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I '" " , I' , I"" , ,I.!'!' \ "'1 " ,,:! , 'Ii 'ii.' ," r', ',!_'iJ :.t'l\ ,I,' , " , , './, I ,', , ,,)It ,,' , , , II " " h', . ," I' ,,;1/ ;" : I , F F ' \ ~ (I 1 , ' , , 'I, _,' ,J r "I i ,I'i",I';,' ., .Ft: I" , I, I !, I i)li 'i I'" " " \\' ,'1 " " 'j, I' , I ' I ~ 1\ , 'J/;! , " ., , , 'i.,I' ",, , , " ")':' , I ,:" "1'1, q '1,1 ~ , " ,,' :1;", !, " , , ," ,'1' VERIFICATION I verilY that the statements contained herein are tNll an~ correct. I underatand that falao Itateme"tl herein are made IUbJect to the penalties of 18 Pa,C.S,A. 04904, relatlns to unsworn falslflcttion to authorities. ,~~u.Qp C- r )..h-c~cJ/uJ Do"aJd c. Hartman' , , " Date: July ,g. 1996, , , ,., , , I , ' ., , , 'I " , , " 'I II , , itl , , I " " , ' " I " " , ' , , ,I ., (I "-_j ',(' oK I"c. ~t.::.~'-' .~ I ~) :w-;;. NOTIFICATION OF ACCIDENT NORTH MIDDLETON TOWN51HP POLICE OEPARTMfNT I' , 211 Nollh MhJdhJlon fhJBd"~ Cotlllilo, PlJflf16yl'Wonln 17013 :t" Pho".: 1717/ 2~3.7UIO .2.. q n1AY Iff., Dill".. ..,,"._....__.__ ~ REPOAUDLE NOTICE 15 HEREDY GIVEN TflAT rHE ACCIDENT IPENTII'IEO lIELOW IS lIEING INVESTIGATED' DY THE NORTH MIDDLETON TOWNOHIP POLICE oEI'AflMENT AND TflAT TlfE COMMONWEALTH OF PENNSYLVANIA POLICE . ACCIDENT IIEPOI1T WILL DE SUIIMITTED AS PtlESC;I1IOEo UY SECTlOtl 31~O Ie) OF THE VEHICLE CODE, \ II o NON.flEf'OnTAOLE IWTlCE 15 HEI1EIlY GIVEN THAT THE ACCIDENT IDENTlFIEDIJELOW 10 Nor IlEING INVESTlGATEllIlY THE NOI1TH MIODLElON TOWNSHIP POLICE DEI'AfI1MENT AND THAI THE C;OMMONWEALHi OF PENNSYLVANIA POLICE ,ACCIDENT tlEPOIn WILL Np, liE tiUlIMITTED AS I'I1ESCI1II1Eo UY SECTION 37~O ICI 01' THE VEHICLE CODE, L~r4.:;!!~:~\.g.Jk..jf/5 ~..; ~:.!r(?.'1!.(~":.rJ "'J,~.~~~f ((J_d,:,_.~:.:.b_~.f(~..J::~;t_L_____ IIAI OF ,.cetOHI IU~li lOCAIIOfl" ' lJ.au..ilLc_,' ~jl,,-61.rI!,!~_{?'i,~?.I,_s'7.. ~..'J-I-~-73DOIJ L<?!7!!.'!--._ I'tlONI;:J:!.l,-sJ?'/ ~"tllAiOil!i'UJi~ EllAlOHNO 15T,.H;: ClA~!i / 1 .&;)__-,b), ('.;J c.J4.:>tJ.-J ---.t__..Lrj_,:> J;J./p":;k-rJ''''?- _~.,-.___LZ_(jL':;... _ TlTLdEJ.. 7'2 '3~ J 6"'H' ollll", " ell' n1t(. L" . NO<. ,,,.. IU' YEAR/M~KE/I.\onf.L f(ij ~_ s.:_~ ':'.1fJ... o?d ,/LJ~.:: ?-_'i!!.i_____ VIN) U-t[~_,., ~ Z. L7. .I<X.6_ 4/f;-':i/_ , ;:Jt( 1- VEHllF9hO"1)1^1~ I : Pi!. ,IV Qt(;' ulJ ~ I V>J ..,r 1,4' r) !. if') -.5] (;1 IN5URA~CE CO(' A~L':U1"'./ ,~~:. Co>,__.. CODE/_i..:.it:L POLICY :2 ~l 'ID (riA!?' PHONE" - . . OWNER NAME & ADDRESS."..S.I-}. ~~"h__ '" ... ..._. ..:PHONi).1 f....$ 'J~L . ~rJ..ltJY_.1Jl!.W.:!:J.!_-=-_j?.~n'!_J>D I ~h oOU _ PHONE ,,\ , "OIlEIlATon5NAI,IE. ()lII::IlAl,O,t,"'O,IIiIA1E ..... C,~AS5 a.. " I \, '''''''' .' \ j','" ,,'. 2 '6Tlii.-jj ;~)'o~i~~s-..-.":;--_.__.._..._,-_.._._-_J'":J l~~ I. _.,.-. .-....-------'=~/~iA1l.--..-___zi~-.--:-.~--., TITLE'..-~~-.. I'; " , VEA.RIMA,KEJMODEL '__'____ ',,',:,' .;' \ INSURANCE CO. _....:.._...___.__..._. CODE _________ POLICY r , OWNER NAME & ADDRESS p()r;~!!~rLO~r.v.k~.\~L(:Jj.ii!Y:I :fiyI-r~ . .OPERATOR'SNAME O;l','"o,",^" '3 ~--_. (A J!;;j fl.L STREET ADOflESS ... ell' :~~'1 VLI!. IIClJ.i,o',"liYiif"--'-' VIN ) . PHONE ';." c,,,il---- D.OD. t.)~ . -- S'AlIi PHONE l:ll' - TITLE YEAR/MAKE/MODEL Vlll, 11li:l--:-~,'-IT5"'1I: .' -- CODE' ___ POLICY VIN .. INSURANCE CO , , , . OWNER NAME & ADDRESS PHONE 4 " l -~TiTlJn~o.',ij-iATl ) t CITY , Viii" Ill0, NO.& 5lAlIi: ,- , " ~ OP[IIATQf-.5 NAl.l{ . .____ D 0.0 . CLA5~ ~ " ili~EEl ADoii['G~ ,I 5TATE 1111 .1"-.... """" ' I .....VIN.~ ~H'''''''' .. . ___,_. ______ PHONE ~ --;'II1nT," . TITLE YEAR/MAKE/MODE L Wln_.. N",... Add/." W.nMi N..... Add/i" . " INSURANCE CO. _._____.~~' . l' ~ N r. " . _ ___________ L wLlftll' " r n J ,)1, I 'tt.,~~.m", ::'''', ( .... ,,!;./')/i I :," , . , I )o'b''-Zl&,''l2.- . f),~(dH ':,v'" ...r(wJ ~(, S"",~..-r 0"" \>.l",I, ~/~,,, """3 -, .;IiS-2./,SS-r---- 1. 1 CODE,., POLICY PHONE jL_..~ WEATHER " ~ CLEMl 0 SNOW 0 SlEET DRAIN 0 FOG Optlllor SlgnaluIIl') ~ ~~;;:~~~ ,,_ CI,..,....IH". . 4. I ~~~? - .3 ~DRY o WET ROADWAY o SNOW DICE 1';XlfIBI'l' '"A'" " ..l .Ballo. No.'