVP PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 2 g Page of FLORIDA TRAFFIC CRASH REPORT WAS DOT PROPERTY INVOLVED IN THIS CRASH9 LONG FORM ❑ SHORT FORM ❑ UPDATE [] TOTAL # OF VEHICLE SECTION(S) 2 (Shaded Areas) 3 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 08/27/2021 1 10:02 PM 11/01/2021 121-1728 187073133 CRASH IDENTIFIERS COUNTY ODE PLACE OR CITY OF CRASH IME REPORTED TIME DISPATCHED ICITYCODE ICOUNTYOFCRASH CITY LIMITS 06 PALM BEACH GULF STREAM 10:04 PM 10:04 PM TIME ON SCENE IME CLEARED SCENE HE K IF REASON (If Investigation NOT Complete) Notified By: 1 Motorist 111:59 COMPLETED 0 10:07 PM PM 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY AT STREET ADDRESS # AT LATITUDE AND LONGITUDE SRA1A 3500 BLOCK In 26.496914 -80.053473 AT FEET MILES N S E W © AT/FROM INTERSECTION WITH STREET, ROADMIGHWAY © OR FROM MILEPOST# 5 VI J BANYAN RD Road System Identifier 1 Interstate 4 County 2 U.S. 5 Local 3 State 6 Tumpikerroll 7 Forest Road 8 Private Roadway 9 Parking Lot 77 Oher Explain in Narrative Type of Shoulder 1 Paved 2 Unpaved 3 Curb $ Type of Intersection 1 Not at Intersection 2 Four -Way Intersection 3 T-Intersection 4 Y-Intersection 5 Traffic Circle 6 Roundabout 7 Five -Point, or More 77 Other, Explain in Narrative RASH INFORMATION (CHECK IF PICTURES TAKEN) Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collision/Impact 1 Daylight 4 2 Dusk 5 Dark -Not Lighted 6 Dark -Unknown 4 Flog, Smog, Smoke 5 Sleet/HaiU Freezing Rain El 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus 4 Sideswipe, same direction 1 5 Sideswipe, Opposite Direction 3 Dawn Li Lighting 6 Blowing Sand, Soil 1 ❑ 8 Water 1 Directly Involved 6 Rear to Side 4 Dark -Lighted Other, Explain in Narrative Dirt 1 Clear (standing/moving) 3 Yes, School Bus 7 Rear to Rear 1 Front to Rear 88 Unknown 7 Severe Crosswinds 2 Cloudy 1 Dry 77 Other, Explain in Narrative Indirectly Involved 77 Other, Explain in Narrative 2 Front to Front 77 Other, Explain in 3 Rain 2 Wet 3 Angle 88 Unknown Narrative 4 Ice/Frost 88 Unknown First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 1 Overturn/Rollover 10 Pedestrian 19 ImpactAttenuator/Crash 30 Concrete Cusion 31 Other Traffic Barrier Location 1 On Roadway 2 Fire/Explosion 11 Pedalcycle 3 Immersion 12 Rahway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Off Roadway 14 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 5 Cargo/Equipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 3 Shoulder 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 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 1 No 2 Yes Object Equipment 27 Guardrail Face 38 Mailbox 8 Ran int Water/Canal 17 Struck By Falling, Shifting 28 Guardrail End 39 Other Fixed Object (wall, 9 Outside Right-of-way 10 Roadside 88 Unknown 9 Other Collision Cargo 29 Cable Barrier building, tunnel, etc.) 88 Unknown 18 Other Non -Fixed Obiect First Harmful Event Relation to Contributing Circumstances: Road 9 Wom, Travel -Polished Surface Contributing Circumstances: Environment 2 ❑ Junction 5 Railway Grade Crossing 1 icy, snow, slush, etc.) ❑ ❑ ❑ 10 Road Surface Condition (wet, El ❑ ❑ 14 Entrance/Exit Ramp 11 Obstruction in Roadway 1 NonJunction 15 Crossover - Related 16 Shared -Use of Path or Trail 12 Debris 1 None 13 Traffic Control Device 1 None 5 Animal (s) � m Roadway 2 Intersection 17 Acceferation/Dceleration Lane 4 Work Zone (construction/ Inoperative, Missing or Obscured 2 Weather Conditions 77 Other, Explain in 3 Intersection -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 ❑ 2 Yes 1 Warning Sign 2Advance Waming Area ❑ 3 Transition Area 2 Lane Shif /Crossover 3 Work on Shoulder or Median 4 Intermittent or Moving Work ❑ 1 No ❑ 2 Yes 1 No 2 Officer Present 88 Unknown 4 Activdy Area 77 Other, Explain in Narrative 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area Only Present TNESSES NAME ADDRESS CITY & STATE ZIP CODE A ONEAL 246 SEA ROAD GULF STREAM FL NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY &STATE ZIP CODE NON VEHICLE PROPERTY DAMAGE VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME ID (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE VEH. # PER # PROPERTY DAMAGE -OTHER THAN VIER EST. AMT. OWNER'S NAME © (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE HSMV 90010 S 1 S Page of VEHICLE # 2 Check if Commercial V ReportingAgency Case Number HSMV Crash Report Number ❑ 21-1728 87073133 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES VIN Check if Permanent 2 Parked Motor VehiGe 3 Working Vehicle 2 P1100399 IL Registration Q JIGNSCGKC5GR416428 Hit and Run 1 No 1 YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor 4 EST. AMOUNT 2 Yes 12021 1 VOLVO AUTO CARRIER WHITE - WHI 2 Functional 88 Unknown ;5,000.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due to Damage: 1 VEHICLE REMOVED BY 1. Rotation 2. Owner Request 1 ARACHAS GROUP LLC CPS7259M 1 No 2 Yes SECOND DRIVER - TAT 3. Driver 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) M CURRENT ADDRESS CITY 8 STATE ZIP CARRY I $63 BITTERSWEET DR NORTHBROOK IL 60062 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check it Permanent VIN YEAR MAKE LENGTH AXLES One: 785892ST IL Registration R 1T9VC5323MW296135 2021 KENT. 30 2 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 ❑ a ❑ ❑ ❑ ❑ Al & BANYAN RD 10 35 2 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 21 21 2 Yes 1 ❑ 2 Yes 1 ❑ 3 4 5 6 3 4 5 6 2 7 18 Undercarriage 18 2 7 88 Unknown 88 Unknown 1 15 16 17 $ 20 Windshield 20 1 15 16 17 8 MOTOR CARRIER NAME US DOT NUMBER CARRY TRANSPORTATION INC 1868131 14 13 12 11 0 g 21 Trailer 21 14 13 12 11 0 g MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER 863 BITTERSWEET DR. NORTHBROOK IL 60062 (630) 2894410 Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 16 (Sport) UtilityVehicle 1 1 Two -Way, Not Divided 1 Vehicle 10,000 Ibs or less Placarded 8 Tractor/Triple 20 17 Cargo Van (10,000 Ibs for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 2 Two -Way, Not with a (4,53o kg) or less) Turn Laed, ❑ 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify Continuous Left Turn Lane 4 more than 10,000 Ibs (4,536 kg)) 10 Bus/Large van (seats for 9-15 1 Passenger Car 18 Motor Coach 3 Two -Way, Divided, Unprotected occupants, including driver 3 Single -Unit Truck (3 or more axles) P 9 ) 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median 4 Truck Pulling Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 il bt b t Tractor (bobtail) 5 Truckoccupants, 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier including driver) 6 Truck Tractor/Semi-Trailer 8 Bus 4,536 than 10,000lbs 9)) 77 Other, lain in NNarrative( 5 One -Way y Traficway 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 MOpped 77 Other, Explain in Narrative Trailer Type 1 Single Semi Trailer 8 Pole Trailer 13 All Terain VehiGe (ATV) 68 Unknown Cargo Body Type Comm/Non-Commercial 2 Tandem Semi Trailer 9 Towed Vehicle TRAILER 1 TRAILER 2 3 Tank Trailer 10 Auto Transport 13 Intermodal 1 Interstate Cartier ❑ ❑ 4 Saddle Mount/rrailer 77 Other, Explain in ❑ 3 HopperVan/EnBox Container Chassis 10 10 4 Hopper 14 Vehicle Towing 5 Boat Trailer Nartative 1 2 Intrastate Carrier ❑ 5 Pole -Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 7 House Trailer 1 No Cargo 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 7 Flatbed (vehicle 10,000 Ibs Most Harmful Event Non -Collision 2 Bus 1 10,000 Ibs (4,536 kg) or less 8 Dump (4,536 kg) or less not Comm 1 Overturn/RolloverComm GVWR2 CWR 1 2 10,001-26,000lbs (4,536-11,793kg) 9 Concrete Mixer displaying HIM placard ❑ Fire/Explosion 3 More than 26,000 Ibs (11,793kg) 10 Auto Transport 77 Other, Explain in Immersion 4 Not Applicable 11 Garbage/Refuse Narrative3 F4 15 12 Log 88 Unknown Jackknife Collision with Non -Fixed Object Collision Fixed Object 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 19 Impact Attenuator/Crash Cushion 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 30 Concrete Traffic Barrier Vehicle Use 20 Bridge Overhead SW cture 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 31 Other Traffic Barrier 21 Bridge Pier or Support Sequence Of Events 8 Ran into Water/Canal 13 Animal 32 Tree (standing) 9 Other Non -Collision 22 Bridge Rail 1 14 Motor Vehicle in Transport 33 Utility Pole/Light Support 23 Culvert 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support 15 ❑ 14046 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 40 equipment Failure tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 1 No (blown Z Yes brake failure, etc.) 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 88 Unknown 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 3rd bth ❑ ❑ 42 Ran Off Roadway, Right 43 Ran Off Roadway, Left Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 18 Other Non -Fixed Object building, tunnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects Roadway Grade 45 Cross Centerline 46 Downhill Runaway 3 Turning Left 14 Slowing 1 Straight Ahead 13 Stopped in Traffic This Vehicle ❑ ❑ 1 Level 2 Hilicrest Roadway Alignment ❑ 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None 5 Turning 8 minRight 16 Leaving Traffic Lane 9 Railway Crossing g gg 3 Uphill 1 No Controls 2 Brakes 13 Wheels 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) LLJ1 ght 2 Curve Right 10 Making U-Turn 88 Unknown Flagman, Officer, 5 Traffic Control signal, tail) 15 Mirrors 3 Curve Left 11 Overtaking/Passing Guard, etc.) Signal 6 Steering 16 Truck Coupling Special Function 1 Special Function Explain in 9 Ambulance 14 Intercity Bus 6 Stop Sign 77 Other, 7 Wipers Trailer Hitch/ Narrative 1 of Motor Vehicle 2 Farm Vehicle Fa 10 Fire Truck 15 Charter/Tour Bus 7 Yield Sign 9 Exhaust System Safety Chains 88 Unknown 3 Police 11 Farm 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 Transit/Commuter Bus 88 Unknown 12 Suspension 88 Unknown LM7 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 8 8 Page of Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 21-1728 87073133 ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS 4 1 LAURA KAY PUGLIESE 11H5/1960 1 I 2 3 2 1 4 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 3145N OCEAN BLVD GULFSTREAM FL 33483 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 N TmlpM I EMS 3 law EnbrcwmaX 77 Otlw. bo in N N w UMpcwn 1 ❑ PERSON # VEHICLE # AME DATE OF BIRTH I INJ I 7OC: S IR O 1 EJECT I HU JEP I ABD I RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 "TmlpM 2 EMS 3 law En(armmmR 77 O M. E� in NarnlNe 8S Unlmwvn ❑EMS ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 1ID/BADGE 758 OFFICER O'NEAL,A GULF STREAM POLICE DEPARTM (PD)POLICE DEPARTMENT HSMV 90010 S 7 B Page of_ DIAGRAM REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 21-1728 1 87073133 HSMV 90010 S 11 NOT TO SCALE 7SRAIA AREA OF IJPACT BAMYAl1 tm 6 8 Page of _ RepoNng Agency Case Number HSMV Crash Report Number NARRATIVE 21.172g 87073133 Vehicle 1 driver stated " I was traveling south bound on SRA1A and collided with a ramp off the rear of a auto transport carrier. I did not see the ramp of the auto transport carrier because it did not have lights displayed at the time of the crash." Vehicle 2 driver Stated " my auto transport carrier was stopped on SRAIIA in the south bound lane. I was delivering a vehicle when Vehicle 1 collided with one of the ramps off the rear of my auto transport carver causing a steel plate to strike my foot. " Veh. 1 struck Veh. 2 causing damage to the driver side ramp of Veh 2 and injury to the driver of Veh. 2's foot, who was standing at the rear of the ramp when contact was made. Veh.1 air bags deployed Veh.1 was disabled due to damage and towed away. The driver of Veh.2 was transported to Bethesda hospital for treatment. There were no other reported injuries at the time. Veh. 2 was driven away from the accident scene by an alternate driver. ADDITIONAL PASSENGERS PERSON # EHICLE DATE OF BIRTHMINJSEX LOC: S R O HU EP ABD RS 2 1 7AME Y NT CE PUGLIESE 1/2/1947 1 3 1 1 JEJECT 1 2 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 3146 N OCEAN BLVD GULFSTREAM FL 33321 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 "T"Mpa 2 EMS 3 Law EMmcerer" T O , E.l M Nart""n W Unbiown 1 ❑ PERSON # HICLE # AME DATE OF BIRTH IN J SEX LOC: S R O EJECT HU EP ABD RS 3 1 CATHERINE DEGABRIELLE 9116/1956 1 2 1 2 1 1 2 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 23668 MIRABELLA CIR N BOCA RATON FL 33433 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 "T—port 2 EMS S law ErMarc"m"M r W , EMA n M 1 Nart""wW— ❑ ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE ORATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. POLICE DEPARTMENT I(PD) 758 OFFICER O'NEAL,A GULF STREAM POLICE DEPARTM HSMV 90010 S 5 8 Page of _ PERSON # 5 1 Driver VEHICLE # NAME 2 Non -Motorist a 1 I 3 Passenger VALENTIN CURRENT ADDRESS (Number and Street) 2050 OLEANDER BLVD APT 3104 DATE OF BIRTH SEX: DRIt 1 Male 1 ❑ 2 Female 1 02/171 88 Unknown ❑ DL Type 3 Required ❑ Endorsements 4 D/ChChauReur 4 5 E/Operator 6 E/Oper-Rest 1 Yes 2 No 3 No Req. Endorsement 7 None Distracted By 4 Other Inside the Vehicle ❑Driver (explain in narrative) 1 Not Distracted 5 External Distraction 2 Electronic Communication (outside the vehicle, explain Devices (cell phone, etc. in narrative) 3 Other Electronic Device 6 Texting (navigation device, DVD player) 7 Inattentive 88 Unknown Reporting Agency Case Number HSMV Crash Report Number 21-1728 87073133 77777� heck f Recommend ❑ IVANOVICH NOVIK Driver Re -exam CITY & STATE ZIP CODE FORT PIERCE FL 1 34950 IUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4lncepadtating 1 None 2 Possible 5 Fatal (within 30 days) 3 3 Non -Incapacitating 6 Non -Traffic Fatality tat Drivers Actions at Time of Crash ❑1 No Contribution Action 2 Operated MV in Carelss or 26 Ran offRoadway 27 Disregarded other Traffic Negligent Manner Sign 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 4 Improper Backing Markings 6 Improper Turn 29 Over-Correcfing/Over Steering 2nd 10 Followed too Closely 11 Ran Red Light 30 Swerved or Avoided : Due Drove too Fast for Conditions to Wind, Slippery Surface, MV, ❑12 13 Ran Stop Sign Object, Non -Motorist in 15 Improper Passing Roadway, etc. 17 Exceeded Posted Speed 31 Operated MV in Erratic, 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action ❑ 1 vision nor lIDSCUr-- 5 Load on Vehicle 9 Smoke 2 Inclement Weather 6 Building/Fixed Object 10 Glare 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) DRIVER OR PASSENGER ❑ 1 DOT -Compliant SEAT Motorcycle Helmet Motor Vehicle Seating Position: LOCATION. 2 Other Helmet Seat Row Other (LOC) 3 No Helmet 1 Len 1NotApplicable 1 Front Air Bag I 3rd 4th DRIVER OR PASSENGER Condition At Time of Crash 1 Apparently Normal 3 Asleep or Fatigued 5 III (sick) or Fainted 6 Seizure, Epilespsy, Blackout 7 Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) 9 Under the Influence of Medications/Drugs/Alcohol 77 Other, Explain in Narrative 88 Unknown Eye Protection (EP) ❑ Restraint Systems 1 Yes (RS) ❑ 2 No 3 Not Applicable 1 Not Applicable (non -motorist) 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used ed 4 Shoulder Belt Only Used 101 d 2 Middle 3 Right econ 2 Second 2 Sleeper Section of Truck Cab 3 Other Enclosed Cargo Area g Ejection (EJECT) 5 Deployed -Other (knee, air belt, etc.) 5 Lap Bet n y Use 6 Restraint Used - Type Unknown 77 Other in 3 Third 4 Fourth 4 UnenGosed Cargo Area 5 Trailing Unit 1 Not Ejected ❑ 2 Ejected, Totally 1 NotA licable e 6 Combination 2 Not Deployed Combination 7 Child Restraint System - Forward Fadng B Restraint System -Rear Facing narrative 88 Unknown 77 Other Row 88 Unknown 6 Ridingon Motor Vehicle Exterior non- � 3 E acted, 1 Partially 3 Deployed -Front 7 Deployment 4 Deployed -Side BB Deployment 9 Booster Seat Boos 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown n n-rooronsr uescnpuon 1 Pe estnan 2 Other Pedestrian in non-moronsr Location AT r ime or crasn 1 Intersection - Marked Crosswalk 8 Sidewalk 9 Island Acrion rnor m r raan 77 5 Walking/Cycling on Sidewalk 5 ❑ (wheelchari, Person a building, skater, pedestrian conveyance, etc. 77 ❑ 2 Intersection -Unmarked Crosswalk 3 Intersection - Other4 Midblock - Marked Crosswalk DrivewCrossing 10 Driveway Access 6 In Roadway —Other (working, playing, etc.) 3 Bicyclist 11 Shared -Use Path or Trail 1 Crossing Roadway 7 Adjacent to (e.g., 4 Other Cyclist 4 Midblock -Marked Crosswalk 12 Non-Traficwa Area Y 2 Waiting to Cross Roadway fan) y 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane - Other Location 6 Bicycle Lane 77 Other, Explain in Narrative 3 Walking/Cycling Along shoulder, median) 8 Going to or from School (K-12) (parked, etc.) 7 shoulder/Roadside 88 Unknown Roadway with Traffic in or Y adjacent to travel lane) 9 Working in Trafficway 6 Occupant of a Non -Motor Vehicle Transportation Device on- o 0 on rcums nces 4 Walking/CyclingAlong (incident response) 10 None 7 Unknown Type of Non -Motorist 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 1st 1 ❑ 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way 1 None Safety Equipment 5 Lighting 2 Helmet a 4 Failure to Obey Traffic Signs Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum[Merge 6 NotApplicable 3 Protective Pads Used 77 Other, Explain 2 5 In Roadway Improperly (standing. Vehicle 11 Improper Passing (elbows, knees, shins, etc.) in Narrative lying, working, playing) 8 Inattentive (talking, g, Wrong -Way 9 g ( g, satin etc) 12 Wron Wa 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, leavingtapproaching) fighting, etc.) 88 Unknown at cnwni inaur:/FaaS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: ALCOHOL BAC SUSPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: 1 No ALCOHOL USE: Test Not 2 Test Refused Given ❑ Breath ❑TEST I Blood �� rinteer?Expla RESULT: 2 PENDING F-1 IE DRUG USE: 2 I ❑ Refused Given1 Test Not ❑ Test 1Blood 7 rfine [:] live ❑ 2 Yes 3 Test Given n COMP ETED 3 Test Given Other, 3 Pending 88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 88 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 2 DELRAY BEACH FIRE RESCUE BETHESDA HOSPITAL 77 Other, Explain in Narrative 88 Unknown DB 21010855 ADDITI NAL PASSENGERS PERSON # VEHICLE # [AME IDATP5F BIRTH INJ I SEX LOC: S R 0 EJECT I HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nd TaMM-12 EMS 3l Elf>amed 77 gNer, E..' In Nanalive N Unbgwn ❑JEMS PERSON # VEHICLE # AM DATE OF BIRTH INJ I SEX I LOC: S I R O 1 EJECT I HU I EP 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 Tnrn —2 EMS 3—Enf-1 TI Oft, E,...M Narrative BE Unbpwn ❑J HSMV 90010 S 4 8 Page of _ PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 21-1728 87073133 1 Driver VEHICLE# NAME PHONE NUMBER Check6 ❑ 2 1 ❑ I Recommend Passenger 1 3 Passenge PHILIP ANDREW PIKE (661) 673-4248 Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 4100 SANCTUARY LN BOCA RATON FL 33431 DATE OF BIRTH SEX: 1 Male DRIVERS LICENSE NUMBER STATE EXPIRES 1 INJURY SEVERITY (INJ) 4 Inca pacitati ng 1one N 5 Fatal (within 30 days) 1 2 Female 2 Possible 04/07/1967 88 Unknown P2006616712700 FL 04/07/2025 3 Non -Incapacitating 6 Non -Traffic Fatality DRIVER DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd Condition At 1 A 2 B 3 C 1 No Contribution Action 26 Ran off Roadway Time of i r 9Disregarded other Traffic Crest Negligent Manner in Carelss or 27 5 Operator 2 No 1 Apparently Normal 6 E/Oper-Rest 3 No Re Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road q 3 Asleep or Fatigued 7 None 4 Improper Backing Markings 5 III (sick) or Fainted 6 Improper Turn 29 Over-Correcting/Over 6 Seizure, Epilespsy, Blackout Driver Distracted By 4 Other Inside the Vehicle Steering (explain in narrative) 10 Followed too Closely 7 Physically Impaired 88 1 Not Distracted 2nd 6 Emotional (depression, 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided :Due 4th angry, disturbed, etc.) 2 Electronic Communication ❑ (outside the vehicle, explain 12 Drove too Fast for Conditions Wind, Slippery , MV 1 9 Under the Influence of Devices (cell phone, etc. rist in in narrative) 13 Ran Stop Sign Object, Non -Motorist in O 1 Medications/Drugs/Alcohol 3 Other Electronic Device 6 Textin 15 Improper r Passing Roadway, etc. 77 Other, Explain in Narrative (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Erratic, 88 Unknown 88 Unknown 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action DRIVER VISION OBSTRUCTIONS 1 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER 1 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) 3 Restraint Systems DRIVER OR PASSENGER ❑ 1 DOT -Compliant ❑ 1 Yes (RS) SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) (LOC) 1 1 3 No Helmet 2 None Used - Motor Vehicle Occupant Seat Row Other 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Sag Deployed Air BDepld 5 Lap Belt Only Used 2 Midde 2 Sleeper Section of Truck Cab 5 Deployed -Other 2 Second 3 Right 3 Other Enclosed Cargo Area Ejection (EJECT) (knee, air belt, etc.) 6 Restraint Used -Type Unknown 1 Not Ejected ❑ 1 NotApplicable 6 Deployed- 7 Child Restraint System -Forward Facing 77 Other 3 Third 4 UnenGosed Cargo Area 3 (explain in 4 Fourth 2 Ejected, Totally 2 Not Deployed Combination 8 Child Restraint System - Rear Facing 5 Trailing Unit 1 ❑ 3 E Ejected, 9 Booster Seat narrative) 77 Other Row 1 3 Deployed -Front 7 Deployed -Curtain 88 Unknown 6 Riding on Motor Vehicle Exterior (non- Partially 4 Deployed -Side 88 Deployment 10 Child Restraint Type Unknown 88 Unknown trailing unit) 4 Not Applicable 77 Other, Explain in Narrative Unknown 88 Unknown 88 Unknown N n-Motorist Description 1 Pe�estnan ❑ Non -Motorist Location At Time of Crash 8 Sidewalk ❑ Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cycling on Sidewalk 9 Median/Crossing Island 2 Other Pedestrian (wheelchari, person in a 2 Intersection -Unmarked Crosswalk 10 6 In Roadway — Other (working, building, skater, pedestrian conveyance, etc. Pas hared-Useriveway 3 Intersection - Other4 Midblock -Marked Crosswalk 11 Shared -Use Path or Trail 1 Crossing Roadway playing, etc.) 3 Bicyclist 4 Other Cyclist 4 Midblock - Marked Crosswalk 7 Adjacent to Raodway (e.g.. 12 Non-Trafficway Area 2 Waiting to Cross Roadway shoulder, median) 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane -Other Location 77 Other, Explain in Narrative 3 Walking/Cycling Along 6 Bicycle Lane 8 Going to or from School (K-12) (parked, etc.) 88 Unknown Roadway with Traffic (in or 7 shoulder/Roadside 9 Working in Trafficway adjacent to travel lane) 6 Occupant of a Non -Motor Vehicle (incident response) 4 Walking/Cycling Along Transportation Device 7 Unknown Type of Non -Motorist Non -Motorist Action rcum ances 10 None 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative t`t ❑ 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way 4 Failure to Obey Traffic Signs 7 Entedng/Exiting Parked/Standing 10 Improper Tum/Merge ❑ 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not A Applicable 3 Protective Pads Used PP 77 Other, Explain Signals, or Officer zoo Vehicle 11 Improper Passing 5 In Roadway Improperly (standing, (elbows, knees, shins, etc.) in Narrative 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking lying, working, playing) 4 Reflective Clothing (jacket, 88 Unknown 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative ❑ backpack, etc.) lighting, etc.) 88 Unknown on, pushing, leaving/approaching) ALCOHOLJDRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL USE: 1 No 1 � 1 Test Not Given 2 Test Refused ❑ 1 Blood 2 Breath 3 Urine ❑ 1 ST RESULT ❑ ❑ DNUoG USE: 2 1 ❑ Test Not Given Test [:] Blood r--7 3 Urine 1 Positive 2 Negative ❑ 2 Yes 3 Test Given 77 Other, Explain 2 COMPLETED Yes 3 Test Given '6Tested 77 Other, 3 Pending 88 Unknown 68 Unknown, if Tested in Narrative 88 UNKNOWN Unknown 88 Unknown, 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 11 VEHICLE # [AME DATE OF BIRTH I INJ I SEX I LOC: S I R O EJECT HU EP ABD IRS 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 NatTrt ,,We 2 EMS 3law E�"drier, Evih in DIEMSAGENCY Narntlw M u- PERSON # VEHICLE # [AME DATE OF BIRTH I INJ I SEX I LOC: S I R O EJECT J HU EP 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 NA Trenaportetl 2 EMS Slaw Enforamner i n d ,, EVWin in NartWve BB Unbven ❑ HSMV 90010 S 3 8 Page of_ VEHICLE # 1 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 1 21-1728 87073133 1 Vehicle in Trans ort VEHICLE LICENSE NUMBER STATE P REGISTRATION EXPIRES Cheek if Permanent VIN 2 Parked Motor Vehicle 1 3 Working Vehicle FIIHHRH74 FL Registration W JIGNSCGKCSGR416428 Hit and Run 1 No YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor 1 EST, AMOUNT 2 Yes 2016 CHEV UT UTILITY WHITE - WHI 2 Functional 88 Unknown E2$,DDD.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due Damage: VEHICLE REMOVED BY 1. Rotation Request E 14. TRAVELERS CASUALTY INS. 3N940831BA 1 No 2 Yes ZUCCALA 3. D2.Onverr Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE IP PHILIP ANDREW PIKE 4100 SANATUARY LN BOCA RATON FL r33431 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check'rf Permanent VIN YEAR MAKE LENGTH AXLES One: Regi 'or' ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check 0 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 ❑ O ❑ ❑ ❑ ❑ A1A 135 35 2 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 02 03 2 Yes ❑ 2 Yes ❑ 3 4 5 6 3 4 5 6 2 7 18 Undercarriage 18 2 7 88 Unknown 88 Unknown 19 Overturn 19 1 15 16 17 6 20 Windshield 20 1 15 16 17 6 MOTOR CARRIER NAME US DOT NUMBER 14 g 21 Trailer 21 14 9 13 121110 13 12 11 10 MOTOR CARRIER ADDRESS CITY T777 ODE PHONE NUMBER Vehicle Body Type 15 Law Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 16 (Sport) Utility Vehicle 16 1 Two -Way, Not Divided 1 Vehicle 10,000lbs or less Placarded 8 Tractor/rriple 1 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 17 Cargo Van (10,000 Ibs 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 Turn Lane more than 10,000 Ibs (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 or more axles) occupants, including driver) 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median r 4 Truck Pulling Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 5 Truck Tractor (bobtail) Median Barrier occupants, indudin driver 7 Motor Home 20 Medium/Heavy Trucks (more P 9 ) 6 Truck Tractor/Semi-Trailer 8 Bus than 10,000 Ibs (4,536 kg)) 77 Omer, Explain in Narrative 5 One -Way Trafficway 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown Trailer Type 12 Moped 77 Omer, Explain in Narrative Semi Terrain 1 Single emi Trailer 8 Pole Trailer 13 All Vehicle (ATV) 88 Unknown 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Comm/Non-Commercial TRAILER 1 TRAILER 2 3 Tank Trailer 10 Auto Transport 13 dal 1 Interstate Cartier tame Chassis 4 Saddle Mount/Trailer 77 Omer, Explain in 3 Hopper Van/Enclosed Box Container Chassis Vehicle Towing 5 Boat Trailer Narrative ❑ ❑ ❑ 4 Hopper 2 Intrastate Cartier ❑ An 5 Pole -Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 6 Cargo Tank 15 Not Applicable 7 House Trailer 1 No Cargo 4 Not in Commerce/Omer Truck 7 Flatbed (vehicle 10,000 Ibs 2 Bus Most Harmful Event Non -Collision 1 10,000 Ibs (4,536 kg) or less 8 Dump (4,536 kg) or less not Comm 1 Overturn/Rollover 2 10,001-26,000 Ibs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard GVWR/GCWR 3 More man 26,000lbs (11,793kg) 10 Auto Transport 77 Omer, Explain in 2 on 4 Not Applicable 11 Garbage/Refuse Narrative Immersion 3 Immersion 4 Jackknife 12 Log 88 Unknown Collision with Non -Fixed Object Collision Fixed Object 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 20 Bridge Overhead Structureain, 7 Thrown or Falling Object 12 Railway Vehicle (Vengine) 31 Omer Traffic Barrier 21 Bridge Pier or Support Sequence of Events 8 Ran into Water/Canal 13 Animal 32 Tree (standing) 22 Bridge Rail 1 ❑ 9 Other Non -Collision 14 Motor Vehicle in Transport 23 Culvert 33 UtilityPolelLight Support 1st 2nd 15 Parketl Motor Vehicle34 Traffic Sign Support 14 ❑ [4046 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 88 Unknown 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 3rd 4th 42 Ran Off Roadway, Right ❑ ❑ 43 Ran Off Roadway, Left Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 18 Other Non -Fixed Object building, tunnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline Roadway Grade 46 Downhill Runaway 3 Turning Left 14 Slowing 1 Straight Ahead 13 Stopped in Traffic This Vehicle ❑ ❑ 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None 2 Hillcrest Roadway Alignment 1 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing 1 No Controls 2 Brakes 13 Wheels 1 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sigh 3 Tires 14 Windows/ 4 Downhill 1 t 8 Parked 77 Omer, Explain in Narrative 10 Person (including Device 4 Lights (head, Windshield 1 CurStrave Sag (bottom) 2 Curve Right ❑ 10 Making U-Tum 88 Unknown Flagman, Officer, 5 Traffic Control signal, tail) 15 Mirrors 3 Curve Left 11 OvertakinglPassing Guard, etc.) Signal 6 Steering 16 Truck Coupling Special Function 1 No Spedal Function 9 Ambulance 14 Intercity Bus Other, Explain in Bus 6 Stop Sign 7 Wipers Trailer Hitch/ Narrative of Motor Vehicle 2 Farm Vehicle 10 Fire Truck 15 Bus 7 Yield Sign 9 Exhaust System Safety Chains 88 Unknown 1 3 Police ❑ 11 Farm Labor Transport 16 Shuttle Bus 10 Body, Doors 77 Other, Explain in Shuttle Bus 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 1 12 Suspension 88 Unknown VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER I PHILP ANDREW PIKE 316,1925(1) CARELESSDRIVING AIPKOTP PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 5 VALENTIN NOVIK 316.1945(1)(A)3 IMPROPER STOP WITHIN INTERSECTION AI PKOVP HANOVIC PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 2 8 Page of_ FLORIDA TRAFFIC CRASH REPORT WAS DOT PROPERTY INVOLVED IN THIS CRASH9 LONG FORM FV� SHORT FORM ❑ UPDATE ❑ TOTAL # OF VEHICLE SECTION(S) 2 (Shaded Areas) .1 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 08/27/2021 1 10:02 PM 08/27/2021 121-1728 187073133 CRASH IDENTIFIERS COUNTY CODE CITY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECKIFWIIHIN_ IME REPORTED TIME DISPATCHED CITY LIMITS �� 1 06 PALM BEACH I GULF STREAM 10:04 PM 10:04 PM TIME ON SCENE IME CLEARED SCENE 7HECK IF REASON (If Investigation NOT Complete) Notified By: 1 Motorist Ill:59 COMPLETED rV1 I 2 Law Enforcement 10:07 PM PM ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY AT STREET ADDRESS # AT LATITUDE AND LONGITUDE SRAtA 3500 BLOCK © 26.496914-80.053473 AT FEET MILES N S E W AT/FROM INTERSECTION WITH STREET, ROAD,HIGHWAY OR FROM MILEPOST# 5 ] I © BANYAN RD Road System Identifier 7 Forest Road Type of Shoulder Type of Intersection 5 Traffic Circle 3 ❑ 1 Interstate 4 County 2 U.S. 5 Local 8 Private Roadway 9 Parking Lot 1 Paved 2 Unpaved $ 1 Not at Intersection 2 Four -Way Intersection 3 T-Intersection 6 Roundabout 7 Five -Point, or More 77 Other, Explain in Narrative 3 State 6 Turnpike/roll 77 Other, Explain in 3 Curb 4 Y-Intersection Narrative iNF RMIATInN I MF K IF PICTURES TAKENI Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collision/Impact 1 Daylight 2 Dusk 5 Dark -Not Lighted 6Dsrk-Unknown 4 Flog, Smog, Smoke SleetMaiU Freezing Rain El 5 Oil5 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus ❑ 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction 3 Dawn Lighting 6 Blowing Sand, Soil 1 ❑ 8 Water 1 Directly Involved 6 Rear to Side 4 Dark -Lighted 77 Other, Explain in Dirt 1 Clear (standing/moving) 3 Yes, School Bus 1 Front to 7 Rear to Rear Rear Narrative 88 Unknown 7 Severe Crosswinds 2 Cloudy 77 Other, Explain in 1 Dry 77 Other, Explain in 2 Wet Narrative Indirectly Involved 77 Other, Explain in Narrative 2 Front to Front 3 Rain Narrative 4 Ice/Frost 88 Unknown 3 Angle 88 Unknown First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object Frost Harmful Event 1 Overtum/Rollover 10 Pedestrian 19 Impact Attenuator/Crash 30 Concrete Cusion Traffic Barrier Location 1 On Roadway 2 Fire/Explosion 11 Pedalcyde 31 Other 15 3 Immersion 4 Jackknife 12 Railway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 2 Of Roadway 3 Shoulder 5 Cargo/Equipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 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 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 1 No 2 Yes Object 8 Ran int Water/Canal Equipment 27 Guardrail Face 38 Mailbox 17 Struck By Falling, Shifting 28 Guardrail End 39 Other Fixed Object (wall, 9 Outside Right-of-way 10 Roadside 88 Unknown 9 Other Collision Cargo 29 Cable Barrier building, tunnel, etc.) B8 Unknown 18 Other Non -Fixed Oblect First Harmful Event Relation to Contributing Circumstances: Road 9 Wom, Travel -Polished Surface Contributing Circumstances: Environment 77 Junction 5 Railway Grade Crossing Ramp 77 icy, snow, slush, etc.) ❑ ❑ ❑ 10 Road Surface Condition (wet, 11 Obstruction in Roadway ❑ ❑ ❑ 1 Non -Junction 14 Entrance/Exlt 15 Crossover - Related 16 Shared -Use of Path or Trail 12 Debris 1 None 13 Traffic Control Device 1 None 5 Animals ( ) in Roadway 2 Intersection 17 Acceleration/Dceleretion Lane 4 Work Zone (construction/ Inoperative, Missing or Obscured Pe 9 2 Weather Conditions 77 Other, Explain in 3 Intersection -Related 18 Through Roadway maintenance/utility 14 Non -Highway Work 3 Physical Obstructon(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 4IntermM nt or Moving Work ❑ 1 No 2 Yes 1 No 2 Officer Present 88 Unknown 4 Activity Area 77 Other. Explain in Narrative 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area Only Present TNESSES CITY & STATE CITY & STATE CITY & STATE VEH. p PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT OWNER'S NAME 0 (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 8 Page of sraEgM anice Qat,tCE pFA 'GiN`'�'� Stumn J ' Dena)dtnent Edward K. Allen Chief of Police h FLA. �f GULF STREAM POLICE DEPARTMENT 246 SEA ROAD GULF STREAM, FLORIDA 33483 561-278-8611 September 2, 2021 Valentin Ivanovich Novik 2050 Oleander Blvd Apt. 3104 Fort Pierce FL. 34950 Dear Sir, Regarding the vehicle crash that occurred on August 27, 2021 in the Town of Gulf Stream, case number 21- 1728. Upon completion of the accident investigation it was determined your vehicle was in violation of improper stop within an intersection on SRA IA. The on scene officer acknowledged the fact that you had been transported to the hospital and no longer at the accident scene and therefore we are enclosing the citation #AIPKOVP, via US mail service. If you have any questions please call the Gulf Stream Police. Gulf Stream Police Dept. 246 Sea Road, Gulf Stream, Florida 33483 Sincerely, -�- c�J�G%��vtiZ�j• f ` Sergeant John Passeggiata 246 Sea Road, Gulf Stream, Florida 33483 Administration (561) 278-8611 8510008690 RR Donnelle CL9'LUIZ. Ali ngnls reserveM. —uwI 1B IA 0 v U. .n- 000NTv ❑ (1) F.H.P. (2) P.D. 3 S.0 OTHER ✓(4) AGENCY NAME PUCA LE) AGENCY # _ IN THE COURT DESIGNATED BELOW THE UNDERSIGNED CERTIFIES THAT HESHE HAS JUST AND REASONABLE GROUNDS TO BELIEVE AND DOES BELIEVE THAT ON RETAINED BY COU R D WEEK DAY` YE /�! ❑A.M. A NAME( INT) FIRST ` MIDDLE LAST 'X * IFFE MTHAANONE Al LICHERE C , STATE LP COOS TELEPHONE NUMBER DAIRTHTT% BA DAY YR CE SEX HOT {/jf l DRIVER //�► O LICENSE $TA / CLASS CDL LICENSE YR. UCENSE E% NUMBER ES ONO CIAL VEHICLE YES NO YR. HCIE MAKE COLOR HAZARDW AL ❑YESED NO iSTY VE L NEE N0. T g�J#G STATE R TAG EXPIRES vr 2 16 PASSENGERS ❑YES NO PON A PUBLIC STREET OR HIGH AY 0 HER LOCATION M Y J' MOTORCYCLE YES NO COMPANION CITATION NUMBER(b) ❑YES ❑NO ❑ ❑ ❑ ❑ N OF NODE FT. MILER S E W 1111 DIO UNLAWFULLY COMMIT THE FOLLOWING OFFENSE. CHECK ONLY ONE OFFENSE EACH CITATION. ❑ UNLAWFUL SPEED MPH SPEED APPLICABLE m�^ (❑INTERSTATE [I SCHOOL ZONE ❑ CONSTRUCTION WORKERS PRESENT) SPEED MEASUREMENT DEVICE: ❑ CARELESS DRIVING ❑ CHILD RESTRAIN ❑ EXPIRED DRIVER LICENSE ❑ VIOLATION OF TRAFFIC CONTROL DEVICE ❑ SAFETY BELT VIOLATION SIX (6) MONTHS OR LESS ❑ FAILURE TO STOP AT A TRAFFIC SIGNAL ❑ IMPROPER OR UNSAFE EQUIPMENT ❑ EXPIRED DRIVER LICENSE ❑ IMPROPER LANE CHANGE OR COURSE ❑ EXPIRED TAG SIX (6) MONTHS OR LESS MORE THAN SIX (6) MONTHS ❑ NO PROOF OF INSURANCE ❑ EXPIRED TAG MORE THAN SIX (6) MONTHS ❑ NO VALID DRIVER LICENSE ❑ VIOLATION OF RIGHT-OF-WAY ❑ DRIVING WHILE LICENSE ❑ DRIVING UNDER THE INFLUENCE ❑ IMPROPER PASSING SUSPENDED OR REVOKED 0LP6ssengeT Under 18 Yrs. BA RE EXAM OTHER VIO R CO E S P INING TO OFFENS ❑YES Rl NO DL SEIZED ❑ YES CTO / SU ION ❑ AGGRESSIVE DRIVING IN VIOLATION OF STATE STATUTE CRAS PROPERTY DAMAGE ❑NO ❑YESANO? SE❑RIIISIDILYIN0 TOANOTHE []YESNO YES ❑NO ❑ YES $ ❑ CRIMINAL VIOLATION. COURT APPEARANCE RECUIREO. AS INDICATED BELOW. ❑ INFRACTION. COURT APPEARANCE REwRED. AS INDICATED BELOW. tx INFRACTION WHICH DOES NOT REWIRE APPEARANCE IN COURT. A 1 P KO V P CIVIL PENALTY 16 $ COURT INFORMATION E T LOCATI ANREST DELIVEflED TO DATE AGREE AND PROMISE TO COMPLY AND ANSWER TO THE CHARGES AND MSTNUCnOMS SPECNTED IN THIS CITATION. WILLFUL REFUSAL TO ACCEPT AND SIGN THECITA110NMAYRESULTINARREST.IUNOERSTANOMYS NANREISNOTANADMISSWN OF GUILT ON WAIVER OF RIGHTS IF YOU NEED REASONABLE FACILITY ACCOMMODATIONS TO COMPLY WITH THIS CTATION. CONTACT THE CLERK OF THE COURT. Yy&VAN4E�`���� N RE IS (RED IF INFRACTIIN 5 APP' AW E IN COURT), HANK NAME Of QFTCER �� B GE NO ID No TROD P UNIT ❑ I CERTIFY THIS CITATION WAS DELIVERED TO THE PERSON CITED ABO AND CERTIFY THE CHARGE ABOVE HSMV 75W1 (Rev. 07/12) A EN Y -INCIDENT NUMBER GULF STREAM POLICE DEPARTMENT 1lr78 211728 UNIFORM INCIDENT REPORT 'CLEARANCES CALL NUMBER `GEOCODE 211728 TOO A ❑ Death of Suspect G El Arrest - Juvenile 2205 INCIDENT(NONCRIMINAL) B ❑ Prosecution Declined H ❑ Warrant Issued IJU TOA ❑ OFFENSE Gulf Stream Police Department C ❑ In Custody of Other Jurisd. 1 ❑ Invest. Pending (,- 2205 SUPPLEMENT 246 Sea Road D ❑ Victim Refused to Coop" J ❑ Closed TOC E ❑ Juvenile/No Custody K ❑ Unfounded 2359 Gulf Stream, FL 33483 F ❑ Arrest - Adult U ❑ Unknown z Phone: (561) 278-8611 Fax: (561) 276-2528 'CLEARANCE CLEARED � p DATE: BY: Q 'REPORT DATEMME 'INCIDENT OCCURRED FROM 9NCIDENT OCCURRED TO MONTH DAY YEAR TIME MONTH DAY YEAR TIME MONTH DAY YEAR TIME 08 27 2021 2205 INCIDENT LOCATION (Street, Apt, C" State, Zip) 3500 BLOCK N. OCEAN BLVD. GULF STREAM FL 33483 *OFFENSE DE N F/M & DEGREE *LARCENY ITYPECRUINALACTNMY 1. TRAFFIC CRASH 1. (Enter up to three for each offense) 1. 2. 3. B- BUYINGIRECEIVING _ _ _ C- CULTIVATING/MFGIPUB. 2, 2. D- DISTRIBUTINGISELLING 1 2 3 - E- EXPLORING CHILDREN 0- OPER/PROPOTING/ASSIST. 3. 3. 1 2 3 P- POSSESSING/CONCEAUNG - T- TRANSP/TRANSMI TING 4. 4. U- USING/CONSUMING 1.- 2 - 3. _ G- OTHER GANG ACTIVITY J- JUVENILE GANG 5. 5_ 1. _ 2 _ 3. N- N GANG ACTIVITY 'LOCATION OF OFFENSE (Enter up to two) 'SUSPECTED OF USING 92 JaiVPrison 59 Daycare Facility 40 Other Retail Store OTHER 1. 2. 13 Parking Garage 41 Factmy/MilUPW 53 Abandoned/ RESIDENTIAL STRUCTURE 14 Other Public Access Buildings RETAIL 42 Other Building Condemned Structure A ❑ ALCOHOL 01 Single Family Home 26 Bar 55 Arena(StadiurN COMMERCIAL LOCATIONS 27 Bu /Selirirade Shop OUTSIDE Fairgrounds/CoNseum 02 Dwelling y ❑ y 03 Residential Facility 15 Auto Shop 28 Restaurant 43 Yard 58 Cargo Cortiairler eside D DRUGS Z 04 Other Residential 16 Financial Institution 29 Gas Station 44 Construction Site 60 Dock/Wharf/Freight/ W 05 Garage/Shed 17 Barber/Beauty Shop 30 Auto Sates Lot 45 Lake/Waterway Modal TerminalLL C ❑ COMPUTER EQUIPMENT U. 18 Hotel/Motel 31 Jewelry Store 46 FleI Woods 61 Farm Facility O PUBLIC ACCESS BLDGS. 19 Dry Cleaners/Laundry 32 Clothing Store 47 Street 62 Gambling Facility] N ❑ NOT APPLICABLE 06 Transit Facility 20 Professional Office 33 Drugstore 48 Parking Lot Casino/Race Trade 07 Government Office 21 Doctors Office 34 Liquor Store 49 Park/Playground 63 Military Installation *TYPE WEAPOWFORCE USED 08 School 22 Other Business Office 35 Shopping Mall 50 Cemetery 65 Shelter -Mission/ 09 College 23 Recreation/Entertainment Center 36 Sporting Goods 51 Public Transit Vehicle Homeless 67 Library 54 Amuseme-nit Park 37 Grocery/Supermarket 52 Other Outside Location 66 Tribal Lands 10 Church 24 Rental Storage Facility 38 Variety/Convenience 57 Camp/Campground 77 Other 11 Hospital 25 Other Commercial Service Loc. 39 Department Store 64 Rest Area 1 2. 3. 56 ATM Machine Separate from Bank 'METHOD OF ENTRY 'METHOD OF ENTRY- MOTOR VEHICLE THEFT °METHOD OF ENTRY- BURGLARY/B&E ENTRY EXIT ENTRY EXIT 1 ❑ FORCE 01 ❑ Motor Runring/Keys in Car 06 ❑ Hot Wire ENTRY EXIT 1 ❑ DOOR ❑ 1 ❑ FRONT ❑ 2 ❑ NO FORCE 02 ❑ Unlocked 07 ❑ Slim Jim/Coat Hanger 1 ❑ BASEMENT[] 2 ❑ WINDOW ❑ 2 ❑ SIDE ❑ *NO- PREMISES ENTERED 03 ❑ Duplicate Key Used 08 ❑ Tumbters Removed 2 ❑ 1' FLOOR ❑ 3 ❑ GARAGE ❑ 3 ❑ REAR ❑ 04 ❑ Wvodoaa Broken 09 ❑ Column Pealed 3 ❑ 2" FLOOR ❑ 4 ❑ SKYLIGHT ❑ 4 ❑ ROOF ❑ 05 ❑ Towed 10 ❑ Ignition Peeled 4 ❑ OTHER ❑ 5 ❑ OTHER ❑ 5 ❑ OTHER ❑ METHODS OF "CARGO THEFT OPERATION . Y❑ N❑ .NO ?07AL 'VICTIM 1 INDIVIDUAL F FINANCIAL INS ION P POLICE OFFICER (IN THE LINE OF DUTY) S SOCIETY O U OTHER VICTIMS TYPE B❑ BUSINESS G ❑ GOVERNMENT R ❑ RELIGIOUS ORGANIZATION U ❑UNKNOWN NAME (Last, First, Middle) ADDRESS (Street, Apt. City, State. Zip) PHONE EMPLOYER NAME AND PHONE ADDRESS (Street, APL, City, State, Zip) `AGE/ EX `RACE U B U A NICITY HGT WGT HAIR EYES D.O.B. ❑ W ❑ I ❑ U U OCCUPATION SN*RESIDENT 1 U RESIDENT 3 Ll MILITARY 5 U OTHER 5 IS STATUS 2 ❑ TOURIST 4 ❑ STUDENT U ❑ UNKNOWN 'VICTIM LI Y IF INJURED, DESCRIBE c.2 o INJURED? ❑ N INJURIES. °AGG. ASSAULT/ °LEOKA INFORMATION CTIM/SUSPECT RELATIONSHIP VICTIMlOFFENSE LINK IT z i HOMICIDE CIRC. 5. TYPE OF ACT. ASSIGN, TYPE ORI -OTHER 0. 1. 2. 3. 4. REPORTING OFFICER CAPT. JOHN HASELEY BADGE NO DATE 727 09/10/2021 ) APPROVING OFFICER BADGE NO. DATE CAPT. JOHN HASELEY 09/10/2021 FOLLOW- UP? r yes, follow-up ❑ Y ❑ N signrnent. ADDITIONAL LI VICTIMNJITNESS U PROPERTY STATEMENTS FORM RECEIVED By. LJ INTELLIGENCE SPECIAL SUPPLEMENTS 0 SUSPECT/ARRESTEE ❑ NARRATIVE 0 OTHER ❑ INVESTIGATION ❑ RECORDS COPIESr INCIDENT REPORT - PART 2 INNUMBIDD� 211728 VICTIM IDENT DATE D TIME NO. &AL, WLEN 1 D.OB. Str q(pOtF�C-�F SEA(RD. GULrSTR'EAAMM®kL3�483 P HI OSNSNE 561-278-8611 O EMPLOYER NAME AND PHONE AL W ADDRESS (Street Apt , City, State, Zip) IZ STATEMENTS OBTAINED UY U N TYPE: U WRITTEN U ORAL U TAPED U OTHER CHECK CATEGORIES STOLEN U RECOVERED U MWOUNDED U RECEIVED U SUSPECTS VEHICLE U VICTIMrS VEHICLE U UNAUTHORIZED USE UABANDONED NO. U DAMAGE TO VEHICLE LIC LIS LIY LIT 1 VINIOAN 'VALUE ❑ THEFT FROM VEHICLE VYR VMA VMO VST VCO VEHICLE Y I KEYS IN U Y I HOLD U Y RELEASE U Y TOP BOTTOM LOCKED ❑ N I VEHICLE ❑ N I VEHICLE ❑ N CONTENTS❑ N I W VEHICLE ASSOC. VEHICLE ASSOC. VEHICLE Y TOWED OWNERSHIP U TAG RECEIPT U TITLE J V / SUSPECT NO. I VICTIM NO. TOWED? ❑ N By VERIFIED BY: BILL OF SALE ❑ OTHER S STOLEN MOTOR NO STOLEN AREA STOLEN U RESID. ADDITIONAL LIJ VEHICLE ONLY ❑ BUSINESS ❑ RURAL DESCRIPTION AUTO INSURER NAME (Company) ADDRESS (Street. Apt. City. State, Zip) PHONE MOTOR VEHICLE RECOVERED DATE REC. STOLEN IN YOUR JURISDICTION IND RECOVERY ONLY ❑ Y ❑ N WHERE RECOVERED? `TYPE PROPERTY 1 NONE 3 COUNTERFETTEDIFORGED 5 STOLEN/ETC- 7 RECOVERED P PHOTO TOTAL VALUE LOSS/ETC Wg&own beioo 2 BURNED 4 DESTROYED/DAMAGEDIVANDALIZED 6 SEIZED U UNKNOWN E EVIDENCE *LOSS QUANTITY DESCRIPTION 'PROP 'VALUE CODE I CODE VICT. VEH MAKEBRAND MODEL DATE RECOVERED NO N0 SERIAL. NCIC OTHER NLWER NUMBER NUMBER *LOSS OUANTITY DESCRIPTION 'PROP "VALUE CODE CODE I VICT VEH MAKEIBRAND MODEL DATE RECOVERED NO. NO, SERIAL NCIC OTHER NUMBER NUMBER NUMBER *LOSS QUANTITY DESCRBTfION 'PROP 'VALUE CODE CODE VICT. VEH MAKE/BRAND MODEL DATE RECOVERED NO. NO. tY SERIAL NCIC OTHER a NUMBER NUMBER NUMBER 'VALUE O d' 'LOSS QUANTITY DESCRIPTION 'PROP IL CODE CODE I VICT VEH MAKEIBRAND MODEL DATE RECOVERED NO, NO. SERIAL NCIC OTHER NUMBER NUMBER NUMBER PROPERTY CODES: 10 Other Valuables 22 Photographic Equipment 72 Musical knstnrrnents VEHICLES STRUCTURES EXCHANGE MEDIUMS PERSONAL EFFECTS 23 Farm Equipmerd 73 Portable Electronic Equip. 35 Aircraft 46 Single Occuparuy 01 Money 11 Cloffung/Furs 24 Heavy CornstrudioMndusinai 74 Water raft EgmpJParts/Acc. 36 Ades 47 Other Dwelfags 02 CreddOebit Card 12 PurmwHandbagsWailets 25 Building Supplies -Caul 29 Other Equipment 37 Bicycles 48 03 Negotiable Instruments 13 Other Personal Effects 26 Tools CONSUMABLE ITEMS 38 Buses 49 Industrial/Manufacturing 04 Exchange Mediums HOUSEHOLD ITEMS 27 Vehicle Parts/Accessories 30 Alcohol 39 Trucks 50 PublidCo rminity DOCUMENTS 14 Household Rents 57 Akcra t Parts/Accessones 31 Dr gsRlarootics 40 Trailers 51 Storage 05 Non -Negotiable Instruments EQUIPMENT 28 School Supplies 32 Consumable Goods 41 Watercraft 52 Other Structure 06 Personal (Identity) Papers 15 Equip- 58 Artistic Supplies/Accessories 60 chemicals 42 Recreational Vehicle OTHER 62 Documents/Personal or 16 Gambling Equipment 59 Carrnping/Hunttrhg/FW*Q 61 Crops 43 Other Motor Vehicle 53 Merchandise Business 17 Computer Hardware/Soft. Equipment/Supplies; 63 Explosives WEAPONS 54 Other Property y 07 Other Documents 18 Office Equipment 67 Law Enforcement Equip. 65 Fuel 44 Firearms 55 Pending Inventory VALUABLES 19 Stereo TV Equip. 68 LawnlYard/Garden Equip. ANIMALS 45 Other Weapons 661dentrty-Intangible 08 Jewelry/Precros Metals 20 Recordings -Audio Visual 69 Logging Equipment 33 Livestock 64 Firearm Accessories 71 Metals, Nor +"dous 09 Art Objects, Antiques 2/ Sports Equipment 70 Medical/Medical Lab Equip. 34 Household Pets ON 9/10/2021 MS. COLLEEN DAVIS, A REPRESENATIVE OF THE PUGLIESE'S DROPPED OFF A VICTIM/WITNESS AFFIDAVIT FROM MR. ANTHONY PUGLIESE AND MRS. LAURA PUGLIESE. THIS AFFIDAVIT WAS REGARDING A TRAFFIC CRASH THEY WERE INVOLVED IN ON 8/27/2021 ON NORTH OCEAN BLVD IN GULF STREAM. THE AFFIDAVIT WAS SIGNED BY THEM AND NOTARIZED BY SHERRY CONNORS # HH 100171. j SGT. O'DONNELL ON 9/8/21 HAD SPOKE WITH THE PUGLIESES AND ADVISED THEM THE OFFICER WHO COMPLETED THE CRASH REPORT WILL COMPLETE AN UPDATE TO BE SUBMITTED TO THE FLORIDA DHSMV., REFERENCE THE ADDITIONAL INJURY VICTIMS ( PUGLIESES' ) NOTED IN THIS CRASH. a z AFFIDAVITS TO BE MADE PART OF THE CASE FILE FOR INJURY VERIFICATION. END. "'G SUSPECT/ARREST SUPPLEMENT UM 211728 ANC ER VICTIM FFENSE LNCIDENTDATE D TIME NO. ADULT JUVENILE UNKNOWN APPROPRIATE CATEGORY CHARGES FILED? E] ❑ ❑ rHECK ❑SUSPECT ❑ ARRESTEE ❑SUSPECT/ARRESTEE ❑RUNAWAY ❑ MISSING n OTHER -ifFR ❑Y ❑ N NAME (Last, First, Middle) SSN DAVIS, COLLEEN ALIAS GANG AFFILIATION ADDRESS (Street, Apt., City, State, Zip) PHONE 561-454-1608 EMPLOYER NAME AND PHONE ADDRESS (Street, Apt., City, State, Zip) OCEAN LEASING LLC 101 PUGLIESE WAY DELRAY BEACH FL 334" LACE OF BIRTH DL11'/STATE OCCUPATION/SCHOOL to W gt 'AGE/ SEX _ RACE U B U A `HEIGHT 'WEIGHT 'HAIR 'EYES d 0.0.0 ❑W ❑ 1 ❑ U rNicrry R MARITAL SCARS. MARKS, TATOOS Q STATUS W ADDITIONAL DESCRIPTNES 0 Q Z SUSPECTED OF USING POTENTIAL INJURIES? ❑ALCOHOL ❑DRUGS •RESIDENT STATUS 1 ❑ RESIDENT 2 ❑ TOURIST 3 ❑ MILITARY 4 ❑ STUDENT 5 ❑ OTHER(ev^.ain) U ❑ UNKNOWN ARRESTEE WAS ARMED WITH ARRESTEE ARMED WITH 1. _ 2. _ 3. _ 99 NONE 138 OTHER FULLY AUTOMATIC FIREARM 16 IMITATION FIREARM 50 POISON 11 FIREARM 14 SHOTGUN 17 SIMULATED FIREARM 60 EXPLOSIVES 12 HANDGUN 15 OTHER FIREARM 18 BB/PELLET GUN 65 FIREfINCENDIARY DEVICE 12A AUTOMATIC HANDGUN 15A SEMI -AUTOMATIC SPORTING RIFLE 20 KNIFEICUTTING INSTRUMENT 70 DRUGS/NARC/SLEEPING PILLS 13 RIFLE 15B SEMI -AUTOMATIC ASSAULT FIREARM 30 BLUNT OBJECT 80 OTHER WEAPON 13A FULLY AUTOMATIC RIFLE 15C MACHINE PISTOL NAME ADDRESS (Sheet. Apt., City, State, Zip) PHONE U V)N I I i. QW 2 2, 2CL . ARREST/OFFENSE DESCRIPTION 'ARRESTIOFFENSE CODE F/M 8 DEGREE WARRANT # ARREST LARCENY TYPE 23H POCKET PICKING 238 PURSE SNATCHING 2 2 2 2 2 23C SHOPLIFTING 23D THEFT FROM BUILDING 2 3 ; 3 3 ; O 23E THEFT FROM COIN -OP MACH 23F THEFT FROM MOTOR VEHICLE Q 4 4 e 1 4 23G MOTOR VEH.PARTS/ACCESS. 240 THEFT OF MOTOR VEHICLE 0 5. 5, 5. 5. 5 23H OTHER: LL Z 'ARREST DATE TIME ARREST LOCATION (Street Apt., City, State, ZLp) F— WIx 'INCIDENT TRACKING NUMBER ARREST DISPOSITION BfUL IY Q MIRANDA WITNESSED BY: TIME READ FINGERPRINTED FINGERPRINT CARD NO. HOTOS TAKEN NO. TAKEN PHOTO ID NO. FBUBCI# ❑Y ❑ N ❑Y ❑ N 'MULTIPLE ARRESTEE SEGMENTS INDICATOR 'ARREST 1 ❑ COMPLAINT 3 ❑ WARRANT 5 ❑ ORDER OF PROTECTION ❑COUNT ARRESTEE ❑ MULTIPLE ARRESTEE INDICATOR ❑ NIA TYPE 2 ❑ IN -PROGRESS 4 ❑ SUMMONS 9 ❑ OTHER JUV. PARENT/ UY DATElTrME NOTIFIED NOTIFIED BY `JUVENILE LJ HANDLED WITHIN THE DEPARTMENT GDN. NOTIFIED ❑ N DISPOSITION ❑ REFERRED TO OTHER AUTHORITIES J PARENTIGUARDIAN NAME AND ADDRESS (Street, Apt, City, State, Zip) RELATIONSHIP PHONE Z W 7 PARENT/GUARDIAN NAME AND ADDRESS (Street, Apt., City, State, Zip) RELATIONSHIP PHONE cn PREVIOUS Y DATE OF DATE OF NCIC # DATE/TIME ENTERED >- RUN/MISS ON T CONTACT EMANCIPATION Z LAST SEEN WEARING Q Z n w REPORTING OFFICER BADGE NO. DATE CAPT )OHN HASELEY 0911012021 APPROVING OFFICER BADGE NO. DATE CAPT )OHN HASELEY 09/10/2021 COURT DATE ivy GULF STREAM POLICE DEPARTMENT Palm Beach County, State of Florida n VIC/ TEWMITNESS AFFIDAVIT I, t D v Y ! I e o hereby give this statement freely and (Type or print aVe ) Q, 0 Voluntarily to rn� rGl (�14I? /�G�B on S Dy Officer's np�) (Date) �� at 31 �15 N , fln G 14/1. My date of birth is 1 ` C;L:LO1 (location of i to 'ew) My address is �/� . n Val. S Phone # 511 l ' F1ell'1lZ9O My Email address is p , Cp M Sworn and subscribed before me, This O-'— day of ��- 20 2tgaa�arc (lf A // ) � (/ personally known to me ✓, (Signadu Notary Public / Ofricer FSS 117.10) Or produced identification , type of I.D. Gulf Stream Police Case # Page of Use a separate page to continue statement R99fl RS0171 025 l a5ed LSLgZLZ 09 6 Xe� dH &RU 6 20Z 0 6 d@S STATEMENT OF ANTHONY V. PUGLIESE, III Prior to the accident I was seated in the right front passenger seat wearing my seatbelt. Just before the impact I was talking with my friend, Phil who was the driver, while also looking ahead. There was no warning of the danger lying in front of us, ie, no barricades, no orange cones, no flagman directing traffic, no reflective flares in the road, no lights inside the vehicle, etc. After the impact when I was able to exit the vehicle I noticed that lights were now on inside the truck. I also observed a female walk out of sight not wearing a vest who reappeared wearing a reflective vest. After the accident we went home. I believe we were in shock. I did not feel immediate pain and was mostly concerned for my wife whose arms were severely swelling and was in pain throughout the night. Saturday morning I called a friend who drove us to Bethesda ER. I was evaluated for right leg and groin pain. My leg was swollen from my groin to my toes, my knee was 4 times its normal size. Additionally, I had a hematoma below my left elbow and my left rib at the midsection was sore. X-rays were taken, nothing was determined broken although the ER doctor advised icing and follow up care with my physician. I was released. I have had two follow up visits with my physician. My knee and leg have been drained twice with blood clots observed during drainage. I still have extreme swelling and pain. I am completely bruised from my groin to my toes. An MRI is likely if swelling and pain does not subside. I have a limp and use a cane for assistance while walking. Also since the accident I have been experiencing ringing in my right ear as well as difficulty hearing from the airbag impact. I have scheduled a consultation with an ENT physician. q, k GULF STREAM POLICE DEPARTMENT Palm Beach County, State of Florida VICTIMIWITNESS AFFIDAVIT I, IAA no 14, Pti A /! -es,e- do hereby give this statement freely and (Iype or print me) Voluntarily to _ q�'. Bernard O'benne/l on O (Officer's name) (Date) at 91d S . My date of birth is _ 1 I —M- l q4,d (location of intervie ) My address is My Email address Sworn and subscribed before me, U This 61-A- day of 4:�,-ef rn-t 12DIro 2.- , 20 identification 'hone# S;-&I- ea. Go -k7 16 d . . personally known to me Gulf Stream Police Case # Page of Use a separate ipage to continue statement SHERRY CONNORS MY COMIMSSION # HH100171 EXPIl�ES: Match 03, 2025 6 a5ed LSLSZLZ 69S 6 xe� dH wd80:0 6 20Z 0 6 dBS STATEMENT OF LAURA K. PUGLIESE At the time of the accident I was wearing my seatbelt seated behind the driver Phil Pike. I was talking to my girlfriend Catherine seated behind my husband. We never saw the impact coming. After the accident occurred, I was in shock and walked home. I spent a sleepless night in pain clutching both arms. The next morning my husband called a friend to drive us to Bethesda ER. We were both individually evaluated. The ER doctor didn't know how I made it through the night. X-rays were taken of both of my arms. I was told the right wrist was broken and the left was shattered and I would need bilateral surgery. I met with the surgeon and agreed to surgery the next morning. My arms were stabilized, an IV with morphine was administered and I was admitted to a room. I did not have use of either arm and was cared for by the nurses. The next morning I had surgery, 2 plates and 6 screws in the right and 8 screws in the left. I was released on Monday. I have limited use of both arms and will continue follow-up with my surgeon. I've since had tailbone pain and I'm awaiting X-ray evaluation results. �j - ""' - L + - .-Ar-Iun" TOACCIP PITATInU Al PKOTP colI1TTY OF ❑ (1) F.H.P. (2) P.D. ❑ (S) 5.0. ❑(4) OTHE G AGENCY NAME CRY 11 APPLN:ABL > AGENCY11 W THE COUgfESIGNATED BELOW THE UNDERSKWED CERTIFIES THAT MESHE M PLAIN I HAS JUST AND REASONABLE GROUNDS TO BELIEVE AND DOES BELIEVE THAT ON RETAINED BY COUR DAY WEEK H DA� El� / IJb ❑AM M. N (PRIIln F T I I lA9T Ly IF DIFFERENT THAN ONE ON DRIVER CENSE%%ERE+ I•/ C STA// PP E TELEPHONE NUMBER DATE OF�O� BIRTH SEX HGT DRIVER �.. • LICENSE STA C �� COL LICENSE YR. LK;ENSE MERCIAL VEHICLE NUMBER ❑yES NO ❑YES NO /� MA STY COLOR PLACARDED WIAA00115 MATERIAL [DYES NO V I LE I N NO. TRAILER TAG N TA YE AG ES 218 PASSENGERS ❑YES ❑NO UPON'A PUBLIC STRE T OR H Y, OR THER LOCATION, NAMELY MOTORCYCLE ❑YES ❑NO A. COMPAMON CITATION NUMBER(SI ❑YES NO FT. MILES ❑N IS ❑E ❑W OF NODE DID UNLAWFULLY COMMIT THE FOLLOWING OFFENSE. CHECK ONLY ONE OFFENSE EACH ORATION. ❑ UNLAWFUL SPEED MPH SPEED APPLICABLE MPH (❑ INTERSTATE ❑ SCHOOL ZONE ❑ CONSTRUCTION WORKERS PRESENT) SPEED MEASUREMENT DEVICE: ARELESS DRIVING ❑ CHILD RESTRAINT ❑ EXPIRED DRIVER LICENSE ❑ VIOLATION OF TRAFFIC CONTROL DEVICE ❑ SAFETY BELT VIOLATION SIX (6) MONTHS OR LESS ❑ FAILURE TO STOP AT A TRAFFIC SIGNAL ❑ IMPROPER OR UNSAFE EQUIPMENT ❑ EXPIRED DRIVER LICENSE ❑ IMPROPER LANE CHANGE OR COURSE ❑ EXPIRED TAG SIX (6) MONTHS OR LESS MORE THAN SIX (6) MONTHS ❑ NO PROOF OF INSURANCE ❑ EXPIRED TAG MORE THAN SIX (6) MONTHS ❑ NO VALID DRIVER LICENSE _ ❑ VIOLATION OF RIGHT-OF-WAY ❑ DRIVING WHILE LICENSE ❑ DRIVING UNDER THE INFLUENCE ❑ IMPROPER PASSING SUSPENDED OR REVOKED ❑ Passenger Under 18 Ym. SAL OTHER VIOLATIONS OR COMMENTS PERTAINING TO OFFENSE: REE)" DYES ❑NO OLSEQED DYES ❑NO SECTIO T�N ❑ AGGRESSIVE DRIVING IN VIOLATION OF STATE STATUTE AS PROPERTY DAMAGE INIU TO MOTHER SEflN1US BODILY RUURY OANOMEP FATAL ES ❑NO DYES.- NO YES ❑NO YES ONO El YES NO ❑ C9IL911AL VIOLATION, WJFrT APPEARANCE REWRiED. AS WDICATED BELOW. ❑ WFMM. COURT APPEARANCE REOUWFD. AS INDICATED BELOW. WL PENALTY IS S WFACH DOES F —T ftEOMRE APPEARMCE W COURT. Al P KOT P COURT INFORMATION � /. ARREST DEINFAED T / DATE I AGREE ANO T COBPLT AND ANSWER TO THE �7TA.� PEI] . W TM CRATKW. II LFUL REFUSAL TO ACCEPT AND SIGN THE LRATKNL W�%��EST.I UNOERSTAN➢pY IS NOFGIIATOfl WAIVER OF PoGHfS.IF YOU NEED REASONABLE FACLLITY A OKL1 Wf11L1F16 CTTA ACT THE CLER ❑ 1 CERTIFY THIS CITATION WAS DELIVERED TO THE PERSON CITED ABOVE AND CERTIFY THE CHARGE ABOVE HSMV 75901 (Rev. 07/12) 91 INCIDENT REPORT - PART 2 INCIDENT NUMBER VICTIM FENSE[INCIDENT D TIME NO. ( FONEAL, AGE/ SSN INAME 1 AL)LEN D.O.B. W �y gyp) 6 S REAM r'L%483 PHONE 561-278-8611 SEA(RD. UL� 0 EMPLOYER NAME AND PHONE W ADDRESS (Street, Apt. City. Stale, Zip) STATEMENTS OBTAINED UY U N TYPE: U WRITTEN U ORAL U TAPED U OTHER CHECK CATEGORIES U STOLEN U RECOVERED U IMPOUNDED U RECEIVED U SUSPECTS VEHICLE U VICTWS VEHICLE UNAUTHORIZED USE U ABANDONED NO, U DAMAGE TO VEHICLE LIC LIS LIY LIT VIN/OAN VALUE ❑ THEFT FROM VEHICLE VYR VMA VMO VST VCO VEHICLE Y KEYStN Y HOLD Y RELEASE Y LOCKED ❑ N VEHICLE ❑ N VEHICLE ❑ N CONTENTS❑ N W VEHICLE ASSOC VEHICLE ASSOC VEHICLE Y TOWED OWNERSHIP TAG RECEIPT TITLF. U / SUSPECT NO. 1 VICTIM N0. TOWED? ❑ N gy VERIFIED BY: ❑ BILL OF SALE ❑ OTHER = STOLEN MOTOR INO.STOLEN AREA STOLEN RESID. ADDfrIONAL > VEHICLE ONLY ❑ BUSINESS ❑ RURAL DESCRIPTION AUTO INSURER NAME (Company) ADDRESS (Street, ApL, City, State, Zip) PHONE MOTOR VEHICLE NO RECOVERED DATE REC. STOLEN IN YOUR JURISDICTION RECOVERY ONLY ❑ Y ❑ N WHERE RECOVERED? 'TYPE PROPERTY 1 NONE 3 COUNTERFEREDIFORGFD 5 STOLEN/ETC. 7 RECOVERED P PHOTO TOTAL VALUE LOSSIETC (entereoAesbelow) 2 BURNED 4 DESTROYF_DMAMAGEDNANDAUZEO 6 SEIZED U UNKNOWN E EVIDENCE 'LOSS QUANTITY DESCRIPTION 'PROP 'VALUE CODE I CODE VICT. VEH MAKE/BRAND MODEL DATE RECOVERED NO NO. SERIAL NCIC OTHER NUMBER NUMBER NUMBER 'LOSS QUANTITY DESCRIPTION 'PROP 'VALUE CODE I CODE VICT VEH MAKE/BRAND MODEL DATE RECOVERED N0. NO. SERIAL NCIC OTHER NUMBER NUMBER NUMBER 'LOSS QUANTITY DESCRIPTION 'PROP 'VALUE CODE CODE VICT. VEH MAKE/BRANDMODEL DATE RECOVERED NO NO. W SERIAL NCIC OTHER NUMBER NUMBER NUMBER 'VALUE x 'LOSS QUANTITY DESCRIPTION 'PROP a CODE CODE d VICT VEH MAKEIBRAND MODEL DATE RECOVERED NO NO I I SERIAL NCIC OTHER NUMBER NUMBER NUMBER PROPERTY CODES: 10 Other Valuables 22 PN*Vrapblc Equipmert 72 Musical Instruments VEHICLES STRUCTURES EXCHANGE MEDIUMS PERSONAL EFFECTS 23 Farm Equipment 73 Portable Electronic Equip. 35 Akcreft 46 Skgk Occupancy 01 Money 11 Clothing/Furs 24 Heavy Consh mliordlndustrial 74 Watercraft Equip./ParWAcc. 36 Automobiles 47 Other Dwellings 02 CreddlOebd Card 12 Purses/Handbags/Wallets 25 Building Supplies Const 29 Other Equipment 37 Bicycles 48 Cornmercial/Businm 03 Negotiable Instruments 13 Other Personal Effects 26 Tools CONSUMABLE ITEMS 38 Buses 49 IndustriatMartufacturing 04 Other Exchange Mediums HOUSEHOLD ITEMS 27 Vehicle ParWAccessories 30 Alcohol 39 Trucks 50 PL"idCo mit pity DOCUMENTS 14 Household Items 57 Aircraft Parts/Accessories 31 Dr gslWarcotics 40 Trailers 51 Storage 05 Non -Negotiable Instruments EQUIPMENT 28 School Supplies 32 Consumable Goods 41 Watercraft 52 Other Structure 06 Personal (Ideri ity) Papers 15 DrugMarcoac Equip. 58 Artistic Supplies/Accessortes 60 Chemicals 42 Recreatkmal Vehicle OTHER 62 Documants/Personal or 16 GambWV Equipment 59 Camping/Huntktg/FishirQ 61 Crops 43 Other Moto Vehicle 53 Merchandise Business 17 Computer Hardware/Soft. Equipment/Supplies 63 E)VIosives WEAPONS 54 Other Property 07 Other Documents 18 Office Equipment 67 Law Enforcement Equip. 65 Fuel 44 Firearms 55 PenditV Inventory VALUABLES 19 Stereo TV Equip. 68 LawNYard/Garden Equip. ANIMALS 45 Other Weapons 66 Identity -Intangible 08 Jewelry/Precious Metals 20 RecordmgsAudio Visual 69 Logging Equipment 33 Livestock 64 Firearm Accessories 71 Metals, Non -Precious 09 Art Objects, Antiques 21 Sports Equipment 70 MedicaUMedical Lab Equip. 34 Household Pets ON 8-27-21, AT APPROXIMATELY 2205 HOURS A TRAFFIC CRASH OCCURRED IN THE AREA OF THE 3500 BLOCK OF N. OCEAN BLVD. (SR Al A) JUST SOUTH OF BANYAN RD. GULF STREAM FL. ALL INFORMATION CONCERNING THIS TRAFFIC CRASH REPORT IS LOCATED IN ( HSMV CRASH REPORT 4 87073133) W t= Z em„ AGENCY NAME -INCIDENT NUMBER GULF STREAM POLICE DEPARTMENT 211728 UNIFORM INCIDENT REPORT 'CLEARANCES CALL NUMBER 'GEOCODE 211728 TOO A ❑ Death of Suspect G ❑ Arrest - Juvenile 2205 121 INCIDENT (NON -CRIMINAL) B ❑ Prosecution Declined H ❑ Warrant Issued a. TOA ❑ OFFENSE Gulf Stream Police Department C ❑ In Custody of Other Jurisd. 1 ❑ Invest. Pending 2205 ❑ SUPPLEMENT 246 Sea Road D ❑ Victim Refused to Coop_ J ❑ Closed Q TOC E ❑ JuvenileMo Custody K ❑ Unfounded 11 2359 Gulf Stream, FL 33483 F ❑ Arrest - Adult U ❑ Unknown z Phone: (561) 278-8611 Fax: (561) 276-2528 CLEARANCE CLEARED O DATE BY: Q 'REPORT DATEMME INCIDENT OCCURRED FROM 'INCIDENT OCCURRED TO MONTH DAY YEAR TIME MONTH DAY YEAR TIME MONTH DAY YEAR TIME 08 2021 2205 TION {27t IN3500 BLOCKIDENT N OCEAN TMGLFSTI2EA FL 33483 ENS FEN UiCRIMINAL TRAFFIC CRASH 1. (Enter up to three for each offense) 1. 2. 3. B- BUYING/RECEIVING _ _ _ C- CULTfVATING/MFG./PUB. 2_ 2. D- DISTRIBUTING/SELLING 1 2 3 - E- EXPLOITING CHILDREN 0- OPERtPROPOTINGIASSIST. 3. 3. 1 2 3 P- POSSESSING/CONCEAUNG - T- TRANSP/TRANSMITTING 4 4 U- USING/CONSUMING 1. _ 2._ 3._ G- OTHER GANG ACTIVITY J- JUVENILE GANG ACTIVITY 5. 5. 1 2 3 N- NO GANG ACTIVITY LOCATION OF OFFENSE (Enter up to two) 'SUSPECTED OF USING 12 Jail/Pnson 59 Daycare Facility 40 Other Retail Store OTHER 1. a. 13 Parking Garage 41 Factory/MiNlPlant 53 Abandoned/ RESIDENTIAL STRUCTURE 14 Other Public Access Buildings RETAIL 42 Other Building Condemned Structure A ❑ ALCOHOL 01 Single Family Home 26 Bar 55 Arena/Stadium/ 02 Multiple Dwelling COMMERCIAL LOCATIONS 27 Buy/Sell/Trade Shop OUTSIDE Fairgrounds/Coflseum ❑ co 03 Reskieential Facility 15 Auto Shop 28 Restaurant 43 Yard 58 Cargo Container D DRUGS 2 04 Other Residential 16 Financial institution 29 Gas Station 44 Construction Site 60 DocklWharf/Freightl W 17 Barber/Beauty Shop 30 Auto Sales Lot 45 LakeANaterway Modal Terminal 05 Garage/Shed C ❑ COMPUTER EQUIPMENT U. 18 HolelfMotel 31 Jewelry Stone 46 Fleld/Woods 61 Farm Facility O PUBLIC ACCESS BLDGS. 19 Dry Cleanem/Laundry 32 Clothing Store 47 Street 62 Gambling Facility/ N ❑ NOT APPLICABLE 06 Transit Facility 20 Professional Office 33 Drugstore 48 Parking Lot Casmo/Race Track 07 Government Office 21 Doctors Office 34 Liquor Store 49 Paric/Playground 63 Military Installation 'TYPE WEAPOWFORCE USED DS School 22 Other Business Office 35 Shopping Mall 50 Cemetery 65 Shelter -Mission/ 09 College 23 RecreatiomTittertain eat Center 36 Sporting Goods 51 Public Transit Vehicle Homeless 67 Library 54 Amusement Park 37 Grocery/Supermarket 52 Other Outside Location 66 Tribal Lands 10 Church 24 Rental Storage Facility 38 Variety/Convenience 57 Camp/Campground 77 Other 11 Hospital 25 Other Commercial Service Loc. 39 Department Store 64 Rest Area 1 2. 3. 56 ATM Machine Separate from Bank `METHOD OF ENTRY 'METHOD OF ENTRY —MOTOR VEHICLE THEFT 'METHOD OF ENTRY— BURGLARY/B&E ENTRY EXIT ENTRY EXIT 1 ❑ FORCE 01 ❑ Motor RunninglKeys i1 Car 06 ❑ Hot Wire ENTRY EXIT 1 ❑ DOOR ❑ 1 ❑ FRONT ❑ 2 ❑ NO FORCE 02 ❑ Unlocked 07 ❑ Slim JmVCoat Hanger 1 ❑ BASEMENT[] 2 ❑ WINDOW ❑ 2 ❑ SIDE ❑ *NO. PREMISES ENTERED 03 ❑ Duplicate Key Used 08 ❑ Tumblers Removed 20 1'FLOOR ❑ 3 ❑ GARAGE ❑ 3 ❑ REAR ❑ 04 ❑ Wroclaw Broken 09 ❑ Column Peeled 3 ❑ 2"o FLOOR ❑ 4 ❑ SKYLIGHT ❑ 4 ❑ ROOF ❑ 05 ❑ Towed 10 ❑ Ignition Pealed 4 ❑ OTHER ❑ 5 ❑ OTHER ❑ 5 ❑ OTHER ❑ METHODS OF 'CARGO THE OPERATION Y❑ N❑ 'NO. 'TOTAL 'VICTIM 1 U INDIVIDUAL F FINANCIAL INSTITUTION P LJ POLICE OFFICER (IN THE LINE OF DUN) S U SOCIETY O OTHER VICTIMS TYPE B❑ BUSINESS G❑ GOVERNMENT Rr,-J' RELIGIOUS ORGANIZATION U ❑UNKNOWN NAME (Last, First, MWdSe) ADDRESS (Street, Apt. City, State, Zip) PHONE EMPLOYER NAME AND PHONE ADDRESS (Street, Apt, City, State, Zip) "AGE/ Li B U A NICITY HGT WGT HAIR EYES D.O.B_ ❑ W ❑ 1 ❑ U U OCCUPATION SN'RESIDENT 1 U RESIDENT 3 U MILITARY 5 U OTHER STATUS 2 ❑ TOURIST 4 ❑ STUDENT U ❑ UNKNOWN 'VICTIM U Y IF INJURED, DESCRIBE C Z INJURED? ❑ N INJURIES: m o AGG. ASSAULT/ 'LEOKA INFORMATION CTIM/SUSPECT RELATIONSHIP 'VlCT1MlOFFENSE LINK m m ? TYPE OF ACT.ASSIGN. TYPE ORI -OTHER HOMICIDE CIRC. 4. 5. 0. 1. 2 3. REPORTING OFFICER OFC ALLEN ONEAL BADGE NO. DATE 08/27/2021 eA APPROVING OFFICER BADGE NO. DATE FOLLOW- UPI? r yes, follow-up ❑ Y ❑ N signment ADDITIONAL VICTIMAMTNESS PROPERTY STATEMENTS FORM RECEIVED BY: INTELLIGENCE SPECIAL SUPPLEMENTS ❑ SUSPECT/ARRESTEE ❑ NARRATIVE ❑ OTHER 0 INVESTIGATION ❑ RECORDS COPIES s�mr PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 21.1728 87073133 1 Driver VEHICLE# NAME PHONE NUMBER Check K I� L1 2 1 ❑ 1061) Recommend PassengeNon-motor 3 Passenger 1 PHIUP ANDREW PIKE 573-4248 Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 4100 SANCTUARY LN BOCA RATON FL 33431 DATE OF BIRTH SEX. 1 Male DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) 2 2 Female 2 Possible 6 Fatality 04/07/1967 88 Unknown P2006616712700 FL 04/07/2025 3 Non -Incapacitating Non -Traffic DRIVER DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd Condition At 1 No Contribution Action 26 off Roadway Time f 1 9D Disregarded ded other Traffic ❑ Crash r F Negligent Manner Carelss or 27 5 E/Opera or 2 No 1 Apparently Normal 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 6 E/Oper•Rest 3 No Req. Endorsement 3 Asleep or Fatigued 7 None 4 Improper Backing Markings 5 III (sick) or Fainted 6 Improper Turn 29 Over-Correcting/Over Driver Distracted By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 2n0 10 Followed too Closely 7 Physically Impaired 8 Emotional (depression, 66 1 Not Distracted 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided : Due 2 Electronic Communication (outside the vehicle, explain El 12 Drove too Fast for Conditions 4th angry, disturbed, etc.) Wind, Slippery Surface, MV, g Under the Influence of Devices (cell phone, etc. in narrative 13 Ran StopSin O 9 Object, Non -Motorist in Medicetions/Dru s/Alcohol 3 Other Electronic Device 15 Improper Passin 9 6 Textin g9 Roadway, etc. 77 Other, Explain in Narrative (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted Speed 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 OBSTRUCTIONS 1 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER 1 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 3] 1 Yes 3 IRS) SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) (LOC) 17 1 3 No Helmet 2 None Used - Motor Vehicle Occupant Seat Row Other 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Air Bag Deployed 5 Lap Belt Only Used 2 2 Sleeper Section of Truck Cab 5 Deployed -Other 2 Second 3 Right 3 Other Enclosed Cargo Area EJedlon (EJECT) (knee, air belt, etc.) 6 Restraint Used -Type Unknown Right 77 Other 3 Third 1 Not Ejected 1 NotA licable 7 Child Restraint System - Forward Facing 4 Unenclosed Cargo Area PP 6 Deployed- 8 Child Restraint S stem - Rear Fadnex lain in 4 Fourth 2 Ejece4 Totally 2 Not De to ed y g ( P P y Combination5 Trailing Unit Z3 3 Ejected, 9 Booster Seat narrative) 77 Other Row 6 RidingOn Motor Vehicle Exterior non- Partial) 3 Deployed -Front 7 Deployment Deployed -Curtain 10 Child Restraint Type Unknown 88 Unknown y 4 Deployed -Side 88 Deployment 68 Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown N n-Motorist Description 1 Pe�esman ❑ Non -Motorist Location At Time of Crash 8 Sidewalk ❑Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cycling on Sidewalk 9 Median/Crossing Island 2 Other Pedestrian (wheelchad, person in a 6 In Roadway Other (working, 2 Intersection -Unmarked Crosswalk 10 Driveway Access y — ( 9, building, skater, pedestrian conveyance, etc. 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail 1 Crossing Roadway playing, etc.) 3 Bicyclist 4 Other Cyclist 4 Midblock - Marked Crosswalk 7 Adjacent to Raadway (e.g., 12 Non-Trafficway Area 2 Wading to Cross Roadway shoulder, median) 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane - Other Location 77 Other, Explain in Narrative 3 Walk ng/Cycling Along 6 Bicycle Lane 8 Going to or from School (K-12) (parked, etc.) 88 Unknown Roadway with Traffic (in or 7 shoulder/Roadside 9 Working in Traficway s adjacent to travel lane) 6 Occupant of a Non -Motor Vehicle (incident response) 4 Walking/Cycling Along Transportation Device 7 Unknown Type of Non -Motorist NOn-MOtOnSt Actionsruircumstances 10 None 1 No Improper Action Roadway Against Traffic (in 77 Omer, Explain in Narrative 1st ❑ 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way ❑ 4 Failure to Obey Traffic Signs 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable 3 Protective Pads Used 2ne Signals, or Officer 51n Roadway Improperly (standing, Vehicle 11 Improper Passing 77 Other, Explain (elbows, knees, shins, etc.) lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking in Narrative 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 1 Test Not Given ❑ 2 Test Refused 1 Blood 2 Breath E 3 Urine EST RESULT 2 FJ 'RUGUSE: ❑ Refused d Given ❑ 1 Blood❑ Urine7 1 Positive ❑ 2 Yes 3 Test Given 77 Omer, Explain COMPING 3 Test Given 73 Omer, 3 Pend ng 88 Unknown 88 Unknown, K Tested in Narrative 88 UNKNOWN 8 Unknown 88 Unknown, ff 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 Omer, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # VEHICLE # [AME DATE OF BIRTH I INJ I SEX I LOC: S I R 0 EJECT J HU EP 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 NU Tv ,.W ] EMS 3 — E.— 77 Otl , E�1 i In Namlha M U. ❑ JEMSAGENCY PERSON # VEHICLE # [AME DATE OF BIRTH I INJ I SEX I LOC: S I R O EJECT HU EP 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 Not TnrNpvlW 2 EMS S law EMorronwM 77 0— E..1-1n N.— S3 Unlmwm ❑ HSMV 90010 S 3 8 Page of PERSON # 5 Reporting Agency Case Number HSMV Crash Report Number 21.1728 87073133 1 Driver VEHICLE by NAME PHONE NUMBER Check if ❑ 2 Non -Motorist 3 Passenger 1 VALENTIN NANOVICH NOVIK Driver Re -exam CURRENT ADDRESS (Number and Street) CITY 8 STATE ZIP CODE 2050 OLEANDER BLVD APT 3104 FORT PIERCE FL 34950 DATE OF BIRTH SEX: 1 Male DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4Incapacitating 1 None 5 Fatal (within 30 days) 4 2 Female 2 Possible 021171959 / 88 Unknown 3 Non -Incapacitating 6 Non -Traffic Fatality DRIJ DL t Time of Crash 3M 26 ons Condition At ❑ ActioCarelDrivers off Roadway adwayr C ❑ Required Endorsements lot 2 Time of Crash ❑ octl 4 D C hp3 Operated MV in 27 Disregarded Traffic ❑ 5 E/Operator 2 No Negligent Manner Sign 1 Apparently Normal 6 E/0 P q er-Rest 3 No Re . Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 3Asleep or Fatigued 7 None 4 Improper Backing Markings 5 Ill (sick) or Fainted 6 Improper Turn 29 Over-Correcting/Over Driver Distracted By 6 Seizure, Epilespsy, Blackout 4 Other Inside the Vehicle Steering (explain in narrative) 10 Followed too Closely 7 Physically Impaired ❑ 1 Not Distracted 2nd 8 Emotional (depression, 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided : Due 2 Electronic Communication (outside the vehicle, explain 12 Drove too Fast for Conditions to Wind, Slippery Surface, MV, 4th angry, disturbed, etc.) Devices (cell phone, etc. in narrative) ❑ 13 Ran Stop Sign Object, Non -Motor st in 9 Under the Influence of c 3 Other Elehol ctronic Device 6 Texting 15 Improper Passing Roadway, ❑ etc. 77 OMedther,Explainin rral (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Erratic, 77 Other, Explain in Narrative 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 OBSTRUCTIONS 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke L7 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER 3 Parked/Stopped VehiUe 7 SignsBillboards 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 IRS) DRIVER OR PASSENGER ❑ Motorcycle Helmet 2 No ❑ Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) Motor Vehicle Seating Position: LOCATION: SEAT RO 'T 12 Seat Row Other (LOC) 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 2 Middle1 Front 2 Sleeper Section of Truck Cab Air Bag Deployed 5 Deplo ed-Other 5 Lap Bait Only Used y 3 Right 2 Second 3 Other Enclosed Carg o Area Ejection (EJECT) (knee, air belt, etc.) 6 Restraint Used - Type Unknown 77 Other 3 Third 4 Unenclosed Cargo Area 1 Not Ejected ❑ 1 Not Applicable 6 Deployed- 7 Child Restraint System - Forward Facing (explain in 4 Fourth 2 Ejected, Totally 2 Not Deployed C5 Trailing Unit ombination 8 Child Restraint System - Rear Facing narrative) 77 Other Row 3 Ejected, 3 Deployed -Front 7 peployed-Curtain 9 tester Seat P y 88 Deployment 10 Child Restraint Type Unknown 88 Unknown 6 Riding on Motor Vehicle Exterior (non- Partially 4 Deployed-Sideto 88 Unknown trailing unit) 4 Not Applicable 77 Other, Explain in Narrative Unknown 88 Unknown 88 Unknown N0n-Motorist Description 1 PetleStilan Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash ❑ 2 Other Pedestrian (wheelchari, person in a 5 building, skater, pedestrian conveyance, etc. 1 Intersection - Marked Crosswalk 5 Walking/Cycling on Sidewalk Island 77 ❑ 9 Driveway 2 Intersection -Unmarked Crosswalk 10 Driveway Access 6 In Roadway —Other (working, 77 3 Intersection - Other4 Midblock - Marked Crosswalk playing, etc.) 3 Bicyclist 11 Shared -Use Path 1 Crossing Roadway 4 Other Cyclist 4 Midblock - Marked Crosswalk Area s Adjacent to y (e.g., 12 Non-Trafficway Area 2 Waking to Cross Roadway 5 Occupant of Motor Vehicle Not in Transport median) 5 Travel Lane - Other Location shoulder, median) 6 Bicycle Lane nkno, lain in Narrative 3 Along 8 Going to from School (K-12) (parked, etc.) 8888 UnknownRoadwaywithTraffice) or Roadway with Traffic in 7 shoulder/Roadside 9 Working in Tralficway 6 Occupant of a Non -Motor Vehicle adjacent to travel lane) (incident response) Transportation Device on- o o s on m mus nces 4 Walking/Cycling Along 10 None 7 Unknown Type of Non -Motorist 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative tiff 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way 4 Failure to Obey Traffic Signs Signals, or Officer 7 Entedng/Exiting Parked/Standing 10Improper Turn/Merge 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable 3 Protective Pads Used 77 Other, Explain (elbows, knees, shins, etc.) 5 In Roadway Improperly (standing, Vehicle 11 Improper Passing u lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking in Narrative 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 ALCOHIOUDRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: ALCOHOL BAC SUSPECTED DRUG TESTED: RUG TEST TYPE: DRUG TEST RESULT: ALCOHOL 1 Test Not 2 Test en d Given ❑ ❑ TEST RESULT. ❑ ID188 USE: 1 188 Test Not Refused Given ❑UOther, Blood ❑ rine [Explain 0 ❑ sUSE: 3 Test Gv 77 Other, Explain 2 COMPLETED 22 YesG 3 Test G van 3 Pending 88 Unknown 88 Unknown, ff Tested in Narrative 88 UNKNOWN Unknown Unknown, ff Tested 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 2 DELRAY BEACH FIRE RESCUE DB 21010855 BETHESDA HOSPITAL 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON * VEHICLE # AME DATE OF BIRTH I INJ SEX LOC: S R O EJECT HU EP 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 NO T—portee 2 EMS 3 Law EMmcamere 77 0t EW— m Nartathe 88 Unkrwwn ❑ PERSON ]VEHICLE # ME DATE OF BIRTH I INJ I SEX I LOC: S I R 0 1 EJECT I HU EP ABD IRS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE -7 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NO Trw pOtOl 2 EMS 3 - En- ]7lJUrer, EpWli m Namtive BB Unbrown ❑ HSMV 90010 S 4 8 Page of — Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 21-1728 87073133 Vehicle 1 driver stated " I was traveling south bound on SRA1A and collided with a ramp off the rear of an auto transport carrier. I did not see the ramp of the auto transport carver because it did not have lights displayed at the time of the crash." Vehicle 2 driver Stated " My auto transport carrier was stopped on SRA1A in the south bound lane. I was delivering a vehicle when Vehicle 1 collided with one of the ramps off the rear of my auto transport carrier causing a steel plate to strike my foot. " Veh. 1 struck Veh. 2 causing damage to the driver side ramp of Veh 2 and injury to the driver of Veh. 2's foot, who was standing at the rear of the ramp when contact was made. Veh.1 air bags deployed. Veh.1 was disabled due to damage and towed away. The driver of Veh.2 was transported to Bethesda hospital for treatment. There were no other reported injuries at the time of the crash. Veh. 2 was driven away from the accident scene by an alternate driver. Update report completed when Law Enforcement learned of injuries after the crash date. ADDITIONAL PASSENGERS PERSON 11 EHICLE # AME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS 2 r ANTHONY NICE PUGLIESE 1/2/1947 3 1 3 1 1 1 3 2 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 3146 N OCEAN BLVD GULFSTREAM FL 33321 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nat Tmnp. 2 EMS 3 law Entac"mm" 7I OCier, EMNIa fn N— W uNmonn 1 PERSON # EHICLE #�CATHERINE AME DATE OF BIRTH INJ SEX LOC: S R O HU EP ABD RS 3 r DEGABRIELLE 9/16/1955 2 2 1 2 1 JEJECT 1 3 2 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 23668 MIRABELLA CIR N BOCA RATON FL 33433 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 "T—Pa 2 EMS S law EMOc"m"r" T] Wiar, ESA— v, 1 N"rtvEw W u.b ❑ ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE ORATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT YPE OF DEPT. 1758 POLICE DEPARTMENT I(TPD) OFFICER OWEAL GULF STREAM POLICE DEPARTM HSMV 90010 S 5 B Page of_ REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER DIAGRAM 21.1728 1 87073133 NOT TO SCALE VEH1 VEH2 HSMV 90010 S g 8 Page of Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 21.1728 87073133 ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE OF BIRTH [NJ SEX LOC: S R O EJECT HU EP ABD RS 4 1 LAURA KAY PUGLIESE 11/1511960 4 2 I 3 I 2 I 1 3 4 3 CURRENT ADDRESS (Number and Street) STATE ZIP CODE 3145 N OCEAN BLVD FGULFSTREAM FL 33483 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Tmlpd 2 EMS 3l EMapanaN l] dt.r, EV Wn h Ns t w Unlncwn 1 ❑ PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX LOC: S R 0 EJECT HU EP 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 t NO Tru Pp M 2 EMS 3l EMacanmtl ]] O ,, E, W. h Nmtive w Unb ❑ JEMSAGENCY ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER IDfBADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 758 OFFICER OWEAL GULF STREAM POLICE DEPARTM POLICE DEPARTMENT (PD) HSMV 90010 S 7 B Page of VEHICLE # 2 Check if Commercial �/ Re porting Agency Case Number HSMV Crash Report Number ❑ 21-1728 1 87073133 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES VIN 2 Parked Motor Vehicle 1 Check if Permanent 3 Working Vehicle P1100399 IL Registration ❑� 4V4NC9EHOMNZ63392 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 Disabling 4 Minor 2 Yes F11 2021 VOLVO KENTUCKY AUTO CARRIER JWHITE-WHI 2 Functional 88 Unknown 4 $6,000.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due VEHICLE REMOVED BY 1. Rotation ARACHAS GROUP LLC CP37268086 to Damage: 1E SECOND DRIVER - TAT 3. v^ err Request 77 1 No 2 Yes 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY & STATE ZIP ALL TRUCKS LEASING 863 BITTERSWEET DR NORTHBROOK IL 60062 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES one: 786892ST IL Registration ❑� 1T9VC5323MW296135 2021 KAIS 30 2 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 ❑ ❑ ❑ ❑ IAIA & BANYAN RD 10 35 2 HAZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area InitialImpact Most Damaged Area IN o ❑ 1No ❑ 3 4 5 6 21 21 3 4 5 6 2 Yes 1 2 Yes 1 2 7 16 Undercarriage 18 2 7 88 Unknown 88 Unknown 19 Overturn 19 1 15 16 17 6 20 Windshield 20 1 15 16 17 6 MOTOR CARRIER NAME US DOT NUMBER t4 9 21 Trailer 21 14 9 CARRY TRANSPORTATION INC 1868131 13 12 11 10 13 12 11 10 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER 863 BITTERSWEET DR. NORTHBROOK IL 60062 (630) 289-4410 Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 1 Vehicle 10,000 Ibs or less Placarded 8 Tractorrinple 16 (Sport) Utility Vehicle 1 1 Two -Way, Not Divided for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 20 17 Cargo Van (10,000 Ibs 2 Two -Way, Not Divided, with a 4,536 k or less Continuous Left Turn Lane 6 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify ( g) ) more than 10,000 Ibs (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 Ibs (painted >4 feet) Median 4 Truck Pulling Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier 5 Truck Tractor (bobtail) occupants, including driver) 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 8 Bus than 10,000 Ibs (4,536 kg)) 5 One -Way Trafficway 7 Truck Tractor/Double Truck 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 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type dal Comm/Non-Commercial TRAILER 1 TRAILER 2 3 Tank Trailer 10 Auto Transport 13 tame Chassis 4 Saddle Mount/Trailer 77 Other, Explain in 3 HopperVan/En Box Container Chassis ❑ 1 Interstate Cartier 10 ❑ 10 4 Hopper An Vehicle Towing 5 Boat Trailer Narrative 1 2 Intrastate Cartier 5Pote-Trailer Another Vehicle 3 Not in Commerce/Government 6 Utility Trailer 88 Unknown 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 7 House Trailer 1 No Cargo 7 Flatbed (vehicle 10,000 Ibs 1 10,000 Ibs (4,536 kg) or less 2 Bus 8 Dump (4,536 kg) or less not Most Harmful Event Non -Collision Comm 2 10,001-26,000lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 1 Oveollover GVWR/GCWR 3 More than 26,000lbs (11,793kg) 10 Auto Transport 77 Other, Explain in 2 Fire/Explosion 4 Not Applicable 11 Garbage/Refuse Narrative 3 Immersion 12 Log 88 Unknown 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 14 19 Impact Attenuator/Crash Cushion 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 30 Concrete Traffic Barrier Vehicle Use 20 Bridge Overhead Structure 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 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 ver33 Utility Pole/Light Support u ;❑ sot 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support [40-46 Sequence of Everna only) 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 1 No 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 2 Yes 3rd 4th brake failure, etc.) 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 88 Unknown 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox ❑ ❑ 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 Crass 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 13 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing Roadway Alignment 1 No Controls 2 Brakes 13 Wheels 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 1 4 School Zone Sign/ 3 Tires Windshield Windows/ 4 Downhill ❑ 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including 1 2 Curve Right Device 4 Lights (head, Windshield 5 Sag (bottom) Left 10 Making U-Turn 88 Unknown 5 Traffic Control Flagman, Officer, 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/ 2 Farm Vehicle 10 Fire Truck 15 Charter/Tour Bus 7 YieldSignSign 9 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 Farm Labor Bus 11 Power Train Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 1 12 Suspension 88 Unknown VIOLATIONS PERSONS NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON f1 NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 8 B Page of Renee Basel From:Todd Passman <todd@passmanlawoffice.com> Sent:Monday, February 14, 2022 11:25 AM To:Renee Basel Subject:RE: GS #2860 (Police Report 21-1728) \[NOTICE: This message originated outside of the Town of Gulfstream -- DO NOT CLICK on links or open attachments unless you are sure the content is safe.\] Dear Ms. Basel, Please find attached our correspondence concerning the BWC videos. We look forward to hearing from you and thank you in advance for your assistance. Kind regards. Todd C. Passman Law Office of Todd C. Passman, P.A. 200 S. Indian River Drive ● Suite 306 ● Fort Pierce, FL 34950 t: (772) 465-9806 f: (772) 465-9868 e: todd@passmanlawoffice.com www.passmanlawoffice.com CONFIDENTIALITY NOTICE: This e-mail transmission and any accompanying documents may contain confidential information, which is legally protected by the attorney-client privilege. The information contained in or accompanying this message is intended only for the use of the person or entity to whom it is addressed. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please respond to the sender by reply e-mail and destroy all copies of the original e-mail. From: Renee Basel Sent: Wednesday, December 08, 2021 10:36 AM To: Todd Passman <todd@passmanlawoffice.com> Subject: GS #2860 (Police Report 21-1728) Good morning, Mr. Passman: See attached correspondence. Kind regards, Reneé Basel 1 The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s). If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Florida has a very broad public records law. Written communications regarding Town of Gulf Stream business are public records available to the public upon request. Your e-mail communications are therefore subject to public disclosure. Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing. Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s). If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Florida has a very broad public records law. Written communications regarding Town of Gulf Stream business are public records available to the public upon request. Your e-mail communications are therefore subject to public disclosure. Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing. 2 February 14, 2022 Via email (rbasel@gulf-stream.org) Renee Basel, CMC Deputy Clerk Town of Gulfstream 100 Sea Road Gulf Stream, Florida 33483 Re: Date of Accident: 08/27/2021 Agency Report No.: 21-1728 HSMV Crash Report No.: 87073133 Our File No. 90.4-21-130 Dear Ms. Basel, Thank you for your December 8, 2021 written response to our open records request and the flash drive we picked up from you on December 14, 2021. On the flash drive there are two (2) BWC videos as follows: 1. A 00:49 second video which starts at 22:20:37 as per the on-screen time stamp; and 2. A 07:56 min:sec video which starts at 22:33:15 as per the on-screen time stamp. According to the police report, the officers were dispatched at 22:04 and our investigation indicates they were on-scene well before both these videos start. Accordingly, we want to be sure that we have all BWC video from that evening. Can you please check and confirm whether these are the only videos in existence or whether there may be any other clips which were inadvertently not contained on our flash drive? We thank you in advance for your kind assistance. Sincerely, LAW OFFICE OF TODD C. PASSMAN, P.A. Todd C. Passman