HomeMy WebLinkAbout24-588 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE#
24-$88 z
INTERSTATE CITY STREET RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFH1C;l F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION 01 — 1—— 2024 1705 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
S 3RDS ST BLOCK NO. e✓ 200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 500 00 FMILES EET e S ❑ E e RAINIER AVE S
1 $ 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:4252879345 30
5❑ LAST NAME YORK FIRSTNAME KYLEN MIDDLE K 1 1 2 31
INITIAL
STREET ❑, 2325 CLEVELAND AVE CITY EVERETT ST WA Zjp, 98201 2
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
,/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USE 2 1 CLASS NATURE OF INJURIES 2❑
3
10 9❑ PI ATE 14 B173155 STATE WA VIN#' 1FMCU9D75BKA68732
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR. 0 0 33
12❑ VIN#' VIN#'
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 A 2011 FORD ESCAPE UT DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO SHARRON YORK 16106 TRANGEN RD ARLINGTON WA 98223 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
14 UABILI V INSURANCE INSURANCE CO GEICO 4413422595 3 4
IN EFFECT &POLICY# 9TOP
cLe CHARGE 1 5 36
vew
LECALLv YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN
16 a ✓ PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES,/ NO D:2069620520
LAST NAME STURGEON FIRST NAME HOLLIS MIDDLE A
INITIAL
17 STREET NEW ADOREs�' 1301 S PUGET DR APT A31 CITY RENTON ST WA ZIP 98055 37
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YES❑NOR INTERLOCK YEs❑NOF YES❑NO❑
19 F] LICENSE # STATE SEX F M D.O.B. 07 25 _ 1955 39
20 ON DUTY STATUS 3 AIRBAG RESTR EJECT , HELMET 2 INJURY 6 NATURE of INJURIES 40
USE CLASS ABRASION,BRUSING
❑21❑ TATE 41
LICENSE VIN# 1
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 1 ] DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO I 9TOP 5
VE."LE ES❑ N J
,J� CITATION# CHARGE i o BOTTOM
LEGALLY Y
25 s � e
7JAWEBER
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
12532 WA0171300
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE44660
COLLISION REPORT III III III III III 111
1591972 CASE# 24-588
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
POS. 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'
On January 17th, 2024, at approximately 1707 hours, I was dispatched to the Safeway located at 200
S 3rd St for a report of a vehicle vs. pedestrian accident which had occurred at slow speeds in the
parking lot.
I arrived and located the vehicle (1), a red 2011 Ford Escape (WA LIC: 803YSU) driven by Kylen K
York DOB 08/15/2005, and the pedestrian who had been struck, Hollis A Sturgeon DOB 07/25/1955.
Hollis advised she had been next to her vehicle in the parking lot of Safeway when Vehicle 1, which
was parked in the spot to the east of her, began to back up and exit the parking spot. While doing to
the wheels of Vehicle 1 turned and ran over Hollis's foot, causing her to lose her balance and fall to
the ground, hitting the back of her head on the blacktop. Vehicle 1 came to a stop upon hearing
Hollis's scream, and Kylen exited the vehicle to provide assistance.
Kylen stated she was backing out of her parking spot, and she did not notice anything/ anyone next to
her but while backing she heard a scream and stopped, which is when she exited the vehicle to see
Hollis on the ground.
Hollis was evaluated by Renton Fire. It was determined she had suffered abrasions to the front of her
left shin, and a hematoma to the back of her head. She was transported by RFA out of caution for
medical evaluation.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JACOB WEBER 01-17-24 06:41 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.KORDEL 9676 1 1/26/2024 3:19:50 PM
BADGE OR ID# 12532 ORI# WA0171300 TIME POLICE DISPATCHED 5:07 Pry TIME POLICE ARRIVED 5:11 PM
PART I PAGE IT]OF 3�
REPORT NO. EE44660 CASE# ' 24-588 DATE AND TIME 01/17/24 17:05
OF COLLISION
N.T.S.
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