HomeMy WebLinkAbout23-3795 a ITFFi "POLCERA II IfI) 1 IlfII ('II (Illf If( fI I . 6 27c
COLLISION REP FIT 1591971
CASE 23-3795 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 28
TRIBAL UNITS 02 STRUCK' FENCE
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
CowsloN 04 - 1-- 2023 1153 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE ROYAL HILL S DR BLOCK NO. e✓ 2500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FEET e S B W e PUGET DR SE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4259191853 30
6� LAST NAME MATTHEWS FIRSTNAME JEAN MIDDLE M 1 1 2 31
INITIAL
STREET ❑, 2709 LAKE YOUNGS CT SE CITY RENTON ST WA 2jp, 980583847 z
'NEWADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCK YES No YEs No
8❑ LICIENSE# STATE Wq SEXI F MMDDYY' 07 - 28 - 1949 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 P1 ATNES# BPX5604 sTAT WAv N# YV440MWK1 J2056341
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12❑ VIN#j VIN#
FROmM TO
34
13 VEH.YEAR2018 MAKE VOLV MODEL V60 STYLE VEHICLETOWED0NOOffBLIN TSIgWgYMEYER vOs❑ENo /
DAMAGE IILLJJII (��IV6
REGISTERED OWNER INFO JEAN MATTHEWS 2625 CASCADE PL WAPTD TACOMAWA98466 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCE CO STATE FARM 461 9681-F06-47 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY ✓ DAM THR OLD MET PHONE
UNIT a2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4254307500
16❑
LAST NAME RENTON FIRST NAME CITY OF MIDDLE
INITIAL
17❑ NEW STREETR 1055 S 7 GRADY WAY CITY RENTON ST ZIP ❑ 37
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 U MMDDYY -�_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TATE LICENSE vIN# 41
PLATE#
42
22❑ PIR TRAILER 1 LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO 1GQ
VEHICLE ❑ C[:] CITATION# CHARGE
LEGALLY YES N`LJ
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED48314
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3795
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) CROSS CHRISTOPHER N
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
510 BEACH DR UNION WA 98592 3605151548 SEX M MMDDYyry 01 - 28 - 1988
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
POS. USE CLASS +
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O 8
SEX' MMDDYYYV
PASSENGER []WITNESSO 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'
Unit 1 was traveling northbound on SE Royal Hills DR after negotiating the roundabout at Puget DR
SE. Driver 1 was suffering from emotional distress due to the loss of a family member and was
enroute to the family residence. Due to this distress, Driver 1 suffered from some sort of medical
condition causing her to either lose consciousness or lose spatial or situational awareness. Due to
this condition, Unit 1 continued straight as the roadway curved and drove off the west side of the
roadway, through a fence (Unit 2) and into a brushy embankment disabling the vehicle. Unit 1 towed
by Gene Meyer. Driver 1 treated at the scene by AID with no obvious injury or condition and released
to a family member.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 04-03-23 01:26 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 4/4/2023 9:57:29 AM
BADGE OR ID# 10008 ORI 4$ WA0171300 TIME POLICE DISPATCHED'; 11:56 AM TIME POLICE ARRIVED 12:00 PM
PART I PAGE IT]OF
REPORT NO. ED48314 CASE# ' 23-3795 DATE AND TIME 04/03/23 11:53
OF COLLISION
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