HomeMy WebLinkAbout23-7449 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
CASE#r` 23-7449 2
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 2$
TRIBAL UNITS 01 STRUCK
RESERVATION
2
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
GowsloN 07 - 01 - 2023 1709 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
4301 NE 4TH ST
BLOCK NO. e✓ --- ----�
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 40 00 FEET e S ❑ W e WHITMAN CT NE
Fill1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2066055407 30
6❑ LAST NAME GRIMSTAD FIRSTNAME CONSTANCE MIDDLE L 1 1 2 31
INITIAL
STREET ❑, 4224 NE 10TH PL CITY RENTON ST WA 2jp, 98058 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYES NO 1/ INTERLOCKYEs NO�/ YES No�/
8❑ LDRIVER # STATE WA SEX'F MMDDYY 09 — 08 — 1947 32
9 ON DUTY❑ STATUS AIRBAG 1 RESTR 1 EJECT 2 HELMET 6 INJURY 5 NATURE OF INJURIES 2❑
USE CLASS POSSIBLE BROKEN L FOOT AND R HIP
3
10❑ Pl aTNBE BVM6108 STATE WA VIN#' 1 FM5K8GT4HGE00477
14
TRAILER STATE TRAILER STATE
11 1 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12❑ vIN#' VIN#
2017 FORD EXPLOR SWa FROM 34
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO u BLIN TOWED BY GOVT.VEHICLE
13 A DAMAGE YES NO YES[:] NO✓
REGISTEREDOWNERINFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ UABILI INSURANCE INSURANCE CO GEICO 6130-59.32.28 3 4
IN EFFECT &POLICY# 9TOP
vEHICE CHARGE 5 36
LEI-1 YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 6
UNIT U2 VEHICCMOTOLE ❑ CYCLE ❑ PEDESTRIAN ❑ OWNER RTY ❑ DYES NO OLD MET PHONE
16❑
LAST NAME FIRST NAME MIDDLE
INITIAL
STREET
CITY' ST ZIP 4❑ 37
17❑ NEW ADDRESS❑'
18❑ CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL—T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t l NO❑
19 LLIICENS # STATE SEX MMDDYY —�_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ LICENSE TATE IN# 41
V 1
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❑ 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 VEHICLELLY ❑ ,.I—I CITATION# CHARGE
25 GQ
LEGA YES N`LJ
s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
E.CHANG 10065 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED78406
COLLISION REPORT III III III III III 111
1591972 CASE# 23-7449
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) KOONTZ MARYE
(I.P.ST FIRST,
ADDRESS&PHONE#
14515 SE 112TH PL RENTON WA 98059 4254666382 SEX i U MMDDYyry 11 - 26 - 1963
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE of INJURIES
�✓ POS. USE CLASS
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYYY
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'
On 07-01-2023 at about 1710 hours I was sent to an injury collision that occurred in the parking lot of
4301 NE 4TH ST, in the City of Renton, King County, Washington.
Upon arrival, I saw Fire personnel tending to a woman laying next to a white SUV with WA plate
BVM6108. The woman laying next to the vehicle was later identified via a WADL as Grimstad,
Constance. She informed me of the following. She said she thought she stopped her car. When she
was getting out, the vehicle started rolling back so she tried to step on the emergency brake.
Constance fell out of her vehicle and the front driver-side tire rolled onto her foot. When the vehicle
rolled onto her foot, her vehicle stopped and trapped her beneath. Constance said she thought her
vehicle was geared in reverse. Constance was lucid and articulate. I did not believe she was under
the influence.
A witness Koontz, Mary came to her aid and drove Constance's vehicle forward off of Constance's
foot. Mary said she thought the vehicle was in drive but the vehicle was not running.
Fire informed me that Constance was being taken to VMC for injuries to her left foot and her right hip.
Constance has had previous right hip surgeries.
No follow up is needed in this case.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
E.CHANG 07-02-23 07:51 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
S.WOODWARD 11528 1 711112023 6:47:26 AM
BADGE OR ID# 10065 OR]# WA0171300 TIME POLICE DISPATCHED 5:10 PM TIME POLICE ARRIVED;5:18 PM
PART I PAGE IT]OF
REPORT NO. ED78406 CASE# ' 23-7449 DATE AND TIME 07/01/23 17:09
OF COLLISION
4�01 �lE 4TF-I ST
PAGE 3 OF 3