HomeMy WebLinkAbout23-6910 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-6910 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4'I00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 5 6 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 06 - 1-- 2023 2153 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
KIRKLAND CT SE BLOCK NO. e✓ 1657
4a❑ MILE POST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 100 00 FEET e S B W e LAKE YOUNGS WAY SE❑
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:2065187483 30
6� LAST NAME NGUYEN FIRSTNAME CECILIA MIDDLE V 1 1 2 31
INITIAL
STREET ❑, 1657 KIRKLAND CT SE CITY RENTON ST WA ZIP 980583818 z
NEW ADDRESS
]❑ 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
2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� BWA4953 sTAr1 WAvrN# JTJGJRDZ4M2147857
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12❑ vIN#' UIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13❑9 2021 LEXS NX 300H UT DAMAGE YES NO YES[:] ✓No
REGISTERED OWNER INFO TRANG HUYNH 5600 KOMACHIN LOOP SE LACEY WA 98513 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO SAFECO H2430940 3 4
IN EFFECT &POLICY# 9TOP
vEwc LEGALLvLE 5 36
Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 OWNER ❑ YES,/ NO D:2064223117
a
LAST NAME NGUYEN FIRST NAME ANTHONY MIDDLE V
INITIAL
17❑ STREET ❑', 1657 KIRKLAND CT SE CITY' RENTON ST WA ZIP 98058 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL t-T�RANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I No� YES t l NO❑
19 F] LDI IVE # STATE SEX M M D.O.B. 11 11 1996 39
20 ON DUTY STATUS 3 AIRBAG RESTR EJECT H SET 2 NJAURSY 7 [NATURE OF INJURIES
SORE LEFT AND RIGHT LEGS ABOVE KNEES, 40
❑21❑ LICENSE TArE VI 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24 1 ] DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
vE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# T AGENCY
26
C.PAGET 8660 WA0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED73323
COLLISION REPORT III III III III III 111
1591972 CASE# 23-6910
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
PM USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.PAGET 06-17-23 11:12 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 6/24/2023 1:09:56 PM
BADGE OR ID# 8660 OR]# WA0171300 TIME POLICE DISPATCHED 9:54 PM TIME POLICE ARRIVED 10:00 PM
PART Ei PAGE IT]OF 4�
REPORT NO. ED73323 CASE# 23-6910 OF COLLISION
06/17/23 21:53
OF CbLLI510N
NARRATIVE
23-6910 Injury collision on private property
Axon:
Axon body cam available
Photos:
Photos uploaded to Axon evidence.com
Narrative:
On 06.17.2023 at 2154 hours, I was dispatched to in injury car-pedestrian collision that occurred at
2153 hours in the garage of 1657 Kirkland CT SE. This address is within the city limits of Renton,
County of King, WA.
When I arrived, I advised everyone that our contact was recorded.
Patient Anthony V Nguyen DOB/11.11.1996 called to report that he was helping his sister park their
car in the garage, when she mistook the gas and brake pedals. Anthony was standing at the front of
the car in the garage when his sister hit the gas instead of the brake. This knocked Anthony
backwards into a cabinet. Anthony complained of soreness above the knee of both legs with the left
leg slightly more painful. There was no damage to the vehicle.
Nguyen's sister Cecilia V Nguyen DOB/12.02.2006 was the person who was driving the car a black
2021 Lexus Nx300H WA/BWA4953. Cecilia has a valid WA learner's permit. The car is registered to
Trang Huynh.
Cecelia and Anthony have the same account of what happened.
Anthony was treated and released by Renton Fire. Anthony was walking and declined further medical
aid right now.
This collision occurred on private property in the garage of the residence.
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer C. Paget/8660 6/17/2023 11:08 PM Renton, King County, WA.
PAGE 3 OF 4
REPORT NO. ED73323 CASE# 23-6910 DATE AND TIME 06/17/23 21:53
OF COLLISION
PAGE 4 OF 4