HomeMy WebLinkAbout23-4767 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-4767 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4900 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#
cawsloN 04 - 1-- 2023 2058 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
PARK AVE N BLOCK NO. e ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV e N LANDING WAY
0 3 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2062276125 30
6� LAST NAME SIMON FIRSTNAME MICHAEL MIDDLE F 1 2 31
INITIAL
STREET ❑ 25100 74TH AVE S CITY KENT ST WA 2jp, 98033 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO✓ INTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET 2 CLASS 1 NATURE OF INJURIES z❑
3
,OF
P1 ATNES# BWA2704 sTAr WAvN# 1FMFU18L64l654926
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 3 1 33
12❑ vIN#' VIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 1 34
13 3 2004 FORD EXPEDI SD DAMAGE YES NO ✓ YES[:] NO✓
REGISTERED OWNER INFO MICHAEL,SIMON 2318 SW339TH ST FEDERAL WAY WA 98023 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO THE GENERAL 53-WA-6202675 3 4
IN EFFECT &POLICY# 9TOP
vEHlcl.e CHARGE 5 36
LEGALLv Yea❑NO❑ CITATION# 10 BOTTOM
15❑ STAIN,DIINGMOT 8 7 6
UNIT U2 VEHICCLE ❑ CYCLE ❑ PEDESTRIAN ❑✓ OWNER YES
[:]I DYES✓ NO OLD MET PHONE
16 a
LAST NAME LEACY FIRST NAME ALONZO MIDDLE D
INITIAL
17❑ STREET Is❑' 77 S WASHINGTON ST CITY' SEATTLE ST WA ZIP 98032 37
NEW ADOREs
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 F] LICENSE # STATE SEX M M D.C.B. 04 27 1974 39
20 ON DUTY STATUS 3 AIRBAG RESTR EJECT , HELMET 2 INJURY 6 NATURE of INJURIES ❑ 40
USE CLASS RIGHT FOOT
❑21❑ LICENSE TArE 41
VIN# 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
24 1 6 DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I vE."LE ❑ ,J� CITATION# CHARGE
25 GQ
LEGALLY YES N J
s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
JASON TURNER 12650 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED56514
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4767
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
PM 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'
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.
JASON TURNER 04-28-23 03:51 AM
NVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 5/2/2023 2:55:25 PM
BADGE OR ID# 12650 OR]# WA0171300 TIME POLICE DISPATCHED! 8:88 Pry TIME POLICE ARRIVED',8:58 PM
PART Ei PAGE IT]OF 4�
REPORT NO. ED56514 CASE# 23-4767 OF COLLISION
04/27/23 20:58
OF CbLLI510N
NARRATIVE
23-4767
On 04/27/2023 at approximately 2058 hours I was working as a Police Officer for the City of Renton.
While working I was dispatched to an unknown if injury accident the intersection of N Landing Way
and Park Ave N.
The notes of the call stated that it was a vehicle vs pedestrian collision with unknown injuries.
Unit 1:
Driver: Michael F. Simon (DOB: 06/19/1963)
Vehicle: Green 2004 Ford Expedition WA LIC: BWA2704
Unit 2:
Pedestrian: Alonzo D. Leacy (DOB: 05/15/1965)
The accident occurred as follows:
Unit 1 was pulling out of the parking lot of N Landing Way and Park Ave N facing east bound. Unit 1
pulled their vehicle too far into the road exposing their front end to the oncoming traffic of Park Ave N.
Unit 1 began to back up their vehicle to get out of the roadway. As unit 1 was backing up their vehicle,
unit 2 was walking north across the driveway of N Landing Way when the vehicle ran over his right
foot with the driver's side rear tire.
Alonzo reported minor pain to his foot and was able to stand and walk on it. He was evaluated at the
scene by fire and transported to Valley Medical Center by Trimed. Alonzo reported having no phone
number, address, or place where he receives mail. I provided both parties with case numbers for the
incident.
There is no further information at this time.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct. Electronically signed by J. Turner 12650 on 04/28/2023 at 0347 hours.
PAGE 3 OF 4
REPORT NO. ED56514 CASE# 23-4767 DATE AND TIME 04/27/23 20:58
OF COLLISION
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lei
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PAGE 4 OF 4