HomeMy WebLinkAbout23-12365 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-12365 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4'/00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 2$
$
RESERVATION 1
TRIBAL UNITS 02 STRUCK
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 10 - 28 - 2023 1324 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RAINIER AVE S BLOCK NO. e✓ 743
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:2063081873 30
6❑ LAST NAME GARRETT FIRSTNAME EDNA MIDDLE 1 2 31
INITIAL
STREET ❑, 11670 DES MO/NES MEMORIAL DR A304 CITY BURIEN ST WA 2jp, 981681420 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYES NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9� Pi ATE 14 CGD9044 STATE WA v N# 2C4RC1DG7HR648271
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR 7 3 33
12❑ VIN#' VIN#.
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE $ 34
13 A 2017 CHRY PACIFIC VN DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO EDNAGARRETT 11670 DES MOINES MEMORIAL DRA304 BURIEN WA 981681420 D:2063081873 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 UABILI INSURANCE INSURANCE CO GEICO 6088533390 3 4
IN EFFECT &POLICY# 9TOP
LEwoLe CHARGE 1 5 36
LECALLv YES❑NO❑ CITATION# 10 BOTTOM
15❑ TANDING MOTOR PEDAL- PEDESTRIAN ✓ PROPERTY DAM THR OLDMET PHONE
�Ul
NIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:4253950502
16 a
LAST NAME DURAN FIRST NAME JOSE MIDDLE
INITIAL
17❑ STREET �' 77 S WASHINGTON ST CITY''' SEATTLE ST' WA ZIP 98104 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICALt-T�RANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NoF YES t l NO❑
19 DRIVE # STATE SEX M M DDY
D.O.B.
09 _ 27 1986 39
ON DUTY STATUS 4 AIRBAG RESTR EJECT WEB MEET 2 NJAURSY 6 [NATURE OF
BACK PAIN,JURIES RIB PAIN,PAIN WHEN BREATHING 40
❑21❑ LICENSE TATE VIN# 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4 Q $ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I 9TOP 5
VE."LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 s � e
7SHA
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26 CROW 12618 WA0171300
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE14818
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12365
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) GARRETT STACEYD
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
4706 SOUTHCENTER BLVD G209 TUKWILA WA 98188 2535927485 SEXi F MMDOYyry 08 - 19 - 1984
PASSENGER Z WITNESS� UNIT# 1 SEA 1 AIRBAG 2 RESTR. 9 EJECT ? 1 USE HELMET CLASS LASS NATURE OF INJURIES
: '1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEXI MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY 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.
SHAWN CROW 10-28-23 04:07 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIREE SCOTT 10272 1013112023 7:14:14 AM
BADGE OR ID# 12618 ORI# WA0171300 TIME POLICE DISPATCHED! 1:25 Pry] TIME POLICE ARRIVED',1:27 pry]
PART Ei PAGE IT]OF 4]
REPORT NO. EE14818 CASE# 23-12365 OF COLLISION
10/28/23 13:24
OF CbLLI510N
NARRATIVE
On 10/28/2023 at about 1325 hours I was working uniform marked patrol as 1 R15 when I was
dispatched to a vehicle versus skateboarder in the Walmart parking lot located at 743 Rainier Ave S
within the city limits of Renton, King County, Washington. When I arrived the skateboarder (Jose
Duran) was sitting upright in the parking lot and the driver of Unit 1 (Edna Garrett) was with him. Jose
said he did not have a head injury, but his back and ribs were in pain. I requested the Renton Fire
Department (RFD) to respond and evaluate Jose.
I spoke to Edna after RFD arrived, and she told me that she was driving her van (Unit 1-2017
Chrysler Pacifica with Washington license plate CGD9044) through the parking lot (eastbound) when
a skateboarder (Jose Duran) came out from behind a parked white colored pickup truck and struck
her van. Edna pointed out that Jose came from her left (north of her van) and struck the front driver
side area of Unit 1. Edna's van had damage to the front windshield and front driver side fender. Unit
1 was able to be driven from the scene, and Edna did not complain of any injuries from the collision.
Stacey Garrett was seated in the front passenger seat of Unit 1 and saw Jose Duran roll into Unit 1
while on his skateboard. Stacey pointed to the area left (north) of Unit 1 as the direction from where
Jose came from, and she confirmed that Unit 1 was headed eastbound. Stacey did not report any
injuries from the collision.
Jose Duran claimed that he was traveling eastbound through the parking lot and that Unit 1 was
traveling northbound when Unit 1 struck Jose. Jose complained of pain to his back and ribs after
colliding into the van. RFD responded and evaluated Jose on scene, but he refused to go to the
hospital at first. Jose left the parking lot, but he returned moments later and asked to be taken to the
hospital because it hurt when he breathed. 1 requested Tri Med to respond, and he was transported
to the hospital for further evaluation. Jose was not wearing a helmet at the time, and his skateboard
had extensive damage on one end.
Officer R. Phillips took photos of the scene and uploaded those photos to Axon. I gave Edna and
Jose each a Renton PD business card with the case number. There was no traffic control in the
parking lot, and no traffic infractions were issued for this collision that occurred in the private parking
lot at the Walmart.
PAGE 3 OF 4
REPORT NO.! EE14818 CASE# ' 23-12365 DATE AND TIME 10/28/23 13:24
OF COLLISION
i
Unit 1
<- - - - - -- *Not drawn to scale
Pedestrian an skateboard
r
(Several unoccupied parked vehicles in parking lot)
PAGE 4 OF 4