HomeMy WebLinkAbout04-19-06
Commonwealth of Pennsylvania
Orphan's Court Division
County of Cumberland
In RE: Estate ot Joyce Gustatson Case
Estate File No. 21-05-1102
STATEMENT OF CLAIM
The undersigned hereby presents for filing against the above-referenced Estate this statement of
claim and alleges:
1. The basis of the claims is as follows:
On or about July 28, 2005, Joyce Gustafson Case caused a motor vehicle accident in
Camp Hill, Cumberland County, Pennsylvania, that resulted in the death of Kenneth Wallace. A
copy of the police accident report is attached hereto as Exhibit "A". The Estate of Kenneth
Wallace has asserted Wrongful Death and Survival Claims against the Estate of Joyce Gustafson
Case for the injuries and losses arising out of the accident. The claimants are Barbara J. Myers
and Paul E. Stone, as Co-Administrators of the Estate of Kenneth E. Wallace.
2. The names and addresses of the claimants are: Barbara J. Myers, P.O. Box 311, New
Bloomfield, P A 17068 and Paul E. Stone, 703 Blosserville Road, Newville, P A 17241.
3. The amount of the claims against Decedent exceed Twenty-Five Thousand
($25,000.00) Dollars, exclusive of interest and costs, and are in an amount in excess of any
jurisdictional amount requiring compulsory arbitration. The exact amount of the claims must be
adjudicated. It is anticipated, however, that they exceed the amount of insurance coverage
available under all policies insuring the decedent for the accident that is the subject of this
litigation.
4. The claims are not contingent. However, the amount of the claims must be
adjudicated.
5. The claims are not secured.
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Under penalties of perjury, we declare that we have read the foregoing, and the facts alleged are
true and correct to the best of our knowledge, information and belief.
613 .# ..?
Executed on this / I day of fA I L , 2006
..</~~~
" ("-
Paul E. Stone
".......1 "
I ) /'1.1- /1.. >.<1"
. C~!:L'//"~ !) ,//j/z---'-
Barbara J. Myers V" /
4
Subscribed and sworn to this K day of m1(.../( L
undersigned Notary Public.
/7 ~
.. / 'J C-,
, / /1 LfeC/j" (J 2/.0
if ~Uv if -#~/L
, 2006 before me, the
Notary Public
My Commission expires:
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Robert R. Black, Notary Public
Carlisle Boro, Cumberland County
My Commission Expires Sept. 28. 2009
EXlllBlr-r A
\':~?Q l 05
Police Agency Patrol Zone
~~
Investigation Date (MM-DD-YYYV)
.:4l10 I [ili]-[ili]-~
Badge Number
I~
Badge Number Approval Date (MM-DD.YYYY)
I ~fQIaJ-[~lbJ-~
.~
COMMONWEALTH OF PEl .YLVANIA
POLICE CRASH REPORTING FORM
Case Closed Reportable Crash
o Yes ~ No <Kl Yes 0 No
,cA T"
Page
[ili]
AA 500 1
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Agency Name
I PA $.TA-TE 1'0 t.. I c.';
Dispatch Time (nil) Arrival Time (mil)
~~
Reviewer
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Precinct
II H-/t ~I{.l >n \J i't(.-
Investigator
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LANCr
L...e1N1,::>
County
County Name
1-0
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Street Ending c:
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~~~ti~9 0 Interstate 0 Turnpike 0 Turnpike ~ State
(Not Turnpike) (EasvWest) Spur l6J Highway
~ Route Number Segment (Optional) Travel Lanes Speed Limit
~ ITIIJ DID [[J [[J
'~I Street Name
'"
l::
~!
~ ~.'nnjnn 0 In'ers:ate
".L~ (r,ot Turnpike)
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o County
Road
Street Ending
[[J
o Turnpike
!EastiWest)
o Turnpike
Spur
State
Hghway
O Courty
Road
o
1111111111111111111111111
Crash Number
I
P0923958
~~
o Sun (B) ThJ
o Mon 0 Frl
* If > 00
complete 0 Tue 0 Sa'
Form F 0 Wed 0 Unk
Notify PENtmOTD Yes (V'\ No
Maintenance IC>'
o North
o Souttl
o East
~ West
o Unknown,
~~
lliiIti2.a ~
I .. See Overlav
House Number (Ii applicable)
CIIIIIJ
For Mid-block crashes orly Use
posta! House Number dnd make sure
P'lncipai Roadway Street Name is
!illcd In If JSlng th's option
o Local Road
or Street
o North
c;
.2 0 South
~ 0 East
q, 0 West
(5 0 Unknown
o private
Road
o Dther!
Unknown
~
o Local Road
or Street
Private
Road
o
Other!
U'lknown
o
, '"
1:
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v Please
~l Fnter
0, Inforl-,]atlor>
<ii; for BOTH
'tl: Landmarks
~; if Us!ng N
~ Thl> Option ~
'" E
~ -g
'"
....J
Degree.. Minutes Seconds
7 ~ Latitude:[Lf I 01 [TI]:~.~
Feet
DIIIJ
Or Miles
[[J,D
o~ 0 North
~ 0 South
St Ending ::J 0 East
[[J ~ 0 West
Drstance ~rom Crash
Scene to Landmark 1
(For Crash between
Landmark 1 and
Landmark 2)
Degrees Minutes Seconds
Longitude: ~ [2E] ~ :1 Sl4 I. ~
[rQftiLr;:gJllLQJ .De..l(jce ~ Yield Slgr o Police C'flcer or TIJ:J Functioning
o TraffiC Signal Flagman 0 No Contra's 0 DeVice Functlonir.q 0 Emergency
C o Not Applicable o Active RR Crossin') o Other Type TCD Improperly Preemotlve
8 U Controls Signal
~ o F^ldSlllng Tr,,\I,c o Stop Sign o Passive RR 0 DeVice Not g) DeVice Functioning
Signal Crossing Controls o Unknown Functioning Properly 0 Unknown
~
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'"
o
9 ti
q,
c:
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Lilne.J::l9se2 (If 'Not Applicable", skip rest of the Lane Closure section)
o Not Aool-ci1b'e 0 Partially JZJ Fully 0 Unknown
Lilne~ 0 North
D~ 0 South
Yes @ No 0
Unknown 0
rilltk
Detoured
E~l€ 0 < 30 Mln
030-60 Min 01-3 hrs 03,6 hrs
FORM' AA-SOO 112/lJ21
PENNDOT COpy
o
C&1
East 0 North and South 0 All
West 0 East clr)d We5t (N,S,E,W)
C8:) 6-9 hrs 0 > 9 hours 0 Unknow~
~
COMIVlO\\lWEAlYH Of Lt>>EI\1I\lSVLVANIA
POLICE CRASH REPORTING fORM
AA 500 2
10011(. lto1r - Jl.j q ~ I (""4
;:"AT
Page:
~
111111\1111\11\111111111\111
P0923958
Crash Number
~
o
:f
10
@
o
Pedestrian
Motor Veh,cle in 0 0
Transport 0 Hit & Run VE'1lcle Illegally Parked Legally Parkea 0 Non - Mororized
o Pedestr'ar on Skates, 0 Disabled Fran, 0 Train 0 Phantom Ver-Ide
Ir, Wheelcha", e:c PrevIOus Crash
(If "Pedestrian' or "Pedestnan on Skates, in Wheelchair, ete", Complete Form M, Section 28)
Commercial Vehicle
o Yes ~ No
(If Yes, Complete Form C)
~
Unit
~
to
::l
Unit No
ffi
Last Name
[fIiliJ € I
I Adoress I City I State
~ I \ I <6 l1cx..LY DJ't.. .;V'1~C.I-tArt\c.S ~ ,,.1.6-
E
..
o
....
.:
c::
.!!!
1l -a
ell
."
~ ~!
li,~ Alcohol Test Type
o I C1() Test Not GI'/en
11>'
V! 0 800d
~Ii
> il Alcohol Test Results
'I
II [Q].[I]
\ Owner/Driver OO=Not Applicable
j ,~ 01=Pnva:e Vehicle O\Nned/
! LE~ Leasea by Dri/e'
~~-I=-s- I Owner First Name
ame as :
I Driver (&J ,
Delete)
o
~'"'"
Date of Birth (MM-DD-YYYY)
@E] ~ GIiliJIJ
MI
[g
LLLIllIIIl-lJ
AlcohollDruqs Suspected
c;BJ ~\o 0
o Alcoho 0
illegal Drugs
A'cohol and Druqs
o
o
o
o
Breath
Unne
Test Refused
Tcst Given,
C ontammatec Re;u'ts
Telephone Number
17,,-<&.<17- ~DG.G. I
z'
I~
State Class
I PIAl I c.
o Medication
Driver or Pedestrian Physical Condition
<1?J Apparently 0 Illeqal Drug
Norma I Use
o Had Been 0 Sick
Drinking
o
o
Unknown
o Umnown
o Other
o \dnknownlf
,est Gtven
O Unknown
Results
Primary V€'hic1e Code Violation
13323
Driver Presence
GJ
1 =Dnver Operated
Vehicie
2=No Dnver
D2=Pr,vatc Vchlcle ~:ot
Owned/Leased by Drivcr
03=Rented Vehicle
04=Slale Police Vehicle
OS=PFNNDOT Vehicle
06=Other State Gov Veh
Address I City I State I Zip
I
o
o
Med,cation
Fa:I'~ ue
Asleep
Charged?
o Yes C8I No
3=Dr;ver Fled Scene
4=Hlt and Run
9=Unknown
--L
07=~Y1linl(lpal Police Veh
08=O\her MJnlcipal
Government Vehicle
09=Federal Gov Veh
98=0\ner
99=U"k'lown
Owner Last Name or Business Name (If Pedestrian, skip this Section)
I I [IIJIJIIJ I I I~I I I
Vehicle Make 'Make Code
II ~vl~k j [ill]
(see uverlay)
I
.-M"~IL Ttc-'~/12.1
I
<Xl Yes
ONo
Insurance Company
o ~~WII \1:bVlC(,.Al.. ,.All v N.t\.....
VIN Model 'Year
~ll ! :t.\, [i] 91" 13J ~I 01 '(I
License Plilte Reg. State Est. Speed Vehicle Towed
ClliIf 15rus-Is-1 I \ IT] If \/\ I \ 012\5"1 (19 Yes 0 ~o
Policy No
II PA~OS-7<O:2.o <6
Insuran~!!.
c:
.g
"'I
E'
12 .E
.!:
~
Unit
1= TOWing Pass, Veh 4=MoLJile/Modula~ HOlT,," 7=Semi-Trailer
D 2= Towing TrJck 5=Carnper 8=Othcr
3= Towing .jlity Trailer 6=Full Trailer 9=Unkncwn
Trailing
Unit NO,O,f I:::lO
- Tr'Jd'ngL:::J
~ Unl:s
...
~
II>
>
'Vehicle Position
Direction of rl , I
'rravel "'-J
Vehicle Color Vehicle Type
l~ ~r3'l 06=Yel'ow ~ Ol=Au\omobde
1/:3 07=Sd/er ~ 02=Motorcycle
08=Gold 03=8us
01=Bluc 09=cBrown 04=Smcl: Tr~c<
02=Red 10=Orange (If "02 ", Complete Form
\ 03='/;/nlte 11 =cPurple M, Section 26)
04=Greell 12=Other (If "20" or "21", Complete
0')=8Ia(k 99=cUnknown Form M, Section 27)
iinitial Impact Point
~ OO=Non-CoIIISlon 14=Undercarnage
i~ 01-12~Clock Points 1S=Towed Unit
13=Top 99=Unknown
;::OR~.l r; AA-500 (12102)
'Movement ~
05=Large Truck
06=SUV
07='1an
10=Snowmoblle
11 =Farm Equip
12=Constructlon EqUIp
13=A TV
18=Other Type Spec Vel,
19=Unk Type Spec Ver
Damage Indicator
r:;l O~None 2=Funcconal
~ 1 =M'nor 3=Dlsabllng
9=\Jnknown
PENNDOT COpy
'See
Overlay
20=Unlcycle. B'cyc!e.
T r cycle
21 =Other pedalcycle
22=Horse & Buggy
23=Horse & ~Ider
24= Tra,n
25=Trolley
98=Other
99=Unknown
Gradient
rj'll=level
U 2=Uphill
Vehicle Model
1 C c:N1vt"l y
Towed By
!:JOHNS
Tag No
I
Tag Year
II
Tag St
ID
Special Usaqe
~
1 hcCommerciai
Pa"en'Jer
Carrier
13=Taxl
21=Tracto, Trai'er
n=lwln Trailer
23= Triple Trailer
31 =M odlfied Veh
99=Unknown
OO=Not ,'l,ppI1cabie
01 ~Ftre Veh
02=Amb:Jlance
03=Potice
08=Ot'ler Emergency
Vehicle
11 =Pupll Transport
3=DO'>vnhill
4=80ttom of Hili
5=Top of Hill
9=U'lknown
Road AJiqnment
1 =Straig'lt
2=Curvcd
9=U,'known
OJ
~
COMMO\\JWEAILTH OF PIENNSVl\lANDA
POLICE CIRASH RIEIPORTIi\lG fOIRM
AA 500 2 I Pe;l ce Use Ordl(-\O\ _\ L.I q C; \ b '2...
~'+I
Page:
[ili]
1111111111111111111111111111
P0923958
Crash Number
I
0
..... ~
10 ..:: Unit
..
t:
::l
r\7o, Motor Vehicle in 0 H,'. & Run Vehicle 0 III II P k ' 0' I P k d 0 '1 d
\Cl T r c,sport ega y ar 'ed Legal y ar e Non - IV DtGrlze
o Peccs:rlJn 0 PeUestrlar oc Skates, 0 Disa!JleJ FrJ'lI 0 Train 0 Phantom Vehicle
n \>Vheekha,r, e;c PreViOUS C'ash
(If . Pedestrian " or 'Pedestrian on Skates, in Wheelchair, etc", Complete Form M, Section 28)
Commercial Vehicle
~ Yes 0 No
(If Yes, Complete Form C)
Unit No
101'4\
last Name
D~)~
Address I City I State
1:2~2~ (2ITHCYl., 1+-.....)( ~l"LL(~l..~
I~
I'"
i E I
I] I
~f---
'E I Alcohol/Druqs Suspected
11 ai 00 No 0
1:1
~ II 0 Alcohol 0
- I
MI
o
Date of Birth (MM-DD-YYYY)
~ ~ [/ I~ l~ 1:<.\
Telephone Number
LLLLLCIJ I UN k.
-I
z-
I ffiJill
l'legal Drugs
Alcohol and Drugs
.....
..
>
"i:"
011
If I
I~
Alcohol Test Type
G8J T est Not Given
o Blood
o
o
o
o
Breath
Urrne
Alcohol Test Results
[]]. IT]
Test Refused
Test Given,
(ont.:m:ntlted ReSults
Owner/Driver OO=Not AppllcaDle
~ 01 =Private Vehicle Owned/
L::J3J I eased by Drrver
PA
State Class
I PIAl I A
o Meclcation
o Unknown
Driver or Pedestrian Physical Condition
G?J Apparently 0 Illegal D'ug
Normal Use
O Had Been 0
Drinking Sick
Med:catlon
o
o
Fatigue
o
o
A,:eep
U~rnown
o Other
o Unknowo if
Test Given
o Unknown
Results
Primary Vehicle Code Violation
I
N'tJ~ 6
Charged7
o ]'es 0 No
Driver Presence
OJ
02 ="rlvate Vehicle Not
Owned/Leased by Dnver
03=Rentc,j Vehicle
04=State Police Vehicle
05=PENNDOT Vetl!cle
05=O:her Sta:e Gov Vel',
OhMuniClpal Pol,ce Veh
08=Otr.er tvlunlcipal
Government Vehicle
Insurance
In~urance Company
o ;;~wn I A (E Am&'/1.l '-"'" r-(
~ @ Yes 0 ho
I :.;i
III
E
11 0 Trailinq
1: I Unit No, cf OJ
-1- Tral'lng
~ I Units:
.~ I
~ Direction of I w I
rra vel
1 =Driver Operated
Vehicle
2=No Driver
3=Diiver Fled Scene
4=H,t and Rur
9=UnkrI0'.h'n
--L
Vehicle Make *Make Code
I1:,Tl:~r0rrONAL 'I ell( J
Model Year Vehicle Model (se'e overlay)
~ I qLJOO DAy L/1"f]. I
Est. Speed Vehicle Towed Towed By
I 0 [sk.l I 00 Yes 0 No IhKS }/ICr>;.Il- 12C:~Iv1. I
Policy No
II rSAH 07S4 23.2\ I
'Movement 0IJ
05=large Truck
06=SUV
07=Van
10=Snowmobile
11 =Farrn EqUip
12=Construcllon Fqulp
13=ATV
1 8=Other Type Spec Vel',
19=Unk Type Soec Veh
Damaqe Indicator
r-::;l 0= None 2 =Fu n ct:ond I
~ 1 ~rvll~or 3=[)lsabl'ng
9=Unknown
PENNDOT COPY
~
Unit
1= Towing Pass. Veh 4=lv1obile/Modular Horne
o 2=Towing Truck 5=Camper
lZ.J 3= "-owir,g Utility Trailer 6=Full Trailer
Tag No Tag Year Tag St
I fT70B4 J) 11.200~1 [E]
\Cl,\.,o~
J: HS.
7=Seml-Trill!er
8=Other
9~Unknown
*See
Overlay
Special Usaqe
@IJ
12=Cornmerclai
Passen1er
Carrter-
13= Taxi
21=lractor Trailer
22= TWin Trailer
23=Triple Trailer
31 =Modified Ve:1
99=U~~nown
. Vehicle Position
~
Vehicle Color
[ili] 06=Yellow
""3 OJ=Srlver
08~Gold
D9=Brown
10=Orange
11 =Purple
l/=Otr,er
9c::=Unknowr i,
Vehicle Type
~ OI=AutomoiJilp
~ D2=lv1otorcycle-
03=Bus
OibSmal1 Truc~
(If "02", Complete Form
M, Section 26)
(If "20' or "21 ", Complete
Form M, 5ectio(127)
01 =B',ue
02=Red
03=Wh,te
C4=Cireen
C:5=Bldck
Init/a/lmpact Point
r:-T"7I GO.=Non-Col'lslon
~ 01.,/=Clock POints
'3=Top
14=Underca'fl2ge
15= TOeled Unit
99=UnKnovin
f=OP.M # AA-500 {12:'02',
lO=Uf1lcycle, BIcycle,
Tricycle
21 =Other Pedalcycle
22=Horse & Buggy
23=Horse & Rider
24= T ra",
2 5= Trolley
98=Other
99=Un~,nown
OO=Not Applicable
01 =Fire Veh
O/=Ambulance
03=Polrce
08=Other Ernerge~cy
Vehicle
11 =Pupil Transport
Gradient
fill =1 evel
~ 2=Uphiil
3=Downhill
4=Bottom of Hill
S= Top of Hili
9=Unknown
R.oad.A./iq n~en ..t.'.J
n 1 =)traIC;ht
~ 2=CJrved
9=lJnknown
.~
COMMONWlEAlL1~ Of PIB~I\JSVn..VAI\JIA
I?OUC[E CIRASI-a RIEIJ)ORTiI\JG fORM
1 Po6c< IMOntto\_14 ~ q \ (.:, 2..
MSOOC
Unit No
@0
Carrier Name
c
o
+:
'"
E
o
-
.5
C!I
23 ~
USDOT#
~17l41
.s:.
C!I
>
i]
...
.
(!)
el
Ell
0,
v
d
Ca/"QO Body TVDe
o Not Applicable
00 Van/Endosed Iklll
o Cargo Tan:t
Hazardous Material
o Yes 00 No
Release Indicator
Unit ~o
IT]
Number of Axles
~ (Code Number of Axle,
~ or '99' for unknoWll)
Page;
0il
@ New
1111111111111111111111111111
Crash Num~
I
(,AI
Change/
'--" Contin uation
Carrier Phone
([l[ili])~-~
GWVR
~
Oversize Load
o Yes @ rI.'o
o Un!mo=1
State Zip
~~ITill
PUC #
Ii
ICU
ITTlTTTrTl
o Flat Bed
o Dump
o Concrete Mixer
o Auto Transport
o Garbage/Refuse
o Bus
o Other/Unhnown
Vehicle Confiauration
o Not Applicable
o Passenger Car - Only Record if
HazMat Placard Displayed
o Light Truck (Van, Mini-Van, Panel,
Pickup or SUV with HazMat Placard)
o Single Unit Truck (2 Axles, 6
Tires)
o Single Unit Truck (3 or More Allies)
o Single Unit Truck (Unknown
Number of Axles)
o TrucklTrailer(s)
o
C&
o
o
o
o
o
Truclt Traaor (Bobtzil)
Tractor/Semi- Trai!er(s)
Medium/Heavy TlUID.- Cannot
Classify
Small Bus (Seats !)"15 ~1I:2.
Including Driver)
Bus (Seats P:'ore 1Mn 15
People. Indudin!! the Driver)
Other
Un!mown
~ ~ ~
2 - Release Occurred 9 = Unknown
Number of Axles
IT] (Code Number of Axles
or '99' for unknown)
I
I
d"IIJ) ITIJ-II IUI. ell
city
ITIJT1T1
Enter 1-digit hazardous material class
'7 '7 '7" '7
DODD
D D D D
~
, - No Release
I
c!
0'
'.;;1
I el
I ~,
, 0:
111
-31
L3 L~
01
>
I~I
'"u
\ ~ i
I.., I
E.
E
o
v
CarqO Body TVJ)e
o Not Applicable
o Van/Endosed Box
o Cargo Tank
Hazardous Material
o Yes 0 No
I
, '\
! I
~"N"'"d'at..
1'0= a AA-5:::c(t2llll)
GVWR
ITIIIIJ
Oversize Load
o Yes 0 reo
o Unhnown
State Zip
l---OTTJTTTTI CD ITIID ITill
ICC #
PUC #
o Flat Bed
o Dump
o Concrete Miller
o Auto Transport
o Garbage/Refuse
o Bus
o Other/Unknown
Vehicle ConfiQuration
o Not Applicable
o Passenger Car - Only Record if
HazMat Placard Displayed
o Light Truck (Van, Mini-Van, Panel,
Pickup or SUV with HazMat Placard)
o single Unit TrUCK (2 Axles. 6
Tires)
o Single Unit Truck (3 or More Axles)
o Single Unit Truck (Unknown
Number of Axles)
o Truck/Trailer(s)
o
o
o
o
o
o
o
Truclt Tractor (Bobtail)
Tractor/Semi- T railer(s)
Medium/Heavy Trud: - Cannot
Classify
Small ~ (~ats 9-'5 Pe1lp!e.
Including Drhter)
Bus (Seats More Than 15
People. Induding trn! Driver)
Other
Un\mown
Enter l-digit hazardous material class
'7 '-7' '7 '7
D D D 0
D D D D
~ L:::,. ~ L:::,.
1 ,; No Release 2 = Release Occurred 9 = Unknown
~EII!~DOT CO~Y
~~=="':""-::::::"'="'~-,--_..._~=~..;....,,--~
(g) 1\1otor Vehicle In 0 Hit & Run Vehcle 0 Ilie')<l\:Y Parked
Transport
o Pedestr'l<ln 0 Pedestnan on SKates, 0 D,sabled From
In Wheelcl1d!r, etc Previous Crash
(If "Pedestrian' or . Pedestrian on Skates, in Wheelchair, etc', Complete Form M, Section 28)
First Name MI Date of Birth (MI\1-DD-YYYY)
[] ~ @E EITIill]
~
..J
COMMONWEA.LTH Of PENNSVLVAN!A
POn..ICIE CRAS~ REPORYlNG !FORM
AA 500 2 I ?O'iCO v,,, 0'\6 \ - 14 0.. ~ \ I.. 1...
0 ~
-
10 E Unit
:!:
c::
:;,
Unit No
ffi
~1
<R) New
Page:
I [ill
D Change!
Continuation
III lllll III I \\111111 \ IllllII
Crash Number
--,
o Legally Parked 0 Non - Motorized
o Train 0 Phantom Vehicle
Last Name
D~e? ~ll ifll~ \.e I
c:: Address! City! State
'~ \ C)~ q /,...}"".....pL C~ L H
E, Driver license Number
] \ Q :s I (, I Co E13 I 51
~i-
'S i AlcohollDruqs Suspected
~\: 00 No 0 lilegal Drugs
"tl'
~ Ii 0 Alcohol 0 Alcohol and Drugs
,~II Alcohol Test Tvpe
oil ~ Test Not GiVen
0"
-.:; I: 0 Blood
";: l
g i: Alcohol Test Results
il [ill. CD
I
U C""'SyY71 rfSrC~
".M'>
Commercial Vehide
~ Yes 0 No
(If Yes, Complete Form C)
Telephone Number
I 4/0 - eLr'IJ - 2::2./ ~ I
Z'
I~
State Class
12~1~ 14~I_AI)I Dj I A
o Medtcation
o Unknown
Driver or Pedestrian Physical Condition
@ Apparently 0 Illegal Drug
Normal Use
o Had Been 0 SICk
Drinking
o Breath
o Urine
o
o
Test Refused
Te:>t Given,
Contil!llin2ted Results
o Other
o Unknown ii
Test GJ\,Ien
O Un,nown
Results
Primary Vehicle Code Violation
;VO/t
Driver Presence
1 =Dfiver Operated
Vehicle
2=No Driver
OJ
OwnerlDriver OO=Not Applicable
r:::r:=:;l 01 =Pflvilte Vehicle Owned!
~ Leased by Driver
02=pri'/ate Vehicle Not
OWfiedlLeased b't Driver
03=Rented Vehlc'e
04=State Police Vehic:e
05=PENNDOT Vehicle
06=Other '>tate Gov Veh
Insurance
. 5 00 Yes 0 No
:.;:;
'"
~, TrailinQ
121 C:..\ Unit No of [Q]
-; TraJlna
, 2. units: -
v
~
~, Direction of Q
I Travel ~
!lEE.
Unit
1 = T OW'f1Q Pass. Veh
O 2ooTovv,nQ Truck
, 3oo"jOWl!lQ """. Traler
'Vehicle Position
Vehicle Color
[ill] 05=Yellow
o cr I 07=Silver
08=Gold
09=Brown
10=Orange
11 =Purp Ie
12=Other
99=Unknown
Vehicle Type
r::::r:::::=l 01 =Autornobi\e
~ 02=Motorcycc
(B=Bus
04=Smdll Truck
(If "02", Complete form
M, Section 26)
(If 420" or "21', Complete
Form M, Section 27)
01 =8lue
D2=Red
03=Whlte
04=Grecn
05=Black
o fatigue
o Asleep
Medication
o
o
Unknown
Charged)
DYes 0 No
3=Drlver Fled Scene
4=Hlt and Run -L
9ooUnknowfI
07=Municipal Police Veh
08=Otr,er MuniCipal
Govcrnment Vehicle
09=Federal Gov Veh
98=Other
99=Unknown
~ - c __ _ _ __ _ .I
Owner Last Name or Business Name (If Pedestrian, steip this Section)" " i
~r<\S I;:> \0 lo.lT\A ~!
~Ma~(e Corle'.
I ffi[]i
(o;ee overlay) I
III
I
I
4=Mobile/Modular Home 7=Semi-Trailer
5=Carnper 8=Other
6",full Trailer 9=Unknown
'Movement ~
'See
Overlay
: ~~~:rab~lio~~'e~ Fi~ Na;;'e
il Address I City I State! Zip
(!I/)..SO yo....k S;, HArtOl/en PA 173~ I
1\ VIi'! Model Year
;:[Sl~ \41~'I \3131~ I~ [iliJO l<t I
, License Plate Reg. State Est. Speed Vehicle Towed
'I N Y [EE] lo\o~ DYes (BNo
05=LanjC Truck
06=SUV
OI=Van
\O=5nowmobile
11 darrn Equip
12=ConSlrucll0n EqUIp
13~A TV
18=Other Type Spec Veh
19=Unk. Type Spec Veh
20=Urllcycle, Bicycle,
Tricycle
21 =Other Pedalcycle
22=Horse & Buggy
23=Horse & Rider
24=Traln
25=Trolley
98=Other
99=Unknown
Initial Impact Point Damaqe Indicator
, ~D '-1 OO=~lon-Coll'slon l'l=Undercarnage r;-] O=None 2=Functlonal
U~__D:~El;::o~ncs_"~~~:~~~~~~~tc__ "~~ loo~~~~rkn~:~~~~lm~__
Gradient
III klevel
U 2=Uphlll
FOFe 0 AA"5C~[; (.2;1)2)
;'>;::;~;\'!DOT COpy
Vehicle Make
II Wu.,-k.h ~.::
Vehicle Model
I '/K
Tag No
I
Tag Year
I \
Tag St
ID
Special Usage
~
12=ComrnerClal
Passenger
Carrier
13=Tax\
21=Tractor Trailer
22=Twin Trailer
23=Tflp!e Trailer
31 =Modified Veh
99=Unknown
OO=Not Appllcahle
01 =Fire Veh
02=^rnbulancc
03=Pollce
08~Other Emergency
Vehicle
11 =Pupil Transport
3=l)owrJhi:1
4=Bottorn of Hill
5=Top of Hili
9=Unknown
Road Aliqnment
1 =Straight
2=C urved
9~U0kllow'1
QJ
--.J,
11111111111111111I1111111111
P0923958
I
~AI
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 3 l:::fr6
(-(Lt<i<;\"'2....
Crash Number
Page
~
A Perso~
l=Drive,
2=Pa'a~nger
7=PrdCS1f1dn
8=Other
9~Unknown
Seat PosillQ[!
D OO=NOl [\ Pa\5enger/Occ~pant
o 1=Or:'le' . Ail Vehicles
02=Front Seat Middle PO,l'on
03=Front Seat RIOhl, SldC
OI\~Second Row ~ left Side Or
Mo~orcycle Passenger
05~Seco"d Row. Middj.o POSition
06=Second p,ow . Rig~t S,dC
Oh Thtrrj RUN Or Greater -
Left Side
08= rrlir-d Rovv Or (~reater -
Mldd'e POSition
DJ= T'Irr() ROVJ Or Cre~~ter
Rig!",t Side
'IO=S\etlper Sec1"lon of TruckC3b
11 =In Other Fnclosed
f'as'icncj'::r Or Cargo Acea
12=1'1 Cpen Area
(B2lck Of Pickup, Ete)
13=Trdl:lnq tJ.'1it
14~Ridl,-,g'On Ve~llcle Fxtcr;or
15~Bus P,lssenne'
98=Other -
99::;:"LJ'lkn{)\tvn
Sslktv faUloment Q~
E OO=None Used / Not Applicable
o 1=Shoulder Belt Used
02=Lap Belt Used
03=Lap And ShoJlder Belt Used
04=C hid Safety Seat Used
05=r'/lotorcycle Helmet Used
Of)=Blcycle Helmet Used
10=Safety Belt Used Ir"properly
11 ~Child S"fety Sed, Used Impropery
12=Helrne' Used Irnproperly
90=Reslrdrnt Used, Type Lhkno'\"l
99=UnknOI..vn
DroL0l
G O="-Jot Applicable
1 =Not flected
2= Totally Elected
3=Partla1ly EJeckd
9=Unhown
H !'jl;sJion F'~Lf1
O=Not Ejected / Not Applicable
1 = ThrOI.J<Jh Side Doof Opening
2=ThrOJgh Side Wwdow
3-= ThroJgh Windshield
4~ ThroJgh Back Door
5= ThroJgh Back Door Tailgate Opel'illg
6= Thro,Jgh Roof Open:n~ iSUYOO:/
c.onvertlble Top Down!
7=ThrO'Jqll Roof Openil,cj (Corr<ertlble
Top Up!
9~Unknown
5~~
B f =Fe'"r'iJlc
M d;lale
:J =Unkr-:ol/V'l
CI
0'
,-'
..
III
E
o
...
f
"
Q.r
0,
~I
Sa ("IV fg'dIQ.'T1enr T vO/o
F OO=Nonc Used / Not Appllca'c!e
01 =front Air Bilg Deployed (for This Seat)
02=Slde Air Bag Deployed If or This Seat)
03=Other Type A'I Bag Deployed
04=Multlple Air Bags Deployed
05~Motorcyrlr ty" Protect on
06=BlcycllSI Wear ng Elbow/Knee/Pads
10=A:r Bag Not OerJloyed, SWitch On
11 =A,r Eaq ND: Dep'oyed, Switch O:f
l)=Alf Bag Not Deployed,
Unk Switch Settrng
1 3=Air Baa Removcd (Prior To Crash)
19=Unk~ovvn If Air Bag Deployed
99~Unknown
iDJ/.r~/ S~ven t.;
C D=No' I"Jured
l=Killeu
2=MaJDT lilJY!
3=Moder":l'
Injury
4=iv.lnCf
3=!nj-Jry,
~e\lerlty
9~lhk"o'i'" If
InJurv
~
I fo.tfl_w.02ri
ll=Not '\ppllcab'c
1 =Not [xtricdted
2=Extrlcated 8y Mec~a~icai ~Aeans
3=Freed By r';on - Mecran'cal Hedl)\
8~Other
9=U\\KnOWI'.
I
I II
1:-)'
Jl EMS Agency: lUmP
~=
I
I Medical Fadlity: I N)A
jf,l!
{;}1 ~
Unit No
ill
Date of Birth (MM-[)[)-VYYY) ABC D E F G H I
[ill- ~ - [ili[ili] [JJ [f]@] 0iJ ~ ~ ~ [Q] @]
Person No I 1
~ Deete,
~O
Name / Add ress Y Phone
[)Cj Same as \
" Operator:
I EMS Transport
o Yes C1() No
Date of Birth (~AMi)D-YYYY) ABC D E F G H [
D~te1 02J-QjJ-CUiliEJ[Q8J[JJ~~B0~~
Unit No Person No
~~
Name / Address / Phone
[}C Same as I
Operator
I EMS Transport
aYes @No
Unit No Person No Date of Birth (r.~M.DD.YYYY) ABC D - - E F G 'H'c~r=
0iJ ~ D~te? IT]- E - LEliliJ [C] l2J @] [ill [ill] ~ QJ ~ [1]
NafTle / Address / Phone
rYiJ Same as I
' '(-~ Operator
I EMS Transport
, DYes ~t,o
Date of Birth IMM-DD-YYYY) ABC D - E F C; - H -{=
D~te? ITJ-ITJ-ITIIJODOITJ[IJITJODD
Unit No Person No
ITJ ITJ
Name / Address I Phone
o Same as I
Operator
I EMS Transport
a Yes a No
Date of Birth (MM-DD-YYYYj ABC D f: F G H I
D~te7 ITJ-[I]-ITIIJDDD[IJ[IJ[I]DDD
Unit No Person No
[IJ ITJ
Name / Address / Phone
o Same as I
Operator
1 EMS Transport
a Yes 0 r.;o
Date of Birth (M\1-DDYiYYi ABC D E F G H I
D~te? ITJ-ITJ-ITIIJDDDOJITJITJDDD
] EMS Transport
_ 0 Yes 0 No
Unit No Person No
ern
Name / Address / Phone
o Same as L
Operator
FORM' AA.500 (12/0:/)
PENNDOT COpy
.--1
COMMOllJumEAILrn OIF lPr8\li\lSVl\lANIA ~T
POllia CRA$~ L't1E1X>[;{TI"IWG fORM
AA 500 4
I PolICe the qn';l -
!1'01-1L( Cl ~ \ lo '2..
Crash Description
c:
~ ~:
E .~ Relation to Roadway
.2 ~
c
15! ~ ~ I Illumination
I ~ ~I
'\ ~ ~ I Weather Conditions
I a; E
II.? ~
I Road Surface Conditions
1-.Dayllght
2~Dark - No
Street lights
1 No Adverse
Conditions
2~Raln
I
8 !
j .2
111;;!
, E I
I ~\
en
.~I
:;]
E
c
o
u
Possible Vehide Failures (V)
OO=Non(' 06=Exhau51
01 = Tires 07=Headlight5
02=Brake System 08=Signa\ lights
03=Stet'nng System 09=Other Lights
04=Suspension lO=Hom
05=Power Train ll=Mlrrors
~~n ~ 1 ffi 2 IT]
~~it~1B2IT]
2-Head On
3=Rear to Rear
(Backing)
3-Dark Street
Lights
4-Dusk
3=SI8Bt (Hail)
4-Snow
12=W'pers
13=Drlver Seating/C ontrol
14=Body, Doors, Hood, Etc
15=Trailer Hitch
16=Wheels
17 =Airbag5
18~ Trailer Overloaded
19=Unsecur,,/shlfled
Trader load
20=lmproper 10wln9
21 =Ob,lructed Windshield
99~Unknown
I. i Indicated Prime Factor Unit No facto! Code
I Do ""I "pl'<1' InO "IOon,1\,,](1 0f1 ~I r;r;:1
t9 nlultlplf' roilqes ~ LW
U,I E / R V D P
II _ ~_~ c:-~~ _ 0 __~ '!r::: ~~~~~ 0:~~~~ar,~~k
FOR.J 0 AA~Y.lt2lK2)
Page
[ili]
~ New
1111111111111111111111111111
CrClSh ~J=
I
_ Changel
'-..) Continuation
4~Angle
5~Sideswjge
(Same Direction)
6=Sideswipe
(Opposite DirectiOn)
7-Hit FIXed Object
8=t{1 Peltas!rian
~
5~Outside Trafficway
6~ln Parking Lane
7=Gore (Ramp Intersection)
9=Unknown
5-Dawn
6=Dark. Unknown
Roadway Ughbng
5=Fog
6=Raln & Fog
8--0ttle r
7=Sleel & Fog
8--0ther
~
4~Slush
5=!ce
6=lce Patches
7=Water: Standing
or Movmg
&O:her
30coHrt Fence Or W;i1
31=Hit Building
32=Hlt Culvert
33~Hit Bridge Pier Or Abutmw
34=Hit Parapet End
35=Hit Bridqe Rail
36=Hit Boulder Or Ollsta:Ue
On Roadway
37=Hrt Impact Attenuator
38=Hrt Fire Hydrant
39=Hrt Roadv.ray Equ'~T.51t
40=Hlt Mail Box
41 coHit T raffle Is!<lnrl
42=H,t Snow Ban~
43=H,l Temporary ConstrL..'1iun
Barrier
48=Hit Other FIXed O~&t
49=Hit Unknown Rxed Oh'&\
50=DvertumlRo:IOvi'f '
51=StnucX By Thro;:m Or F;C~
Object
52=Pot Holes Or Ott:v
Pavement Irrl'9u!a:it:15
S3coJackntfe
54=hre In Vehide
58={)ther !'ion-<:: o~:';S'on
99= Un known Harmful hent
=
17=CMe\ess Or ~l'Ca!
Backing On Ro~d~'_<r;
18~Driving On The Wr=g
Side Of Road
19=Making Improllff
Entrance To H:gh\':<J}'
20=Making ImprQtn'r Em
from Highway
21 =Careless Paric:inglUnparting
22=OverlUnder
C ornpensation At Cum:'
23=Sp('('(jing
24=Dnving Too Fast
For Conditions
25~Failure To Ma:nta:n Propl'T ~
26=Driver Reeing POCa> (Pel Ch.=)
27=Driver Inexpffiena>d
28=Failure To Use ~ Eqlip
92=Affected By Physical Conrl:-t:Jn
98--Dther Improper OJw.JUj Acfuns
99=Unl::nown
-1
~~jt ~ 1
[ill] 2
[iliJ 2
IT] 3m om
IT] 3 IT] om
Pedestrian Action (P)
OO=None
01 coEntering Or Crossing At
Specified Location
I' D2=Walkin9. Running, Jogging,
Or Playing
I
I
I
I
Unit No IT]
OhWomng
()4." Pushing V ehid<>
05=ApprwchiT\{j Or I..eil'i.ng Veblf'
06=Wor.:'T\{j On Vehile
07 coSt3l\ding
98=Other
99=Unknown
IT] Unit r:oIT] IT]
P~i\:;\!DOT COP'!
. '~----=C=~_=~.'___. __'~-=-
12~Wlpers
13~Dnver Seating/Control
14=Bodv. Doors. Hood. Etc
IS=Tral[er Hitch
16~Wheels
17~;"I(bags
18~ Trailer O,erloaded
19~Unse<::ureJShifted
~ ITJ Trailer Load
~ 2 20~lmproper Towing
21 ~Ob5tructed Windsnle!d
I rn CD ITJ 99~Unknown Pedestrian Action (P) 03~Workjng
: ~:'t 1 2 OO~None 04~Pushlng Vehicle
01=Entering Or Crossing At 05=Approaching Or Leaving Vehicle
'I Specified Location 06=Worklng On Vehicle
I lyu[;'Gred Prime Factor Unit No Factor Code 02=Walklng, Running. Jogging, 07=Sta"dlng
; On nu' r"V"ot tIllS .nf"ffid!Jon on IT] IT] Or PlaYing 98=Other
0: I ~~~ D P IT] IT] 99~Unknown
LL=' -C") . C)_~_~1;::' Je~;: i!.:"~:'::~;,~~~... J . "0" No ~..~.~_ _~"O" NO[I] CD
rnr::l 0 ,"..'\.4-~tJ2l'02l - _n= C-,~~==~~
l-3":~':J:J7 CO~Y
.--1
CODJJ\\)JO~U~ OIF l?b\lI\lSVl\!AI\lIA
~n.oC!E iCMS~ [li[EIM)Lltlfl\\lG FORM
I Po!ice 1Jse.9.\1lY
1ft DI-ll-(qq \ (P"2..
,::'A'l
Page
lol~1
M 500 4
Crash Cksai tio 0 O"Non-Collislon
<: _~ 11 n hRear End
.2 ~
.... "
I_~o ~~~ Relation to Roadway 0 '"On Travel Lanes 3=Median
_ 2"Shoulder 4=Roadslde
.5t
'S, ~ ;'l Cumination 0
I b ~ I
'1IIHli::rl=_ loi "DO
I=Wet
rl,"~;,:8~J8M:'~
,\1 III P:-easePvt []] 0 0 ~
fV2n1'> in 3 ~
:I~il~~~alll[]] D 0 ~
t~i\bli ~
II i II Hann Event L/R Most? Utility Pole Number
.e\l 1[]]Do~
li,irn,o:J 0 0 ~.L.LJ
',. e,! ITIITITI
'i\'~11 Pi=tJ~ 3 ITJ D 0 ITIITITI
~ll'l 'b'':;~' , o:J 0 0 ITIIIIIJ
I first Unit ~~o Hann Event Mort Unit No Harm Event
[H,umfu/ CD o:J Harmful ITJ [I] \
17\! ,i ~~n~ ~~~(~~h i
~I_l:_ 00 not repeal th6 Inft)fmatK>n 00 mul!..:pie pJge5
r-I
I I
I
2=Head On
3~Rear to Rear
(Backing)
1 Daylight
2~Dark - No
Slreet Lights
LNo Adverse
Conditions
2~Rain
3_0ark - Street
Lights
4"Dusk
3=Sieet (Hail)
4--Snow
2=6TInd, Mud, Dirt,
3=Snow Covered
I
I
0,' \
i~
I ~j
'ill
\~
, -D
I,l
frllflronmfflfiJll ROiIdway
Fll:Pmial FiKtOrS (fIR) 1
OO=None
01~Windy Condition5
02~Sudden W€illher Condition5
03=Other Weather Conditions
04=De€r In R()(ldway
OS--Dbstade On ROildway
O&=01her An'1m31 On Roadway
07=Glare
08=Worl:: Zone Related
[J] 2ITJ 3[I]
11 =Sllppery Road Conditions (Ice/Snow)
12=Sub5tance On Roadway
13=Potho!es
14=Broken Or Cracked Pavement
15~ TeD Ob5tructed
16=5011 Shoulder Or Shoulder Drop Off
n=Othel Roadway rac\or
29=Other Envlronrnental Factor
99=Unknown
FtlSSib!e '1ehide Failures (V)
OO=l\.'Ol1c 06=Exhau;1
01dires 07=Headlight5
02=Bra~e System 08=Slgflal Lights
OJ,oSteering Syslem 09=Dther Lights
04=S~on 10~Hom
05=f'0wer Train 11~Mlrrors
~it ~ 1
L
rZi New
ml II UIllll\ II\tltll~I'11
p
Crash Number
I
CJ Changel
Continuation
4=Angle
5=SideswiQ€
(Same Direction)
5=Oulslde Trafficway
6~ln Parking Lane
5-0aw1'l
6=Dark - Unknown
Roadway lighting
5=Fog
6=Rain & Fog
8~Hit Pedestrian
6~Sideswipe
(Opposite Direction)
7-Hit Fixed ObJecJ
9 O1herfUnknown
7~Gore (Ramp Intersection)
9=Unknown
8=O\her
7 ~Sleei & Fog
8~01her
9=Unknown
6~lce Patches
7=Wa,t\Jr: Standing
or MOVing
Harmful Events (Harm Event) 30=Hit Fence Or Wall
01=Hit Unit 1 31=Hlt Building
02~Hit Unit L 32=Hlt Culvert
03=Hit UnI\ 3 33=Hit Bri\1g.; Pie, Or /l.butmeflt
04=Hlt Unit 4 34~Hlt P~rdpet End
OS=Hit Unit 5 35~Hlt Bndge Rail
06=Hit Other Traffic Unrt 36=Hlt Boulder Or Obstacre
07 ~H it Deer On Roadway
08=Hlt Other Animal 37=Hlt Impad At1enuator
09=ColLslon With Other Non 38=Hit Fire Hydrant
Fi~ed Obect 39=Hlt Roadway Equipment
II =Struck 8y Unit 1 40=Hlt Mad Box
\2=Struc~ By Unit 2 4\=Hi\ Tratfl\: Island
13"Struck By Unit 3 42=Hlt Snow Bank
14~Struck By Unit 4 43=Hit Temporary Con51ruction
1 S~Struck By Unit 5 Barrier
16"Struck By Other TraffiC Urit 48=Hit Other Fixed Object
21=Hlt Tree Or Shrubbery 49~Hit Unknown Fixed Object
22=Hlt Embankment 50=OverturnIRoll Over
B=Hrt Utility Pole 51 "Struck By Thrown Or Fa!ling
24~Hlt TraffiC Sign Object
25=\-\i\ Guard Rail 52=Po\ Ho\es Or Other
26=Hit Guard Rail End Pavement Irregularities
27=Hlt Curb 53=Jacknlfe
28=H.t Concrete 0, 54=f:re In Vehicle
Longltudlna! Ba,rier 58=Other Non-Collision
29=H,l Ditch 99"Unknown Harmful Event
4=Slush
5=lce
8=Other
Driver Action (0)
OO=No Contributing Action
0', =[)mer Was [)is\Tac\eo
02=Dnv,ng Using Hand Held Phone
03=Dnvlng USing Hands Free Phone
04=Maklng Illegal U-Turn
05=lmproper/Care:ess Tur;'lng
06= Turn:ng From 'Nrong Lane
07=Proceeding W/O
Clearance After Stop
08=Runnlng Stop Sign
O'hRur,n:ng P.ed tight
1 O=Failure To Respond To
Other Traffic Control DeVice
11 = Tailgating
12=Sudderl Slowing/Stopping
13=lIlegally Stopped On Road
14=Carele55 Passing Or Lane
Change
1S=Pas5ir.g In No Passing ZOf\e
16=[)ilving The Wrcl1g Way Ol'l
l-Way St'eet
~~it ~ 1
~~
17=Careles\ Or Illegal
Backing On Roadway
18=DrNtng 011 The Wrong
Side Of Road
19=Makmg Improper
Entrance To Highway
20=Makil1g Improper EXit
from Highway
21=Careless ParkinglUnparking
22~OverlUnder
Cornpensiltlon At Curve
23~5pe~dln9
24=Driving Too Fa,t
For Condltion5
25=Failure To Maintilin Proper Speed
26=Driver Fleeing Police (Pol Chase)
27 =Dnver Inexperienced
28~Fatlure To U5e SpeCialized EqUIp
92=Affected By Physical Condition
98=Other Improper Driving Action5
99=UnknoWll
-1
[ilil
Unit CD
No
2m 3 [I] 4[I]
1ITJ 2m 3ITJ 40]
--'
COMMONmflEAL YIH m: \O!E\\H\lSVIL v A\\lIA
I?OUCIE C~Si11lR\EPOlail\\lG ~ORM
AA 500 F
~A-r
Road Surface Type
o Brick or 810ck 0 Dirt Special Jurisdiction 0
2~1 (V'I Concrete SI G I "" No Special 0
<p.; 0 ag, rave or 0 Other ~ .
O 81 I. Stone Jurisdiction
ac,top 0 Unknown 0 C II e/U ty
I 0 Naflonall'ark C~~~us niversl 0 Unknown
: Please complete Unit Information for each unit involved in a fa~1 crash. Do not repeat the information in the fields above on multiple pages.
11"1 rn Principle Impact Point 0
~ o Non-Collision 011 12 010
II Driver Restrictions 0 ~~~pi~~dn~ith 0 ~~~:r Pennsylvania 0 Top 0 1~' . 02 ~
, Compliance 009 03
. 0 Restrictions Not U cOO
I N 0 n~nown Undercarriage
I @ 0 Restrictions! Complied With Compliance 0 08 040
Not Applicable 0 Compliance 0
Towed Unit
c Unknown .__ 07 06 05
II :;;,,0 Driver Endorsement@Required-oNotapennsylvaniaOUnknownO 0 0
, E Compiled With Driver
Compliance
12 0 Required' Non 0 Unknown
- 0 Compliance Compliance
c None R~quired
21- 0 Required.
s .~ Compliance Unknown
!:;) Driver License
Compliance
o Not Required for
Vehicle Class
o No Valid License
for Class
@ Valid License for
I Class
: Drug Test Type 0 Blood
II ,k- ~ None 0 Urine
[I II Drug Test Results - (Up to four Results)
I 0 = No Test Given S = AmphetamInes
i 1 = No Drug Reported 6 = PCP
: 2 = Marijuana 8 = Other
I I ~ = Cocame 9 = Unknown Test
4 = OpIates Results
'1
I
\111--\ Unitt
'11m
,I
o Not Licensed
Driver Restrictions
Comphance
o No Restrictions!
Not Applicable
r::
o
:;;
'"
E
..
\~
5 ~
...
r:
:;)
Driver Endorsement
(ompl,ance
o None Required
Driver License
~ompl;ance
I
I, Drug Test Type
o None
o Not Licensed
o Blood
o Urine
if
I
I !
. I
- ~ I
U1
'I
II ~~
Drug Test Results . (Up to Four Results)
o ~ No Test Given 5 = Amphetamines
1 = No Drug Reported 6 = PCP
2 = Marijuana 8 = Other
3 ~ Cocaine 9 = Unknown Test
4 ~ Opiates Results
m:'l:: c ~'i'~
o
o
o
Unk it CDL or
CDL Required
Not a Pennsylvania
Driver
Unknown
o Other
o Unknown if Test
Given
[gO
~[l 0
o Not a Pennsylvania
Dnver
o Unknown
Compliance
o Other
o Unknown if Test
Given
~D D
DO
Page
~
~ New
c..J Change!
Continuation
Avoidance Maneuver
O No Avoidance
Maneuver
o Braking - Skid
Marks Evident
Braking - No Skid
o Marks, Driver
Stated
Under Ride Indicator
~
No Underride or
Override
o
Underride,
Compartment
Intrusion
111111/11111 ~llIIllllljllll
Crash Number
--,
Military 0 Other Federal Sites
Indian Reservation 0 Other
o Braking. Other
Evidence
o Steering - Evidence
or Driver Stated
o
Other Avoidance
Maneuver
o
Inconclusive
(:Ri Steering and Braking
- Evidence or Stated
o
Unknown
Undenide, No Override, Other
0 Compartrr,ent 0
Intrusion Vehicle
Underride, Unknown if
0 Compartment 0 Underride or
IntrUSion Unknown Override
Emergency Use 0 Lights Flashing
00 Not in Emergency 0
Use Siren Sounding
Principle Impact Point
o Non-Collision
OTop
o Undercarriage
o Towed Unit
o Unknown
Avoidance Maneuver
o No Avoidance
Ma neuver
o
Braking' Skid
Marks Evident
Braking' No Skid
Marks, Driver
Stated
o Restrictions
Complied With
o Restrictions Not
Complied With
O Compliance
Unknown
o Required. 0 Not a Pennsylvania i
Complied With Driver I
o Required. Non 0 Unknown I
Compliance Compll.ance
o Required.
Compliance Unknown
o Not Required tor 0 Unk if CDL or
Vehicle Class COL Required
o No Valid License 0 No.t a Pennsylvania
for Class Drrver
o ~f~:~ License for 0 Unknown
10
I
! Under Ride Indicator
o
No Underrrde or
Override
o
Underride,
Compartment
Intrusion
Emerqency Use
o
Not in Emergency
Use
pa~i\!DOT CO~V
o Both Lights and
Siren
o Unknown
000
DI~l1 1201020.
o 09 03 0
o 08 040
07 06 05
o 0
o
I-
o
o
Braking. Other
EVidence
Steering. Evidence
or Driver Stated
o Inconclusive
o Other Avoidance
Maneuver
o Steering and Braking 0 Unknown
Evidence or Stated
Underride, No
o Compartment
Intrusion
o Override, Other
Vehicle
Underride, Unknown if
o Compartment 0 Underr'lde or
Intrusion Unknown Override
o Lights Flashing
o Siren Sounding
o Both Lights and
Siren
o Unknown
- . -'.~~-~--
.--1 '
Page
[j]QJ
1111111111111) 111111111111/1
P0923958
Crash Number
I
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 5 ! Pc-he!le onIY\1-c, - \ ~ 0.. ~ \ (., 2...
AI
o
E
III
...
1D Q\
,!:!!
c
I
I
I
I
l
I
Ii . .
-c:-- ___- , __
1 Witness Name
111 ~(( Alfitck,d
21 ,1;-=
l'
[, Narrative and additional witnesses: Accident Investigation Notification Issued? CEJ
,~ C..:.eH-P htme-~~:~Hnit-#-I--No-€elt-Phone
f UniLJt_2----.l.i..l1knQ:ml.ce\ I PnolKllss:
I Lnit it -' Cell Phone Not In Gse at Time of Crash
I
I
I~
>
...
I'll
...
..
I'll
2
'tl
c:
I'll
",I
21 ~
c:
...
~
/t,TT:1 C.lf ti>
Property Damage 0
AtJ.b.e.JucatiQU-oLthis-CDllisionSR--58L\V p, t Ro undis_a_llvJ.LlanLIDad1vay-1Y.itlL
speed limit lij 55 \WH. The crash location is a ramp from SR ItllS North Bound to SR
581 \Vest Bound in Camp Hill Bom. Cumberland County, The ramp IS short and ends at
a concfete barrierl'l'faris :1pprox j-ft11lgTI. The bantersm-elds the concrcre-piitcrr:;-th,
~uprol:t-t~I~idge,...t hat--pass<;s~-SR-5Z+-<Jt-this-mter~ecti(.m._L\.Lthe.J.iln.e-u LLl
collision the weather was sunny and clear. The roadwav was ell' . and clear of any
possIble obstructions
-t-llli-c ras h--{'18:O U rred-a5-hni 1- #J-w.a s-st op~-a t-thc~nd-o 4RB-ra I n p-fnJI11-+tj..j-~-Hort
to SR 581 West. Unit,+ 3 was the yJ vehicle in line to mer e onto SR 58] and was
waiting for a hreak in traffic so he could safely merge onto SR 581. Unit if I \Vas
travelIng on the ramp trom IIlT3 nOl1h to SK3S'1 west and was approacl1!ng the rear 0
t:httt-.n.-3-~--1.::7 n i r"'c-I-fm letl-to-stt)p--aml-wa-it-tera-brea-k-1fi-t Fa ffi C El ft{l-I'}a~*,t-fl-l.;ntt--#-:-)
_____'ml.!.Jlli;le.hidsJnJ'r.illlU.LLU.nit #- ') that \Vere stQQpcd on the nm1R waiting to men!.c Unit
,; I traveled around both vehicles on the left side and entered directly ll1to the Right Hand
lane ofSR 53 I West Bouno and directly Into the path ot UI1IITT'Unit :; 2 \Vas traveling
! mrS-R--5 8-l-\Vcst-B-oumhIlApprox-5i1,V1-Ptt:-b'ni-t-#Z-apphed-rts-brakes-antl-attempt ed--trt
~------. ~----------
~-----
I
FORM # AA-500 (12/ll2)
PENNDOT COpy
.. --1
COMMO~Ul!(EAUIrJ Of PEi\H\lSVlVAI\lIA
POllCIE CRAS~ IllIE~ORTII\lG fORM
AA 500 N I PoilU' UI<' TP'o, _ 11.1 q c;, \ (, 2.
~
New
11\ 111111]111111 \ 11111111111
Crash Num~r
-,
Page
rn
C)
Change!
Continuation
22
Narrative and additionalll\(i~net~~fi
,'\\"ff'iC-to-avtllt -'l 'm...>-bn1HH-~--f::!-nit-fi-2-wasurlJbk to a \ oid-ccmt,ret<lnct-was-'3"trUck il (
~ ..'
fl.,,,, drLve-"vbeds_b~t # 1 AfttLimpacLUnilK2 hegan to slide Oilt o[contro] and the
Trailer began to jack knife. Aftcr initial impact Unit # I was then knockcd into Unit Tf 3,
stiTl stopped and waiting to safely merge onto SR 581. Unit # 2 was now out of control
,md-tne-PTol'llfasserwcr side-ohhe4Tartor strack a concrete barrTerLtrar-w:rs-aiUTl~ lIlt:
ha....,e-oi_thl:-JJLI-5-ov~:pass The irnpact-cau~d-Se-vcr~nagC-to-thc Passenger 50J >
Front of Unit t; 2. The Trailer that Unit # 2 waS hauling then struck the concrete bridl!,e
piltar with its front passenger side, This impact caused the trailer to cornpletely break in
l'jall and scparare--fr'<5T11l1TI1t :;. 2, The tr3itCf1t1enS11Cl and pmncd Una u l oetwC'en 1tSel r
dl1d-tIK'--c1-A--tHFH:'r€t~"-barFier--prote('-tiHg-t-l-lB-9r-i-Bge-pd larso---t.Jnit-# ) t hen :~I i d for-aj'+p-fHx-40
Ft 3ncl came to rest alonl! the concrete barrier on the ORPosite side of the 1 1/15 0\'<:rp355,
At tlm pOint Llllt # 2 was on fire. Within a few seconds Unit # 2 became fully engulkd
111 flamcs. \\l1i1c the operator was still trappecfmslde. Operator # :2 was cnal::;Je to he
Ex t r i cat eel-I'rom-t he-v eh i c I e-anel--h i s-ent i-re-btxf-y-was--severely-b u m etl;--b n-i t-t----H'ina-h c:; t
puint Wl1S_P1llilCd_b_cl\'Leelllhuear half o [theJrailcr of Unit # 2_andJhe_c..Qnc..Iet~J1.mIi_(.T,
Operator H I had to be removed horn her vehicle with the assistance of passing motorists
and Fire Dept Personnel. Unit # :, tlnal rest position was on the on falY)P to SR SF, I from
('J 1--j+t-5-:-al1lTc-same-pmnt or ilIlpacrwittrcnlTJ'rl.
>
'';:;
<'iI
... For further ckt,lils relative to lbe examination of the phvsical evidence refer to the
...
Q
;:: supp\cn)cnta\ report attached to this report completed by State Police Crash
~
c: Recollstructi(lnisCTrooper :v1KlmER.
Q
VI
VI ---- ' -..------- _._~
(!J
c: LJ...pon this officer's arrival at the scene, this offker observed the followin\l
<"
~
>- evidence:
...
~
"'ij bnl t-#+-;vas-pmned---between-the-TraD er-of-f::Jnit+-2-and--cemcrde--bam et-a-H h\.-
~ ..
<( baSeJlLthe_blidge
-- Unit -;+ I had severe damage to both dlivers side and passenger side
- Operator #- 1 was standing out of her vehicle and had a minor cut on her ieg
Skid-marks-telt by Unit if 2 fronrinitialimpacl pDirrrwitht'nirr-i---m-trnarresT
p.Gsiti~) n-~-
- Trailer uf \}nit # 2 suffereel severe damage and \Vas tom in half
.. Part ofTrai1er was still attached to L;nit #- 2
- Umt ;(lwasttll1y cngulted lD tlarnes and restmg agall1st eoncrOCre1-'\arner
Gper-ato r-#-2-s till-i nS-1o e.{) f-v e h i(;-I '-'
.. Seyere damage to j2assenger side front of Cnit # 2 from imRact with concrete
barrier
, - Severe Fire Damage to ca6 at Unlt t+ 2
c-t:h1Tt--#--T-I-r:rd III i [llIl damagctcr8rivcrs-S id e-Rear
- OperatoL1LJ_was__sl;JndinB nllf of his...,..vehicle with nn injill_Y
- Damage to concrete Barrier from impact with Front Passenger Side of U nll if?.
- Damage to Top of Bridge Pillar from Impact with Trailer of Unit IT 2
-
FOR:) 0 AA-SCO" (12lll2)
?Ei'~Xr;OT CC?V
l--
~.
COMMOl\lWEALYM OIF PEl\JNSVLVAi\HA
POllC1E CRASM RIEPORTIl\lG IFORWl
AA 500 N 11'01"( u\<OrR'lol_ \ 1...\ q <1\ '-2..
Page
ICE]
Q?;)
o
New
Change/
Continuation
III II 111\1\ \ II I \\1111111\ III
Crash Number
--,
Narrative and additional witnesses;
Interviews:
--c)-pcmtor F-I-joyce'(J:-eF;-SE-tmc1\il:Wedvn-stem:ilTr-287'05-8.nr1~\-Yh rs_
CASE.statcdthat-sJ1e-.Wa$.-Ol1-lhC--H;lmp-tronl-S-R-\-1 ;-\-$-<lnd-WaS-1.1:Y~~1~S.R
581 \Vest Round. She slated that she was on her way home. CASE staled that she \V~\S
traveling at a pretty slow speed and then saw what she thought were two vehicles parked
at~he endofTIllnrC~SEsratClnhatshe thoughTthesc vehIcles were pulled over there
anJ-+J+at-t~~F{'-RBt-w-aj+i-Rg-to merge onto SR 581. CA&&-tI1:eR-5ttt~mt-s-Re-pnS sed
the two stoDp-ed vehicles and then merged onto SR 581. She stated that she looked for
traffic but never saw the Large Truek already traveling on the lane she merged into.
CAS!:: dId nol rec311 any detmls aner Impact WIth the Truck. Soe only rcmembersbell1g
helped - from--her-vehTcle-by-passing-moto Ii:> l:>.
Operator #- :2 NO STA TEME0.'T POSSIBLE
-..- Opcrcrrorf,-3-Joh n-erai'g-Si!;IReI\-tmt'rvlewellW'iSLerrt:0i718-+(15-----::lT01-S-0-hrs.
0
> S-l'.E.l RSR~.;;tat~l-tl1<lt-hG-w-aJ;--S~ml1d-a-h4tG-pKc.k-Hp-tnlGk-on-tJ1Q-I:.:'1m-p
~ ~
<il
.. from S R 1 \!l 5 north to S R 581 West. STE1RER was waiting for a break in traffic and
..
<il --. -~._---_._- --
~ fClr the vehicle in front of him to merge onto 581. \Vl1ile stopped on the ramp, STE m E g
"0
C watched as a \vniTeBulCK: passed 5 ot11fi ml andlne tllue VlclCCp I rucKinfroriroTml11.
Q
III and t hen en tcred -iAt (}-{ruffic wi t hOUt-sto~pit1g;-STEIR-E R-stat ed-tha t-the-wh i le-cn roc rc\ssed
V1 ---.-
0
c __~_dllel'tly into the patL!__of a Tractor Trailer that was alrcadv trav_cling (m SIL5J3J~\Le.lt
.".
-~ --
C' B (1 L1lllI The car then struck the Tractor Trailer. After mitia! impdcl with the Trdcll1r
~ Trailer the trucK pushedthe car into tne dr\\ers sick rear ofSTETRTR:'s v\.'h1C1e.
.~ S"fEIRE-R. -\ \' a tched-a~~t ne-1:-1-a-ctor-:fran er-then-s lid- otlt--ofcontrohm d-strucb:n,:oncret e
:l
~ bcl:Ti ec aUh e_b ,is C_O Lthe_ b ri dge__SJ E I R ER_s tated_th3 uhe...Iruckiuuneiliatcly_caugbdi [t_
Ile stated that the Truck separated from the trai Ier and the truck slid along the concrete
b~nier betlxe C0111lng to rest. STEiRER then saw the white eilr that lOitlally passed him
was-pinncd-bchvecn-rhe-s-eparmed 'fnrtteram:htre-crrnCfele han-iel - S 1. E !REit-aI<1l'TK\vi1h
other-molO r~st,"-a ssisted-the-.GpeJ:3tGr--G t:.t !:Ie '" hit e Blljck-b~1 p ing--hc+-ex it-thc-+ehi-c1e
He then watched as other motorist stoooed [0 attemot to extricate the ODerator of the
Tractor Trailer. He staled the Tractor Trailer was on fin: and was beginnmg to become
fLTITyengumxrin tlames. !-[e stated that the doors wouJQ not open and tl1at the motonsts --
had to m cwe-tt wa-y-fren1--!fle-fftlCk-h:'-8 voi d-i nj~em-the-grewi~-fire.
-~\\T\tness -:::1
-- el1ns-'ftJN*ER
1------- 16..RO$ewoOl.LSLEalmO-\.lth...Y l\ )JJDS__EhoneJL1D3=G29~J
YU'lKER \Vas {nterviewed on Scene 07/28/05 at 0815 hrs_ \(liNKER was driving the
BL.le Pick L p Truck that \vas stopped \n front of Cnit # 3 on the ramp waitl\1g to merge
011 ro -SR-j'81\\ e s l. Y tJKK1:R-srat'cdl.na chectITtrmrseem-e-wtrtTeimicrputtDurin '(0
t ra tli G-{iut.2..[-\J-+IW_+aF!:,te--Snyder-T-I:uGk{unit-#J)-SH+ppt'd-be-illn4--h i J11..--~{.l)N-K+.R-dj d-~e-t h ~
--~--_.._._--- --
~
22
FQ;l:J 0 AA-5Ol)N (12)\12)
~EO:DOT COP'!
"--1 .
COQ;J~nr'JWiEM..m OIF 01'IEi\l\\'J5VLVAI\lIA
[XlIILIG ~1fO LlIE~LlYH\lG IFORM
AA 500 N I Po!:ce Use ~ 01 -14 ~ or Ic'... '2
Page
rn
<6J
G
New
III 1\\11111\ 1\11111111111111
Crash Number
II
Changel
Cootinuation
~lTati'lte and additional witnesses:
n
Tr3ctor l(ailt:r strikclLniJjtLinJ~driYcrs side, and~ watchecLas [he Tract.DLIrailer
beg:l!1 to slic(>out uf control. He stated the truck struck the concrete ban-ier aIUr111 the base
ot the bndge and almost immediately caught fire. The trailer from Unit #2 then~pinned
ne-\Vhltc-Buick-bet\\l:t:11 it dllllthe LlllllJ ele lJaIl iel.
W\\ness ;i2
Terrie Lee FETROW
'/:,fnVI1\stkr R(t-Elters. P:~\73r9--Phone # 7T7~45'))
.~j="Cr.R QW was i n tl~'-A'e-G-eR-&Eenefl+i~28iOS-a t-01QO-hFS:-F~-.RG-W--sta;e.e-t lld\-&h~
was following a white Buick from 11/15 north to SR 581 West and was gQjj}g to merl.!e
\)r11u 'is I West. As she was following the WhIte Buick she watched as the car wcnt
aroundJiarge I)rown trucK and a smalT151ue pIck up trLlck. r t I RUW ~tatecl that \Vhlte
en r \V as-[1( \ t -t ra vel j ng-fl (-a-hi ghfftte-t}f-speed~bll t -fa i led-ta-s (op-and-wtlt+-ttl--rnerg~sa fe' _
\) n to S 1< 5 X L_i\~_tbc\\'hjLi:__(.:_aLpllssc;iLthl,.UYLQ...l.ellicle.s-.S.tQP.Jled-<llLtht:_\.}jLElm p_iL(:nhT~d
Into trJf!ic with out slowing down. FETROW stated the car pulled out dIrectly into the
patllOfJTractor lrai ler already traveling on S R 581. She watched us the Tructor TraIler
c r-------~stnlck-tr. e-\YTl ite-ca r-and-- push cd-; ri nto-th e-sid-c-the-bro\\TIlmd-sropped-o not h e-o rr ra m r.
5 Ihe_\.\J1iLccaL..\\:as__thclLdnll~-b:y_t.hc-trai.lcL.oLthUi:af'lnr Tr\:lilpr >1n" "";'llleQagalnsuhe
c ~ U--f-Lll ~
15 concrete barner FETROW stated the Tractor Trailer struck the Concrete butTier and
; almost immediately bur~t into t1anles. FeTROW watched as a man attempted to open the
~ dOOnT\TnelractlSrTfailer, OUn11C Goor woultl-not open. S11e stTIfRlflTIH anotnerm::Yh
Cl
\5 app.rzl,\chl.od -w-i.th..a--{>fow--4ar-and-hc-a lSf)-w a s -un ab I c- to-ope.n4he-Goorto t he truck~-S he
l!:
". stated the tlt.C was l!dtirH.!. hiQQer and everyone hac! to back off from the truck.
~:l
~:L
~Ii
==i
5
<Ii
r------ _.-
i Witness #3
Denise ROHETTEFRY
1-3-3-;\-\Vi I::j o-Farms-VTHa1!e-HmTIsburg-P1\i-Tnl-rhone-;:''-;TI-=56i~
\ R OB.ELlEERY__was.inte[:\jc\~ed-on-scene-07/28!OS at 09C101us..-ROBETTEI='R v
i Slated that she was follo\vlfH( the Giant Foods Truck on SR 5RI West Bound at Approx.
SO I11ph R08ETTEFRY stated that the truck was in tile right hand lant as it approached
r- the SR1Trs-iTItcrsection:-ROBETfETft't\\7atcned as a whIte vehicle I raveleclITiTlutlC)
i
\ ~1a I-I (H\ k cd Ii k C C1-brown-0Fea,l-truck-and-i mo-t he-ri g ht-ha l1(1-l-a ne-4t,s;.R--).,~~f.hc.-car--
i RU\\cd out directly into the path of the Tractor Trailer. ROBETTEFR Y watched as the
I
! Tractor Trailcr applied It's brakes and struck the drivers side of the white car The truck
f----.-----lost control and then struck the concrete bamcr atthe base ot ttleblT<1gc. lZOHETTEFRr
then-:5topped-I~i-"and-aHempted-to-ex-trieate-the-ttperatm--ofthe-Tfactor-Tftltkl~\:tt
~~QJ.lld.JlOLO pClLthe_dru2r~Sbe....theIL.llii1ched~J..el1.jYLth..\..TIill'Jllirs_a1Lempttd to 0 pen the
door but were also unable to open the door.
\\-
,I
r-----
II,
f{:R:J 0 ~::J (12)02)
--
P;S:"~:JOT CO?Y
L
...-1 .
COMMO\\lU\!iEALYM Of pn:hJI\lSVLVAI\lIA
li'OllCE CRASh'! LttlEPOR1DIIlG FORM
M 500 N I Pel"e lK<- 0"1'
I 1-\0\ - IL\ ~ "\l (.2.,
Q9
New
1111111111111111111111111111
Crash Number
"I
Page
GEJo
Change!
Continuation
Z2
Narrative and additional witnesses:
Operator Ti 2 was pronounceJ dead on scene 07/28i05 by Cumberland County ChIef
Deputy Coroner radCl ECKENRODE. See attached Coroners Report for case 0 f death.
~nl i IrcatlolLDf Deatll-was--Handl,~d b.v-CwuberlancLCulll1ULComers_n ni, ,'"
- ~
~-
Operator #2 PA Operators License was not able to be recovered due to it being
lksfroyeo as a result onhe m:rcKtJre.
Trooper f\lark DEAN Troop H Harrisburg Forensic Services l'nit responded to and
Photographed the Scene. See attached Supplemental.
'[:ffit.1-ter-6ftfy-M-,A.,-I-N-Z-E R-Tro 0 p If I [arri:ihttrg-Etrlli31olt--Aittrlysts-and
R e c: Q n s truclliJlLS pee ial isul.s..s.ish: d_a uhc....s.c.rnc_ and is co mpJc.t ing....ll..JiJlL( ceo n s t ru e t ion () f
this Inclcknt Supplemental to follow.
._--------_.~~_.
<'J l::'msco p e-:\'tc:; sage --wrrs-;;-ent-oTI-O=t+}f)/(rs-in-compli rrncn\rjtl,F-R-6~t5--fa tell; l y un
> h 1 ghl.\ay-ot:-tratlic-\\.'aY A " 0 p yj :>...dttacbeclto--this_r:ep" rl
::;
e
....
Q
2 Assisted on scene by Cpl. STANTOI\, and Troopers MAINZEK FISHER, ano
"tl
c FORTtn+--rrll areTfiembers of Troop H Hanisourg Smtton.
fil
'"
'"
<'J ---~---
c Respondil~g EMS and Fire Departments:
...
~
'-' E\1S FIRE DEPT
~ Camp IliJITi\1S C ree f'SldeFi re
-
.; Wes\-Sftore---A-I::S C -ftt1'l1THi-H--Fi re
:::I
<::( \V I:~LShQfc Bl S \'ic_SLShQruire
Lower Allen Twp EMS Hampden Twp Fire
Upper Allen T\'vp fire
N f'w~,>_ReJ ease...J2.repared..-I\-c:.op y is at! ;1(' hecLtoJ.hestatin n (' n P }'.-DLthis..re.pru:t
T111s repon remmns open, penCling revleWOy tne DauplrtnCourttyl}mrtcn'\tmmeys
r) rfi ('e--for-po 5S i b k-tfcttHm a 1- prosi:'l'U liHl,\-;--
I---- ---
----
----- E
!
FOR:.; Q AA-5CC:! f11llI2)
L
pa~i\!DOT COpy
-.J
COMMONWEALTH OF PL . .SYLVANIA
POLICE CRASH REPORTING fORM
Case Closed Reportable Crash
DYes 0 No 0 Yes 0 No
v+5
Page
[lEJ
t)Sl New
o Change!
Continuation
1111I11111I11111111111111
Crash Number
-,
M5001
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Narrative and additional witnesses:
ON 0772137D-S-AT0800Rf{~ESPONDED TO-THE-S-CENE OF THE ABOVE MENTIONED
-BRAS++-tWAS-REOOE-S-rED TO PHe:r-06RAPH--THE-8eENE BY TPR-:---MleHAEt-l:::AN6;-PSP-
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I PHOTOGRAPHED THE ABOVE MENTIONED SCENE ON 07/28/05 AT APPROX. 0820 HRS. -
U011'j\.:) A-NtK:0N-N90S-35MM-eA:MER.A~2S--TO-80-MM-tl=NS-;-NtKON--VLKSrI-UNIT AS N ,
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FORENSIC SERVICES UNIT.
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2005-0448
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