ST9704-CS 990501o;. , ~ '.
TEXAS PEACE OFFICER'S ACCIOENT RE]~ ST-3 (Eft. I~ 1/96) MAIL TO: ACCIDENT RECORDS. TEXAS OEFARTMENT OF PUBUC SAFETY, PO BOX 4e,"7, AUSTIN TX
PLACE W, aE ~0,- .~ 9 ~)' O ~ ~ .~//
. COUNTY shoe eeLY W roses CITT UWrS
IF ACCIDENT WAS OUTSIDE CI1T UMITS, [] FI [] [] DO NOT WRITE DPS NIl.
INDICATE DISTANCE FROM NEAREST TOWN MILES NORTH S E W OF ' IN THiS SPACE
CITYOITIill
LOC.
ROAD ON WHICH ~ CONSTR, [] YES SEED :~0 CODE
ACCIDENT OCCURRED /C::)C~ ~'. ,~Cr,~A~;~ "~/-'V~' · aNE ~O UMIT
B~K imam ~nm OR n e CONSTR. ~ YES S~ED
tNTERSE~ING ~E~ ~ ~NE ~ NO UMIT ' S~R
OR RR X'ING NUM6~ '
N~ AT mT~S~ON /0 ~ ~ ~. D ~ ~ D OF / '
~ Ul~ I NI fiRS~W ~Ul~ H~Y. FAT. R~,
[] A.M. IF EXACTLY NOON DR. REC. ~
WFFK TL~ ~ HOUR / :,2,40 [] P.M. OR MIDNIGHT. SO STATE
ACCIDENT ~ ~ ......
IF BODY SWLE = VAN OR BUS,
UNIT
HO. ,- emO. e,CLE rE..OENT .0 ,~ .~OAG't ~ '/~,~ ~/¢,.O,C.TE SEAT,N.
MODEL 5~Jl//E' STYLE ' P
YEA" i '~ '7~ coLoN ~,~ ,,',~ NAME
MODEL & MAKE ~ H I ~ . Ysat /am
DRIVERS ~ ~,/~/..~rA ~'~0 ~* ,~,,',~T/-/~,z ;~Z2 ,<, ~ ?~0/~ . aBE;
NAMF ~ , ~ (~:.
~ u
SPECIMEN T~ iA~OHOL/DRU6 ~Y~S) ~ ~/~ ~E OFFICER, EMS DRIVER,
1-BROTH 2-B~D 3-~H~R 4-NONE ~REFUSED A~OHOL/DRUG ~ALYSIS RESULT FIRE FIGHTER ON EMERG~CY? D YES ~ NO
LESSEE D
OWNER ~
UABILIW ~S~~s F~ ~ ~/ 3~ ~0'z~'~ VEHICLEDAM~ERA~N6.l~rb'~
INSURANCE ~ NO ~u~
UNIT M~R V~lC~ S T~IN ~ ~A~CLIST~ ~F~L~L / V~ I~ ~ ~F ruDDy s,~ = w oR 8us,
NO. 2 ~ ~ ~DESTRIAN D ~ ~ VEH IDENT NO INDICATE S~TING C~K~
MODEL BODY ~ ~Z. ~ pM~ ~ ?~
Y~R ~? CO~R ~ ~ NAME ~C~ S~
MODEL & MAKE ~ ~ ~
PHONE
NUMBER
NAME ~ ~ llOO~ ~55 (~e~i. C~, ~AfE.'~ '
UCENSE sue cms/~ ' uo ~
~/~ PEACE OFFICER, EMS DRIVER,
SPECIMEN TAKB (A~OHOL/DRUG ~ALYSIS) ~ ~ NO
1-BREATH 2-BffiOD 3-OTHER 4-NONE ~REFUSED ALCOHOL/ORUG ANALYSIS RESU6 FIRE FIGHTER ON EMERGENCY? ~ YES
LESSEE ~ ~ ~
OWNER ~ ~Hs lliniu, cl~, ~AT[, a~
INSURANCE: NO ~TAf~' VEHICLE DAMAGE RATING f ~ ~'
.,..,,.
.,,, '"'"" I/1'""'"
CONDITION ~ CONOITION SURF~E
1-B~P ~
2-OA~ 2-RAINING 7-S~BING 2-W~ ~GRAVEL '
3-OARK-N~ UGHED ~SNOWlNG ~HIGH WINDS ~MUDOY I Y ~SHELL
4-DARK-LIGHT~ ~FOG ~HER ~SNO~/C ~DI~
i-DUSK 5-BffiWlNG OU~ ~HER ~HER
IN YOUR OPINION, DIO THIS ACCIDENT RESULT IN AT L~ST $500.00 DAMAGE TO ANY ONE PERSON'S PROPER~? ~ YES ~ NO
CHARGES FI~ CITATION .
_ CITATION
NAME CH~GE NUMBER
i I ALCOHOLlORD'6 ANALYSIS
SOUCITATIgl EJECTED CODE FOR TYPE AIRBAR CODE HELME, .wE CODE FOR iCOIIRBE ;F C/4aALIIS net
{SOL) RESTRAINT USED INJURY SEVERITY m leOTOn veecl.E)
TO DAMAGE REMOVED TO ~ -~ "5'. )~F/.J~..~T'/'~{.J.~/'~(~JC)-
DAMARE !~TES EJ NO ~..~,H~4°3' (.~j~__~-'~:~-'f. TZ_ ~.~'~.,//'~'
RATING t~' I~b'Z"' i 8Y
OCCUPANTS IT IS NOT NECESSA~ TO SNOW ARORESSES UNLESS NILlED OR INJURED. S
POSITION
NAME [LAST NAME FIRST) ADDRESS ISTREET. CITY. STATE. ZIP)
DRIVER SEE FRONT /4%//~ -
UNIT NO. 2 (COIIPtETE ONLY IF UNIT ~ TOWED DUE VEHICLE p,)v/ccTd r..jj,(,~E~
RATING
OCCUPANT'S IT IS NOT NECESSARY TO SHOW ADORESSES UNLESS IOLL~9 QR INJURED. SOL EXCT9 STUNliT AIRB~ HELNET AGE SZX lid jURy
POSITION NAME (LAST NAME FIRST) ADDRESS (STREET, CJTY, STATE, ZIP) ~
COMPLETE IF CASUALTIES NOT IN MOTOR VEHICLE
REET, CITY, STATE, ZIP) SOL SPECIMEN RESULT HELMET AGE SEX INJURY
TAK CODE
DISPOSI110N OF KILLED AND INJUNE~
NU TIME ARRIVED E NO. ATTENDANTS
TAKEN TO AT SCENE INC. ORIVER
COMPLETE THIS SECTION IF PERS4)M KILLED
ITEM NLIMBER DAlE UP ur..m:n NUMBER DATE OF DEATH TIME OF DEATH ITEM NUMBER DATE OF DEATH TIME OF DEATH
INVESTIGATOR'S NARRATIVE OPINION OF WHAT HAPPENED [ATTACH ADDITIONAL SHEETS IF NECESSARY) . DIAGRAM [ I ONE WAY '~ TWO WAY ~ DIVIDED
/J...~'.Z ~1,~ /~j ~. .~.,~,.:~V~.,~V~.~r'~[ ~/~ /c:.~ (~,.D,C.TE
........................................................ NORTH
.... .... ..............
.... ~ ...............~ .........~ ..........~ .......................................................
FACTORS AND CONDITIONS USTED ARE THE INVESTI6ATOR'S OPINION TRAFFIC CONTROL
STHED FAC/ORS/CONDITION$ MAY O-NO CONTROl. OR INOPERATIVE ~-.TUAN WXS w-we PASSINS ZaME
FACTORS/CONDITIONS CONTRIBUTING OR MAY NOT HAVE CONTRIBUTED 1-OFFICER ON FIJ~MAN 6-IARmN6 SIGN TI-OTNEO CONTROL
SOL:C~TATION L .) CODE FOB TYPE AIDBAG CODE h .T USE ~ ; NO~
(SOL) RESTRAINT USED
INDICATES P~RSDN'$ DEGreE TO DECEIY~ CONTACT FDOM P~JSQNSA - lOT ~A - SF~LT & SNOULDEG $TIAP~T-
SEEKING P~GFESSIONAL EMINENT AG/FOD AN ATTORNEY.Y - YESI - SEATBELT & N - NO DEP%QYMENT2 - WORN-NOT OAMAGEOA - IliCAPACtTRTJNG INJUNY2 - GL~O
E - SHO(JLDED S'TRJ~ ONLY 4 - NOT WORN C - POSSIBLE iI~UBY4 - NONE
TOWED DUE I ~NICLE
TO DAMAGE MOVED TO
DAMAGE
RATING [] NO
COMPLETE ALL DATA ON ALL OCCU S, POSITIONS RESTRAINTS USED, ETC.: HOWEVER,
OCCUPANTS~ IT IS NOT NECESSARY TO SHOW A~~D. SOLL~ECTEDIEST1U, ITAIRBAGHELMETi AGEI S(XII~URY
P~SITION NAME (LAST NAME fiRST} % ADDRESS (STREET, CITY, STATE, ZIP) USED CODE
DRIVER SEE FRONT
~--,.,~
UNIT NO. 2 ICOMPX.ETE ONLY W UNFrTOWED DUEVEHICLE
DANADE No' z WAG A WOTQN VEHICLE)TO DAMAGER/MOVED TO
RATING FI YES [] NO BY
COMPLETE AII DATA ON ALL OCCUPANTS' NAMES, F~)SITION$, RESTRAINTS USED, ETC.; HOWEVER,
OCCUPANT'SIT iS NOT NECESSARY TO SHOW AOORESSES UNLESS IGLLE~ OR INJURED. SOLF,~CTaBLTmAInAJP. S~S~ELMETAGES~(mJUnY
POSITION NAME (LAST NAME F1RST) ADOOESS (STREET, ~ USE~ CON~
/
DRIVER SEE FRONT
~ ..
COMPLETE iF CASUALTIES NOT IN MOTOR VEHICLE
~ ~ TY,'E
PEDAU;YCLISTCASUALTY NAAIi: Ik/,,,, ;:;.'_:'~ ~""';;T} CASUALTY ADDRESS (STREET, CITY, STATE, ZIP)SOL SPECIMEN RESULT HELMET AGE SEX INJURY
ETC. TAKEN CODE
DISI~)SITIDN OF KILLED AND INJURED IF ,
/TIME TIME ARDIVED NO. ATYEDOANTS
ITEM NUMBERS TAKEN TO NOTIFIED AT SCENE INC. DRIVER
COMPLETE THIS SECTION IF PERSON KILLED
ITEM NUMBER MDER DATE OF DEATH TIME OF DEATH ITEM NUMDER DATE OF DEATH TIME OF DEATH
INVESTIGATOR'S NARRATIVE OPINION OF WHAT HAMNED (ATTACH AOOITIONAL SHEETS IF NECESSARY) DIAGRAM I ~ ONE WAY ~ ,I TWO WAY :: DIVIOEO
RS AND CON01TIONS lISTED ARE THE INVESTIDATOR'S URNION [ ~ ' i I TRAFFIC CONTROL
0OTHER ACTO S/CONDITIONS MAY e-NO CONTNO'. 0it Met S-TUON M le-N6 I,-,,SSmS ZONE ~'~
.TR,,uT,.D ' ON .,,, ...A,E CO,.,,..~ ;.-.~::~,..,~: ,.-~ ~s,,,.'.s .-0.,.
14. m~UILED 01 TRAFFIC '.NtE 33'. FAJLEll II I'~ I01 -- EMEIGi~ VEH;CLE 51. OI~NED D~ INTO TRAFFIC LA~E
· - '-, I" ' ' '-
TEXAS PEACE OFFICER'S ACCIDENT ~IEPOi!T S'F.3 (EN. 1/1/96) MAIL TO: ACCIDENT RECORDS, TEXAS DEPARTMENT OF PUBUC SAFETY, PQ BOX 4087. AUStiN TX 787730001
PLACE WHERE
ACCIDENT OCCURRED ~ ~ LOC. lie.
coo.,, A (/~ ~ c.-, o..,. P~"~ '~
· IIIIOIILYIFIN~ID(CITYLiIITS
IF ACCIDENT WAS OUTSIDE CiTY UMITS. ~ [] [] D [] _ DO NOT WRITE OPS NO.
INDICATE DISTANCE FROM NEAREST TOWN MILES NORTH S E W OF c~r o~ TOe, IN THIS SPACE
LDC.
ROAD ON WHICH /(::::~ ~ ~ ~s~ /'~ ~D CONSTR. [] YES SIF. ED ~ CODE
ACCIDENT OCCURRED , .~ ZONE FINO LIMIT
~ INTERSECTING STREET CLOCK ,uaea ,ainu ares Bm,a Oe ~eef C~eE CONSTR. [] YES SIF. ED _
OR RR X'IN6 NUMBER ~ ZONE [] NO LIMIT __ SEVI~JI'f __
NOT AT ,.,~SEOT,O./ OZ[] .. [] [] [] [] OF "~"~' ~'A/' ~.I
[] MI. N S E W s,oe,na, nT,e,r~erm a~Euscsms e,nxsa,mm~r.
o,TE oF/I,~A'-~ ( <~:~ .~,,0F%~,,~a~,,~ [] ,... ,, ,~, .Do. J .._ __
ACCIDENT 19 HOUR / :.__~__~ [] P.M. O, elm, SliT. SO STATE
UNIT IF BODY STYLE = VAN OR euS.
NO. 1 - MOTOR VEHICLE VEH IOENT NQ INDICATE SEAtiNG CA.BAC
YEAR CQU)R MODEL BODY
MOOEL &MAKE NAME STYLE .
ORIVER'S ~ PHONE nan
NAME ,d./ NUMBER
allillS$ STIIEtT,~S
DRIVER'S LAST mET mme4.E (
UCENSE . OOB EX __ OCCUPAtiON
sPEcIMEN TAKEN ~A~'~ROL/DR S~FUSEO F'] OL/ORUG ANALYSIS RESULT PEACE OFFICER, EaR DRIVER,
I~REAT~[] 2-BLOOD 3-OTHER NO E ~ FIRE FIGHTER ON EMERGENCY? IR YES [] NO
ISTItEET, ClT~. SrATL
UABIUTY [] YES
VEHICLE DAMAGE RAtiNG
INSURANC unx~ nucY
OTOR VEHICLE [] TRAIN [] PEDALCYCLIST [] IF BODY STYLE = VAN OR 8US.
O. TO PEDESTRIAN [] OTHER FT VEH IDENT NO INDICATE SEATING CAPACITY
NOTOR VEHNO21~tpC~
YEAR COLOR MODEL BODY UCENSE
NAME STYLE PLATE
DRIVER'S ~ ~ PHONE YEA, m muuea
NAME NUMBER
LICENSE DOB SEX ~ OCCUPATION
SPECIMEN TAKEN (ALCfiHOL/DRUG ANALYSIS) ["'1 PEACE OFFICER. EMS DRIVER,
l-BREATH 2-81.000 3-OTHER 4-NONE 5-REFUSED ALCOHOL/DRUG ANALYSIS RESULT _ FIRE FIGHTER ON EMERGENCY? [] YES [] NO
LESSEE []
OWNER []
LIABILITY [] YES
VE
INSURANCE [] NO IIGUnAIICE COUPAllY IL, UlE muC/mumeEl
DAMAGE TO PROPERT*f OTHER THAN VEHICLES
$
"""' F']'"'" I']""" E3
CONDITION ~CONDITION SURFACE
1-BLACKTOP
l-DAYlIGHT l-CLEAR/CLOUDY 6-SMOKE l-DRY
Z-DAWN 2-RAINING 7-SLEETIN6 Z-WET ~2GRAVEL ·
3-DARK-NOT UGHTED 3-SNOWING 8-HIGH ~ 4-SHELL
4-OARK-UGHTED 4-FOG ER 4-SNOWY/ICY 5-DIRT
5-~ ~ 5-OTHER 6.-OTHER
IN YOUR OPiNiON, DID THIS ACCIDENT RESULT IN AT LEAST $500.00 DAMAGE TO ANY ONE PERSON'S PROPERTY? [] YES [] NO
CITATION
:.".:fief NUMGER __
CITATION
NAME . CHANGE
SIGNATURE OF INVESTIGATOR ~ IO NO. ~ 58
.c..~ ~s~ ~ AND m.~: : )
.,~ i '3"
~ + PAR~Y BLVD
$1~ ~$T ~N AND POLC
ACQDENT NUMBER: ~'OI
O
Z ~1~: ~opp~t C~NTY; ~S ~TA~
~ I I