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Fatal Crash Report

Fatal Crash Report

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Published by Lyle McBride

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Published by: Lyle McBride on Sep 09, 2010
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WN
FLORIDA TRAFFIC CRASH REPORT
DO NOT WRITE IN THIS SPACE
orof
PMAM
PARKWAY FRONTAGE RD NSR 37 (S FLORIDA AV)05/5226
81536469
POLK
12222212
09/08/2010
2212
100017643
LAKELAND
MAIL TO: DEPR. OF HIGHWAY SAFETY AND MOTOR VEHICLES, TRAFFIC CRASHRECORDS, NEIL KIRKMAN BUILDING, TALLAHASSEE, FL 32399-0537or
LONG FORM
SFEET
MILE(S)
AM
E
:
COUNTY2. UNDIVIDEDFEETTIME OF CRASH
AT THE INTERSECTION OF (street, road or highway)
Eor
NO.OF LANES
PM
SCOUNTY / CITY CODEON STREET,ROAD OR HIGHWAYWorTIME OFFICER NOTIFIED1. DIVIDED
   T   i   m   e   &   L   o   c   a   t   i   o   n
N
PM
NEXT NODE NO.
FROM NODE NO.
HSMV CRASH REPORT NUMBER
MILE(S)
FEET
AT NODE NO.
:
TIME OFFICER ARRIVEDINVEST. AGENCY REPORT NUMBER
CITY OR TOWN
MILE(S)
AM
(Check if inCity or Town)
FROM INTERSECTION OF (street, road or highway)
:
DATE OF CRASH
SHOW FIRST POINT
15000245403384401PARKWAY FRONTAGE RD NFL1998FLLAVERNE CHARLES SCHAUB338442
UK
1HAINES CITY
1,2,3,4,5,6,15,16,17,20
2800 HWY 17-92 W #662800 HWY 17-92 W #66LAVERNE CHARLES SCHAUBHAINES CITY2G1WL52M5W913479724CHEVA811ZKFLWEBBSS1005233400301FL2578172594411STATE FARM16135101301/03/1934
EST. VEHICLE DAMAGESTATE
1 Yes 2 No21. Trailer
PHYS.DEFCITY AND
1. Phantom
AND ZIP CODE
REQ
STATE / PEDESTRIANTRAILER OR TOWED VEHICLEVEHICLE INDENTIFICATION NUMBER
MATERIAL SPILLED?
DATE OF BIRTHDRIVER LICENSE NUMBER
IF YES EXPLAIN IN NARRATIVE
AND CIRCLE
DL19. Overturn
ON(Number and Street)Est. MPHSEXNAME OF VEHICLE OWNER1. Tow Rotation List( Trailer or Towed Vehicle)CURRENT ADDRESS
18. Undercarriage
ICC MC IDENTIFICATION NUMBERSSTATE
S
2. Tow Owner's Requestor1 Blood 3 Urine 5 None
E
ATCURRENT ADDRESSSTATE
RECOMMEND DRIVER RE EXAM
OF VEHICLE
(Number and Street)
Section
STATECITY ANDNAME OF DRIVERACTION
W
2.Functional
CURRENT ADDRESS
1 Yes 2 No
   P   e   d   e   s   t   r   i   a   n
MAKE
1 Yes 2 No
S. EQUIP.
DAMAGED AREA(S)
END
2 Breath 4 RefusedNAME OF MOTOR CARRIERCITYALC/DRUG3. Driver
3.No Damage
(Number And Street)
1 Yes 2 No2. Hit
POSTED SPEED
20. Windshield
4. Other
WAS HAZARDOUS
NAME OF OWNERAND ZIP CODE
RunandPLACARDED
VEH.LICENSE NUMBER(Check Box if Same As Driver)(Number and Street)
DAMAGE
HAZARDOUS MATERIALS
VEHICLE TRAVELLINGUS DOT
BEING TRANSPORTED
1
CITYINFORMATION(Commercial Vehicle Only)
IF YES INDICATE NAME OR 4 DIGIT NUMBER FROM DIAMOND OR BOX ONPLACARD, AND 1 DIGIT NUMBER FROM BOTTOM OF DIAMOND.
ALC / DRUG TEST TYPE
N
TYPESTATE
   V   e   h   i   c   l   e
1. Disabling
DRIVER'S PHONE NO.VEHICLE REMOVED BY :EJECT.
3. N/A
ZIP CODECURRENT ADDRESSPOLICY NUMBERDRIVERTRAILER TYPEINJ.RACE(Take From Driver License)MOTOR VEHICLE INSURANCE COMPANY (LIABILITY OR PIP)USEEST TRAILER DAMAGERESULTSRES.
TYPE
ZIP CODEYEAR
DL TYPERACESEXREQUIREDENDORSEMENTSINJURY SEVERITY
and
SHOW FIRST POINT
14WEBBSK995TQAIG0842387321 CENTURY SECURITY INS5N433DSFL0111303/27/1970WH000000000001211201FL200416LAKELAND40401999031
1,2,3,4,15
MANRIQUE JAVIER MARTINEZSR 37 (S FLORIDA AV)
MANRIQUE JAVIER MARTINEZ
4
3D7KU28C34G190990(863) 858 4306
ELECTRONIC REPORT
2
33809
8198 E TOM COSTINE RD
FL
7000UK3380912
LAKELAND
3M6355507010702FL
8198 E TOM COSTINE RD
DODG06
3 Fatigue/Asleep15 Low Speed Vehicle2 Alcohol - Under Influence08 Law Enforcement1 Male
2.Hit19. Overturn
1 White
ALC/DRUG
12 Dump
2.Functional
RES.
07 House Trailer01 Private Transportation
DAMAGE
1 Yes
W
04 Medium Truck - 4 rear tires11 Other Government
OF VEHICLE
PHYSICAL DEFECTS
05 Boat Trailer
ACTION
2 Elsewhere in State
Page
13 Concrete Mixer14 Train
STATE
4 D/Chauffeur
   P   e   d   e   s   t   r   i   a   n
(Take From Driver License)
7 None10 Bicycle6 Pending ALC/DRUG Test Results03 Commercial Cargo08 Bus ( driver + seats for over 9-15)13 All Terrain Vehicle12 Moped5 E/Operator
1 Yes 2 No
6 Safety Helmet07 Motor Home (RV)
INJ.
   V   e   h   i   c   l   e
EJECTED
7 Eye Protection09 Bus (driver + seats for over 15)
REQ
RACE
MATERIAL SPILLED?
ALC/DRUG TEST TYPE
2 Female8 Bus Passenger4 Rear Left4 Foreign 5 Unknown
EST. VEHICLE DAMAGE
RECOMMEND DRIVER RE EXAM
2 Front Center
1 Blood 3 Urine 5 None
5 Air Bag - Not Deployed
ALCOHOL / DRUG USE
1 Yes 2 No
MAKE
1 A 2 B 3 C01 Automobile1 Not Drinking or Using Drugs06 Private School Bus3 Non - Resident Out of State02 Van
(Number And Street)
21. Trailer1 Yes 2 No
5 Rear Center
TRAILER TYPE
VEHICLE TYPE
STATEDATE OF BIRTH
5 Had Been Drinking
WAS HAZARDOUS
3 Child Restraint
BEING TRANSPORTEDIF YES EXPLAIN IN NARRATIVE3.No Damage
09 Fire/Rescue11 Motorcycle
4. Other1. Tow Rotation List
03 Light Truck/ P.U.- 2 or 4 rear tires
(Driver / Ped.)
2 Breath 4 Refused
4 Alcohol & Drugs - Under Influence77 Other
INFORMATION
10 Auto Transport
(Check Box if Same As Driver)ZIP CODE
1 Yes 2 No
06 Utility Trailer
ICC MC IDENTIFICATION NUMBERS
1 Not in Use2 Eyesight Defect4 Other
ZIP CODE
1 No
EJECT.
2 Seat Belt / Shoulder Harness1 Front Left2 Yes
EST TRAILER DAMAGE
09 Towed Vehicle
NAME OF OWNER
E
 / PEDESTRIAN
7 Other Physical Defect
POLICY NUMBERS. EQUIP.
TYPE
RESULTS
DAMAGED AREA(S)
US DOTCURRENT ADDRESS
AND CIRCLE
CURRENT ADDRESS
77 Other
USEAND ZIP CODE
N
(Commercial Vehicle Only)
3 Non-Incapacitating
(Number and Street)ZIP CODE
SAFETY EQUIPMENT IN USE
STATE
1. Disabling
RESIDENCE
or2. Tow Owner's RequestNAME OF MOTOR CARRIER
08 Pole Trailer07 Ambulance
MOTOR VEHICLE INSURANCE COMPANY (LIABILITY OR PIP)Est. MPH
01 Single Semi Trailer
YEAR
2 Black
VEHICLE INDENTIFICATION NUMBER
LOCATION INVEHICLE
3. Driver
4 Incapacitating
DRIVERCITY
15 Cargo Van
2
TRAILER OR TOWED VEHICLE
Run
5 Fatal (Within 30 Days)
VEH.LICENSE NUMBER
5 Illness
DRIVER LICENSE NUMBER
2 PossibleRequired1 None6 Non-Traffic Fatality4 Hearing Defect02 Tandem Semi Trailer
END
04 Saddle Mount/Flatbed
WAS HAZARDOUS MATERIALS
04 Public Transportation
STATEVEHICLE TRAVELLINGCURRENT ADDRESS
S
(Number and Street)TYPE
03 Tank Trailer6 E/ Oper-Rest
HSMV-9003 (REV. 01/02)
( Trailer or Towed Vehicle)CITY AND
1 No Defects Known9 Other
TRAILER TYPE
6 Rear Right05 Public School Bus
VEHICLE REMOVED BY :CITY ANDCURRENT ADDRESS
14 Garbage or Refuse
CITYDRIVER'S PHONE NO.SEX
1 County of Crash
1
6 Seizure, Epilepsy, Blackout3 Partial
DL
PHYS.DEF
02 Commercial Passengers
Of
AT
3 No Endorsement
3. N/A
Section
77 Other
PLACARDED
3 Hispanic
IF YES INDICATE NAME OR FOUR DIGIT NUMBER FROM DIAMOND OR BOX ONPLACARD, AND 1 DIGIT NUMBER FROM BOTTOM OF DIAMOND.1. Phantom
NAME OF VEHICLE OWNER
7 In Body Of Truck
(Number and Street)STATE
20. Windshield
3 Front Right4 Air Bag - Deployed
VEHICLE USE
POSTED SPEED
05 Heavy Truck - 2 or more rear axles
18. Undercarriage
   C  o   d  e   I  n   f  o  r  m  a   t   i  o  n
NAME OF DRIVERSTATE
3 Drugs - Under Influence10 Military
ON
06 Truck Tractor (Cab Bobtail)2 No
 
100017643 81536469
HSMV CRASH REPORT NUMBER:INVEST. AGENCY REPORT NUMBER:
SHOW FIRST POINT
and
44WEBBSAU0172655M639QVAGENCY INSURANCE OF MARYLAND1300033877-006701WAVERLY402093B210501587670PO BOX 67FLFL3140507/27/19586SR 37 (S FLORIDA AV)210321
1,12,13,14,15
KATHY ANN BISHOPKATHY ANN BISHOP(863) 662 538821FTDF15Y9PNA14707FLWAVERLY21PO BOX 6714FORD333877-0067
EJECT.ALC/DRUGNAME OF MOTOR CARRIER
1. Disabling
CURRENT ADDRESS
1. Phantom
SEX
RECOMMEND DRIVER RE EXAM
3. DriverCITY ANDSTATE(Check Box if Same As Driver)
PLACARDEDBEING TRANSPORTED
18. Undercarriage
REQ
YEARICC MC IDENTIFICATION NUMBERS
DAMAGE
MATERIAL SPILLED?
DAMAGED AREA(S)
NAME OF DRIVER
S
TYPENAME OF OWNERCITY AND1. Tow Rotation ListDRIVER LICENSE NUMBER
IF YES EXPLAIN IN NARRATIVE
W
TRAILER TYPEUS DOT / PEDESTRIANSTATE
WAS HAZARDOUS
ZIP CODEor
2.Functional
ON
E
( Trailer or Towed Vehicle)INJ.STATEVEHICLE INDENTIFICATION NUMBER
DL
AND ZIP CODE
N
   V   e   h   i   c   l   e
IF YES INDICATE NAME OR 4 DIGIT NUMBER FROM DIAMOND OR BOX ONPLACARD, AND 1 DIGIT NUMBER FROM BOTTOM OF DIAMOND.
ZIP CODE
3.No Damage
CITYALC/DRUG TEST TYPE
1 Yes 2 No
Section
ZIP CODEPOLICY NUMBERCURRENT ADDRESSMOTOR VEHICLE INSURANCE COMPANY (LIABILITY OR PIP)1 Blood 3 Urine 5 None4. Other2. Tow Owner's RequestRESULTSEst. MPH
1 Yes 2 No
2 Breath 4 Refused
2.Hit
CURRENT ADDRESS
3
21. Trailer
EST TRAILER DAMAGEPHYS.DEF
   P   e   d   e   s   t   r   i   a   n
(Number and Street)EST. VEHICLE DAMAGE(Number And Street)USEVEHICLE TRAVELLINGDRIVER'S PHONE NO.POSTED SPEEDINFORMATION
1 Yes 2 No
STATE(Take From Driver License)
20. Windshield
AND CIRCLE
(Number and Street)DRIVER
19. Overturn
(Commercial Vehicle Only)STATE
3. N/A
1 Yes 2 No
HAZARDOUS MATERIALS
S. EQUIP.CURRENT ADDRESS
OF VEHICLE
TRAILER OR TOWED VEHICLE
TYPE
MAKE
Run
RES.
END
VEHICLE REMOVED BY :CITYNAME OF VEHICLE OWNER(Number and Street)RACEVEH.LICENSE NUMBERSTATEATDATE OF BIRTHACTIONSTATEZIPCITYCITYADDRESSADDRESSOWNER'S NAME
$
EST. AMOUNTPROPERTY DAMAGED - OTHER THAN VEHICLES
2#
STATE
1#
PROPERTY DAMAGED - OTHER THAN VEHICLESEST. AMOUNTOWNER'S NAME
$
ZIP
101
3
04
1
06
3
1
3
01
11
33
0101
2
1
0101
32
01103
3
11
2
2
0103
3
2
01050101
1
01
2
10103010303103
2
11
1
2
03101
3
01
2
010203010102
16 MV Hit Sign / Sign Post14 Failed To Maintain Equip./Vehicle07 Entrance Ramp29 MV Ran Into Ditch/Culvert08 Equipment / Vehicle07 Entering/Leaving Parking SpaceBusiness
ROAD SYSTEM IDENTIFIER
06 Shoulders - Soft / Low / High18 Obstructing Traffic
POINT OF COLLISION
01 Slag/Gravel/Stone02 Straight - UpGrade / 28 Collision With Moveable Object on Road01 Collision With MV in Transport(Rear End)06 Changing lanes05 Puncture / BlowoutNarrative)
VEHICLE MOVEMENT
77 All Other (Explain3 Vehicle SideControl07 Signs / Billboards06 Steering Mech.1 Not Applicable08 Private Roadway2 Shipping Papers07 Working In Road1 Primarily05 Making Right Turn03 Making Left Turn1 None24 Collision With Traffic Gate12 Exceeded Safe Speed Limit34 Fire2 Primarily11 Disregarded Traffic Signal13 Collision With Moped11 Collision With Bicycle03 Entered03 Brick/Block04 Walking Along Road With Traffic11 Posted No U-Turn02 Nearby27 MV Hit Other Fixed Object05 Loose Surface Materials01 Paved37 Cargo Loss or Shift02 Inclement Weather01 Clear(Explain In06 Working on Vehicle In Road06 Stop Sign05 Local03 Influenced By Intersection13 Public Bus Stop02 Wet32 Occupant Fell From Vehicle77 All Other (Explain In Narrative)06 Bridge09 Smoke02 Def Brakes07 Alcohol - Under Influence26 Collision With Fixed Object Above Road02 Obstruction With Warning02 Cloudy31 Overturned09 Collision With MV On Roadway03 Parked / Stopped Vehicle10 Officer / Guard / Flagperson05 Load On Vehicle04 Concrete30 Ran Off Road Into Water03 Curve - Level04 Fog05 Turn Lane08 Collision With Parked Car02 Not On Road77 All Other ...10 Followed Too Closely(Explained In Narrative)Lights09 Railroad Signal04 Trees / Crops / Bushes77 All Other (Explain In Narrative)03 Obstruction Without Warning25 Collision With Crash Attenuators21 MV Hit Bridge/Pier/Abutment/Rail02 Dusk08 Standing WaterIn Narrative)01 DaylightIn Narrative)09 Worn / Polished Road Surface01 On Road77 All Other (Explain In04 Dark (Street Light)07 Collision With MV in Transport(Backed Into)04 Curve - Upgrade / 04 Icy
ROAD SURFACE CONDITION
04 County12 Toll Booth
TYPE SHOULDER
20 MV Hit Concrete Barrier Wall02 Unpaved
SITE LOCATIONSOURCE OF CARRIER INFORMATION
03 Failed To Yield Right - of - Way
VISION OBSRUCTED
Narrative)77 All Other (Explain19 MV Hit Fence77 All Other (Explain InDowngrade01 Vision Not Obscured01 No Control77 All Other (Explain In
VEHICLE DEFECT
05 Collision With MV in Transport(Right Turn)02 Careless Driving (Explain In Narrative)Runaway Vehicle01 Crossing Not At Intersection4 Recreational01 Straight - Level05 Railroad
VEHICLE SPECIAL FUNCTIONS
Narrative)04 School Zone01 No Improper Driving / Action18 MV Hit Guardrail
TRAFFIC CONTROL
39 Median Crossover04 Collision With MV in Transport(Left Turn)08 Flashing Light12 Driverless or06 Turnpike / Toll
TRAFFICWAY CHARACTER
Downgrade09 ParkingLot-PublicNarrative)3 Police Pursuit5 Emergency Operation06 Collision With MV in Transport(Sideswipe)3 Open Country38 Separation of Units03 DawnNarrative)08 Fog09 Standing In Pedestrian Island24 Driver Distraction (Explain
WORK AREA
03 RainPlaying In Road11 Passing04 Improper Backing02 Collision With MV in Transport( Head On)23 Vehicle Modified16 Drove Left of Center
FIRST / SUBSEQUENT HARMFUL EVENT(S)
77 All Other (Explain In03 Collision With MV in Transport(Angle)In Narrative)
CONTRIBUTION CAUSES - DRIVER / PEDESTRIAN
21 Driving Wrong Side / Way22 Fleeing Police06 Building / Fixed Object
PEDESTRIAN ACTION
12 No Passing Zone13 Disregarded Stop Sign77 All Other (Explain In Narrative)05 Improper Lane Change
LIGHTING CONDITION
Residential6 Construction Maintenance10 Glare02 Blacktop04 Road Under Repair / Construction02 Crossing At Mid-block Crosswalk2 Farm
ROAD CONDITIONS AT TIME OF CRASH
01 No Defects06 Improper Turn01 No Defects17 MV HIt Utility Pole / Light Pole08 Exit Ramp20 Disregarded Other Traffic88 Unknown04 Driveway Aceess10 Making U-Turn01 Interstate22 MV Hit Tree/Shrubbery03 Speed Control Sign05 Traffic Signal03 Shoulder88 Unknown14 Collision With Train19 Improper Load33 Tractor/Trailer JackknifedDefect77 All Other07 Yield Sign
WEATHER
01 Straight Ahead11 Private Property05 All Other36 Downhill Runaway03 Crossing at Intersection03 State23 Collision With Consruction Barricade Sign08 Drugs - Under Influence04 Median08 Properly Parked05 Dirt03 Worn / Smooth Tires01 None77 All Other (Explain In10 Collision With Pedestrian01 Dry08 Standing or02 At Intersection15 Collision With Animal01 Not At Intersection / RR-X-ing / Bridge02 Special Speed Zone02 Slowing / Stopped / Stalled02 U.S09 Alcohol & Drugs - Under Influence05 Walking Along Road Against Traffic17 Exceeded Stated Speed Limit07 Windshield Wipers(Explain In Narrative)09 Improperly Parked07 Forest Road04 Defective / Improper4 Driver
LOCATION TYPE
35 Explosion10 ParkingLot-Private03 Slippery04 Backing15 Improper Passing12 Collision With Bicycle (Bike Lane)07 Holes / Ruts / Unsafe Paved Edge05 Dark (No Street Light)
ROAD SURFACE TYPE
Narrative)03 Curb5 Other
4
CHARGECHARGECHARGEFL STATUTE NUMBERNAME OF VIOLATORNAME OF VIOLATORFL STATUTE NUMBERCITATION NUMBERNAME OF VIOLATORNAME OF VIOLATORFL STATUTE NUMBERSECTION #FL STATUTE NUMBERCITATION NUMBER
Of
2
CITATION NUMBER
Page
   V   i   o   l   a   t   o   r   (   s   )
SECTION #SECTION #SECTION #CHARGECITATION NUMBER
 
12338153646910001764305529/8/2010 1227VEHICLE #2 WAS TRAVELING NORTH ON S FLORIDA AV IN THE LEFT HAND STRAIGHT THROUGH LANE. VEHICLE #3 WAS TRAVELING NORTH ON S FLORIDA AV IN THE CENTERSTRAIGHT THROUGH LANE. VEHICLE #1 WAS TRAVELING SOUTH ON S FLORIDA AV IN THE LEFT HAND STRAIGHT THROUGH LANE.DRIVER AND PASSENGER OF VEHICLE #2 ADVISED THAT THEY WERE TRAVELING NORTH AND ENTERED THE INTERSECTION ON A GREEN LIGHT. VEHICLE #3 WAS BESIDE VEHICLE#2 AT THE TIME OF THE IMPACT. DRIVER OF VEHICLE#2 ADVISED THAT VEHICLE#1 CAME FROM THE LEFT AND INTO HIS PATH. VEHICLE #2 TRIED TO BRAKE AND VEHICLE #2 HIT THEPASSENGER DOOR AREA OF VEHICLE#1.OFFICER D. BAKER #240 WAS FIRST ON SCENE AND ADVISED THAT THE PASSENGER OF VEHICLE#1 APPEARED TO BE DECEASED.WITNESS #1 ADVISED THAT HE WAS TRAVELING SOUTH ON S FLORIDA AV IN THE LEFT HAND STRAIGHT THROUGH LANE. HE ADVISED THAT VEHICLE #1 WAS ONE CAR AHEAD OFHIM AND THAT CARS WERE STOPPED IN BOTH NORTH AND SOUTHBOUND LEFT TURN LANES WITH RED TURN ARROWS. HE ADVISED THAT VEHICLE #1 PROCEEDED FORWARD ANDMADE AN ABRUPT LEFT TURN AND ACCELERATED INTO THE PATH OF VEHICLE#2. HE ADVISED THAT VEHICLE #2 WAS TRAVELING AT NORMAL SPEED.WITNESS #2 WAS TRAVELING SOUTH ON S FLORIDA AV IN THE LEFT HAND STRAIGHT THROUGH LANE WITH VEHICLE #1 DIRECTLY IN FRONT OF HER. WITNESS #2 ADVISED THATVEHICLE #1 MADE A LEFT TURN FROM THE STRAIGHT THROUGH LANE AND INTO THE PATH OF VEHICLE #2.EMS RUN NUMBER 51346 THEY WERE NOTIFIED AT 12:23:05 1ST UNIT ONSCENE WAS MEDIC35 AT 12:27:40 2ND UNIT WAS ONSCENE WAS MEDIC41 AT 12:41:17
PMMAIL TO: DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES, TRAFFIC CRASHINVEST . AGENCY REPORT NUMBER
(NARRATIVE)
HSMV CRASH REPORT NUMBERAMPM
:
FLORIDA TRAFFIC CRASH REPORT
TIME EMS ARRIVED (FATALITIES ONLY)AM
NARRATIVE/DIAGRAM
RECORDS SECTION, NEIL KIRKMAN BUILDING, TALLAHASSEE, FL 32399-0500DATE OF CRASHTIME EMS NOTIFIED (FATALITIES ONLY)
DO NOT WRITE IN THIS SPACE:
COUNTY / CITY CODE
31
S
2
1WINTER HAVEN
1
1411PLANT CITY12/29/195633881121314205/06/1969JEARLENE MEEKS DAUGHTRY 5233566-84691333338-092DAVID SWOPE3309/24/1939FLEDVIN GUERRA MENDEZ1LAKELAND21FLFL8198 TOM COSTINE RD5117 MOLL ACRES DR507 AV J
CURRENT ADDRESSDATE OF BIRTHPASS#CITYEJECTPASSENGER'S NAMEINJSEC#SEXSTATEDATE OF BIRTHSTATESEC#S.EQUIP.SEC#LOCS. EQUIP.RACEZIP CODECITYRACECURRENT ADDRESSPASSENGER'S NAMEPASS#S.EQUIP.INJLOCSEXDATE OF BIRTHDATE OF BIRTHSTATEPASSENGER'S NAMESTATESEC#S.EQUIP.INJS.EQUIP.CURRENT ADDRESSLOCZIP CODERACECURRENT ADDRESSSTATEPASS#PASS#SEXEJECTEJECTINJEJECTLOCSEXINJCITYDATE OF BIRTHZIP CODECITYDATE OF BIRTHPASSENGER'S NAMECURRENT ADDRESSSEC#CITYPASSENGER'S NAMES. EQUIP.RACEPASSENGER'S NAMELOCCITYRACERACELOCZIP CODESEC#CURRENT ADDRESSZIP CODEPASS#EJECTZIP CODEEJECTPASS#INJSTATESEXSEX
SECTION#CHARGEFL STATUTE NUMBER
      V      i     o      l     a      t     o     r      (     s      )
SECTION#NAME OF VIOLATORCITATION NUMBERCHARGECITATION NUMBERFL STATUTE NUMBERNAME OF VIOLATOR
SO
LAKELAND POLICE DEPARTMENTPCEMS1281BUCKLIN, STEPHEN A1
JEFF PHILLIPS , 4520 SUGARTREE DR E, LAKELAND, FL 33813
34
1
ELLIE STROM 215 EASTWAY DR, LAKELAND, FL, 33803,
LAKELAND FIRE DEPT1
LRMC
09/08/20102
1. INVETIGATION AGENCYIF YES, BY WHOM?
2. NOPHOTOSTAKENDATE OF REPORT2. NO1. YES
ISINVESTIGATIONCOMPLETE?
IF NO THEN WHERE?IF NO, THEN WHY?2. NO1. YES1. YES
WASINVESTIGATIONMADE AT SCENE?
BY - NAMEINJURED TAKEN TO :
2. OTHER
3. Police Officer5. Other2. Paramedic or EMT
FIRST AID GIVEN BY - NAME
1. Physician or nurse
ZIP CODECITYCURRENT ADDRESSZIP CODECITYCURRENT ADDRESSWITNESS NAME (1)
OfPage
STATEWITNESS NAME (2)STATE
OTHERPD
FHP
DEPARTMENTID/BADGE NUMBER
4. Certified 1st Aider
INVESTIGATOR- RANK SIGNATURE

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