HomeMy WebLinkAbout23-5771 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-5771 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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 05 - 1-- 2023 1737 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
DUVALL AVE NE BLOCK NO. e✓ 1700
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:2533741505 0 7 30
6� LAST NAME GREEN FIRSTNAME KIANNA MIDDLE M 1 1 2 31
INITIAL
STREET ❑ 10305 SE 264TH ST APT G205 CITY KENT ST WA Zjp, 980306716 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� CBA5287 sTArI WAurN# 1GNFK130X7R121363
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. A'RLR. 1 5 33
12 3 5 VIN#j VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE J 9 34
13 2 2007 CHEV TAHOE DAMAGE vEs 0NO agW�MEYER vEs❑ No
REGISTERED OWNER INFO KIANNA GREEN 10305 SE 264TH STAPT G205 KENT WA 98030 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICV# 9TOP
VEF" CHARGE to BOTTOM 5 36
EGALLY YES No CITATION# 3A0357733,3A0357733 INATTENTIVE DRIVING,OP MOT VEH
15❑ STANDING 8 7 6
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
UNIT 02 ❑ PEDESTRIAN ❑ YES,/ NO D:4252463448
VEHICLE CYCLE : OWNER 16 a
LAST NAME FORDS FERRANT FIRST NAME DIANA MIDDLE I B
INITIAL
17❑ STREET ❑', 15559 206TH AVE SE CITY RENTON ST WA ZIP 980599045 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE WA ]SEX IF D.C... 10 _ 02 _ 1946 39
LICENSE# MMDDYY
WELMET {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS 1 ❑
21❑ LICENSE B93574T TAre WA VIN# 1FMZU77E83UA17580
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2003 MAKE FORD MODEL EXPLORE STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO DIANA..IT 15559206THAVESE RENTON WA 01159 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU PORGY#E CO STATE FARM 299 5174-B27-47MIN 1 9TOP
VEHICLE CITATION# CHARGE
25❑ i o BOTTOM
LEGALLY YES N�
J
s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
K.LANE 10008 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED65536
COLLISION REPORT III III III III III 111
1591972 CASE# 23-5771
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) STEPHENS NEVAEH M
(LAST FIRST,
ADDRESS&PHONE# D O.B.
10305 SE 264TH ST APT G205 KENT WA 980306716 2533741505 SEX F MMDDYyry 04 - 26 - 2013
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER ZWITNESS� UNIT# 1 POS 3 AIRBAG 2 RESTR. 4 EJECT 1 USE 2 CLASS 7 COMPLAINT J KNEE PAIN
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX' MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY
POS. NATURE OF INJURIES
USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.Q.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 2 was on southbound Duvall AVE NE, stopped for traffic back from a red light, and stopped just
north of NE 17th PL as to let traffic enter/exit if needed. Unit 1 was traveling southbound on Duvall
AVE NE approaching Unit 2 and the stopped traffic. Driver 1 states she was distracted by her
daughter inside of the vehicle and did not realize traffic was stopped in front of her. When she
realized, Driver 1 attempted to brake and swerve but could not avoid the collision. The front
passenger corner of Unit 1 struck the rear driver's side corner of Unit 2 causing moderate/heavy
damage to both vehicles. Unit 1 towed by Gene Meyer.
Driver 1 was cited for Inattention to Driving by not driving with due care and caution and failing to
realize traffic was stopped in front of her which was the proximate cause of the collision. Driver 1 was
also cited for operating a motor vehicle without insurance as she advised Unit 1 was uninsured.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 05-23-23 05:51 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 512412023 10:04:26 PM
BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED 5:39 PM TIME POLICE ARRIVED',5:43 PM
PART I PAGE IT]OF 3�
REPORT NO. ED65536 CASE# ' 23-5771 DATE AND TIME 05/22/23 17:37
OF COLLISION
z
m
- ***NOT TO SCALE***
DUVALL AVE NE
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