HomeMy WebLinkAbout23-13961 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-13961 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 12 - 1-- 2023 1246 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
HARDIE AVE SW BLOCK NO. e✓ 300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2064759733 0 11
30
6� LAST NAME OMAR FIRSTNAME SAID MIDDLE M 1 F 2 31
INITIAL
STREET ❑, 13445 MARTIN LUTHER KING JR W M103 CITY SEATTLE ST WA 2jp, 98178 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO I INTERLOCK YES NO YES R NO
8 LRIIVERCENS # STATE SEX'M MDMDo 10 - 23 - 2008 1 2 32
9 ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 HELMET USE 2 1 CLAY NATURE OF INJURIES z❑
3
10 9❑ PI ATE
S1t CCT5199 sTArI WAurN# 1 Y1SK5485 WZ417999
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. YRLR. $ 1 33
12 2 5 VIN#j VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 1 $ 34
13 2 1998 GEO PRISM SD DAMAGE vEs 0NO f �AWkkRS vEs❑ No
REGISTERED OWNER INFO HAMADI HUSSEINI 13445 MARTIN LUTHER KING JR WM103 SEATTLE WA 98178 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
4
14 LIABILITY INSURANCE❑ INSURANCE CO 3
IN EFFECT &POLICY# 9TOP
VEHICLE JUVY MOLT VIO CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# JUVY 1 o BOTTOM
15❑ STANDING 7 6
MOTOR PEDAL- 'PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2066641801
16 a
LAST NAME HIGH FIRST NAME JERRY MIDDLE H
INITIAL
17❑ STREET ❑', 11024 WOODWARD AVE S CITY SEATTLE ST WA ZIP 981783158 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES
t l NO�
19 LICENSE#DRIVER'S STATE WA SEX MMDC7YY
M D.O.B. 04 22 _ 1949 39
HELMET {NJURY 7 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 3 RESTR 4 EJECT 1 USE 2 CLASS UPPER BODY/AIRBAG ❑
21❑ LICENSE BGY1939 TAre WA VIN# JF1 GD29622G516267
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
G HI 44
VEH YEAR 2002 MAKE S(JB�Q MODEL ►MPREZA STYLE DAMAGE TOWED NOO✓ BLIN TOWED By ov YES
NO
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE I PORGY#E CO STATEFARM 0812747-F15-47EIN STOP 5
VEHICLE ❑ ,.I—I CITATION# CHARGE io BOTTOM
LEGALLY YES N
25 a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE32816
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13961
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) HIGA TERESITA H
(LAST FIRST,
ADDRESS&PHONE#
11024 WOODWARD AVE S SEATTLE WA 981783158 SEXi F MMDDYyry 10 - 11 - 1951
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER ZWITNESS❑ UNIT# 2 POS 8 AIRBAG 3 RESTR. 4 EJECT 1 USE 2 CLASS 16 UPPER BODY/HEAD/AIRBAG
NAME
'(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYVYV
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 was traveling northbound in the 300 blk of Hardie AVE SW. Unit 2 was traveling southbound in
the 300 blk of Hardie AVE SW. On this date it was raining steadily with the roadway covered in water.
Driver 1 is a 15-year-old unlicensed driver. For unknown reasons, Unit 1 crossed over the center line
and into the southbound lanes of travel and ithe path of Unit 2. The front end of Unit 1 struck the front
end of Unit 2 causing heavy damage and airbag deployment. Driver 2 and Passenger 2 were
transported to Valley Medical Center with upper body injuries as well as injuries from the airbag
deployment. Both vehicles towed by Bankers tow. Driver 1 was ID'd by mother who arrived at scene.
For further information regarding this identification and information regarding pending charges
forwarded to the juvenile court, see full AEGIS case report.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 12-06-23 11:53 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 12/21/2023 7:43:57 AM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED 1Y:47 PM TIME POLICE ARRIVED',12:52 PM
PART I PAGE IT]OF
REPORT NO. EE32816 CASE# ' 23-13961 DATE AND TIME 12/05/23 12:46
OF COLLISION
ti
is
PAGE 3 OF 3