ST9302-AG001024 (4)TEXAS ~ OFFICEI'$ ACCIOENT B~I01KT~ ST-3 (Eft. 1/1/96)
Pi. ACE WHERE,
ACCIDENT OCCURREO~ ',,
COU"~
,F ~CC, O~T WAS OUTSI~ C,TY MM,TS.
MAIL TO: ACC3OEXT RECOlD.S. 1TX&S OEPANTMENI' OF PUOIJC SAFETY. PO MO( #17. AUSTIN TX 11T73.0011
INOICATE DISTANCE FROM NEAREST 'TOWN
MILES NORTH S E W OF
ROAO ON WHICH
ACCIDENT OCCURRED
INTERSECTING STREET
OR RR X'ING NUMBER
NOT AT INTERSECTION
/ r I~ ~ lC,,. / ~ ~ ZONE UMIT
[]FT. [][][]~ OF
I
[]--EMi. N S E W sxoWmUlmfTOlmmillTmTEm~ilmuilemNleWMet
°'"'°' 5 b
DAY OF
~ :"'"~,m~ ~-J ~u'~l~ ~ .our I0 : ~
[ -
OQ NOT ~kflilTE OFS NtT.
IN THIS SPACE
FAT. REC.
UNIT
NO. I - MOTOR VEHICLE
Y~ q~, co,,,,,
MOOEL _ & MAKE
VEil IDENT NO q ~/-~ ~:..'~ ~A,~ q ~L)/.., ,~ i G ?.Y ff
~rYLE_
IF 900t' STYLE = VAN OR BUS,
INOICATE SEATING CAPACft'Y
UCENSE
ORIVER'S
SPECIMEN TAKEN (AI,,~OHOL/ORUG ANAJ.YSIS) ~
l-BREATH 2-RLOOO ~.OTHER 4-NONE 5-REFUSER
LESSEE F'l
ALCOHOL/DRUG ANALYSIS RESULT
.E.GHTEG ON EMER..CY? [] YES ~ NO
mSU,ANCE [] .0
VEHICLE OAMAGE RATING
UNIT MOTOR VEHICLE ~ TRAIN ~ PEOA~YCUST
NO. 2 ~WED [] PERESTRIAN ~ OTHER
MOOEL ~ & MAKE
DRIVER'S
NAME
DRIVER'S
LICENSE ~
STATE MUllER
SPECIMEN TAKEN (ALCOHOL/DRUG ANALYSIS}
l-BREATH 2-6~00 3-OTHER 4-NONE ~REFUSED
LESSEE ~ ~.~ ~, O,''t- A'~,
lAME {IL~&Y$ S~OW LES,SEE IF ~.~1. ~THLI~
INSURANCE [] NO {)IQ ~;~/";
- '
v~, IOENT .0 IF~ ~ ~ 3 Z ×~ TM
BOOT
IF BOOT STYLE = VAN OR BUS,
INDICATE SEATING CNJACITY
OCCUPATION ~F¥/../~ ~ 4
PEACE OFFICER, EMS ORIVER,
FIRE FIGHTER ON EMERGENCY?.
--m YES
~ NO
AOOJi~ {aia~.~i. CITY, ST'TL ~1~
VEHICLE OAMAOE RATING
DAMAGE TO PROPERTY OTHER THAN VEHICLES
· ~1[ ~O AOO~ES$ :~iE~. GIT% STATL Z]fl OF ~
LIGHT L~
CONOITION
1-OAYLIGHT
2-OAWN
3-OARK-NOT LIGHTED
4-DARK-UGHTER
5-DUSK
WEATHER ~. l: SURFACE
-- ~ CONDITION
: I-CL.EAR /CLOUOY 6-SMOKE 1-ORY
Z-RNNING 7-SLEETING Z-WET
3-SNOWING I-HIGH W1NDS 3-MUDOY
4-FOG 9-OTHER I 4.-SNOWY/ICY
5..Rt,,OWING OUST [ 5-OTNER
V~ ROAD
SURFACE
I-BLACKTOP
2-CONCRSTE
3..GRAVEL
4,.SHELL
5-DIRT
6~THEll
OESCRIOE ROAD CONOITIONS (INVESTIGAIr~S OPINION)
IN YOUR OPINION, 010 THIS ACCIDENT RESULT IN AT LEAST $500.00 OAMAGE TO ANY ONE PERSON'S PROPERTY? ~S"YES [] NO
CHARGES FILEO CITATION
NAME ~ 0 PO (7,. CHAAGE NUMBER
CITATION
NAME 0 I',.) (~ CH.A_I. EE NUM&~R
TIME NOTIFIED MJtr " . ~ME AR~VEO AT .
[oF.c,...
|~~.~~~.M [n-u Ic-~u~ u-mKl~ 14.m~ [c.N~m~ 14-~
?-I.t TO SMICIT I-I SO~CITATI01I [11-I Ill-NINE
RATIN6 i T~l, 1~ I YES ,~NO .
i COMPLETE ALL DATA ON ALL OCCUPANTS' NAMES. POSITIONS. Nt&illAJNTS USE,. ETC.:
OCCUPAHT'$ i IT IS NOT NECESSAItY TO SNOW AOONESSES UNL~S~ IOLJ~:D ON INJURED.
POSITION I .u__aU_~ (LAST' NAME FIOST) AO011ESS (STIIEET. Cl~t. STATE. ZIP)
0RIVER t SEE FRONT
[
IF AMBULAHCE USO. SHOW
TIME TIME ANNIVEO N~ ATTENOANTS
NOTIFIE0 AT SCENE INC. 0111YEN
~ _ . i ..... I .......... ~ ' --' t
ITEM .UMB~B~'~ I TIME OF DEATH
INV~ST~DATOR~S NARRATIVE 0PINION OF WHAT HA~F~ED (ATr~:H AO0471ONAL SHEETS IF NECESDAAY) ./ [ 01AGNAM J ~ ONE WAY {~ TWO WAY ~OMt0 [ ~Y~d~.J<~o
b,~,,~z. U~,:4 L.~A~ 4-f/~.*,-t~/~?, .~fo..~r~./¢.~...~.~.~J ~
EACTOA$ ~JdO C0N01TION$ USTEO ARE THE INVESTIGAT011'S 0PiniON
0THEA FACTON$/C0NOITIONS MAY
FAL~0flS/C0NOm0NS C0#TmlUTING 0' MAY NOT HAVE CONT.JIUTEO
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