HomeMy WebLinkAbout24-6909 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
SASE 24-6909 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENC 4100 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#
COLLISION' 07 - 01 - 2024 1900 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S 43RD ST BLOCK NO. e✓ p ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e NB SR167
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:4254665814 30
6 LAST NAME HALVORSON FIRSTNAME CAITLIN MIDDLE M 1 1 2 31
INITIAL
STREET ❑ 28602 16TH AVE S,APT 103 CITY FEDERAL WAY ST WA ZIP 98003 z
'NEWADDRESS
7❑ CDL I ,/ INTGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO ERLOCK YES NO�/ YEs NO
8❑ LICENSE# STATE Wq SEX'F M1-O B 06 — 18 — 1988 32
9 ON DUTY❑ STATUS AIRBAG 9 RESTR 9 EJECT 1 HELMETU SE CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� CGH3627 sTArI WAvrN# 2HGFC2F53HH541519
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. YRLR. 5 1 33
12❑ vIN#' UIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE
D ClV/C SD TO BLIN TOWED BY GOVT.VEHICLE 3 7 34
13 2017 HOND CIVIC SD DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO CAITLIN HALVORSON 2860216TH AVE S,APT 103 FEDERAL WAY WA 98003 D:4254665814 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO STATE FARM 2318849-FO2.47V 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE 5 36
LEGAL
Lv YES❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a : OWNER ❑ YES, NO D:5642300575
LAST NAME TAYLOR FIRST NAME COLLEEN MIDDLE M
INITIAL
17 STREET IULFORD RD E CITY EATONVILLE ST' WA ZIP 98328 37
NEW ADOREs�' 36703 P
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t— l NO❑
19 LDI IVER # STATE WA ]SEX IF M D.C.B. 05 _ 24 1991 39
20 ON DUTY STATUS 13 1 AIRBAG I RESTR EJECT I H U MEET LASSY NATURE OF INJUR
6 PAIN ON BOTH I KES NEES AND RIGHT ELBOW ❑ 40
❑21❑ TArE 41
IN#LICENSE V `1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4 0 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
J RAYGOZA 12503 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF08772
COLLISION REPORT III III III III III 111
1591972 CASE# 24-6909
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) PISAREV IGOR D
(LAST FIRST,
ADDRESS&PHONE#
225 S 51ST ST,UNIT H RENTON WA 98055 2069449871 SEX M MMDOYyry 12 - 30 - 1995
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ ❑✓ POS. USE CLASS
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYYI -
PASSENGER ❑WITNESS❑ UNIT# SEAT I AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.MMDD -❑
YYYY.
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.
J RAYGOZA 07-16-24 10:20 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.THIELMAN 11462 1 8/26/2024 7:02:56 PM
BADGE OR ID# 12503 OR]# WA0171300 TIME POLICE DISPATCHED 7:07 Pry/ TIME POLICE ARRIVED',7:10 PM
PART I PAGE IT]OF 4�
TIME
REPORT NO. EF08772 CASE# 24-6909 OF COLLISION07/01/24 19:00
NARRATIVE
RPD CASE#: 24-6909
On 07/01/2024 at approximately 1920 hours, I responded to SW 43rd St and NB SR167, in the City of
Renton, King County, Washington, for an accident report by phone. Dispatch relayed over the radio
that ten minutes ago a vehicle vs pedestrian accident occurred, and that the boyfriend of the
pedestrian had questions.
I called the reporting party who identified himself as Pisarev, Igor Dmitriyevich DOB (12/30/1995) and
he said that at approximately 1910 hours he was walking westbound on S 43rd St with his girlfriend
identified as Taylor, Colleen Mae DOB (05/24/1991) to get some pizza from The Spot located at 4224
E Valley RD. As they were walking across the intersection of S 43rd St and SR 167 while using the
crosswalk a vehicle unit 1 identified as a gray 2017 Honda Civic WA/LIC CGH3627
VIN#2HGFC2F53HH541519 drove towards them and collided with Colleen causing her to roll onto
the hood of the vehicle. Colleen then fell to the ground after she rolled off the hood of the vehicle and
sustained minor scratches.
The driver of unit 1 identified as Halvorson, Caitlin Mary DOB (06/18/1988) put her vehicle in park and
checked on Colleen and Igor and gave them her information which included her license, registration
and insurance. Colleen said she was fine, and Caitlin gave Igor and Colleen a ride to their home. Igor
decided to call on Colleen's behalf because they didn't know what to do and said they wanted to
report it just in case Colleen's situation got worse. I spoke with Colleen, and she said she still felt fine
but wanted a case report just in case she ended up going to the hospital later. I provided Collen with
the case number and attempted to call Caitlin to get her side of the story, but no one answered the
phone. I was unable to cite Caitlin since I was not at the location at the time of the incident and
because there were no apparent injuries on Colleen. Colleen also didn't want to press charges and
just asked for a case report.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by J. Raygoza on 07/01/2024 at 1930 hours in the City of Renton.
PAGE 3 OF 4
REPORT NO. EF08772 CASE# 24-6909 DATE AND TIME 07/01/2419:00
OF COLLISION
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PAGE 4 OF 4
