1500001341 - Newton Police Department

Commonwealth of Massachusetts
Number
Motor Vehicle Crash Vehicles
2
Police Report
Police Use Only
Date of Crash Time of Crash
12/15/2015
NEWTON
09:59:00
24HR
<
AT INTERSECTION:
1
1
2
1
3
LOCATION
1 Occupants
X Vehicle 1 ___#
q
q Hit/Run
M Lic. Class D
Sex____
18
18
Lic. Restrictions
1
19
CDL ________
1
2
MA Zip ___________
BERLIN
01503
City _________________________________
State______
City ___________________________________________ State______ Zip ___________
PLYMOUTH ROCK ASS
Insurance Company______________________________________________
Vehicle Action Prior to Crash
Vehicle Travel Direction:
N X
S E W
Responding to Emergency?____
Last
Event Sequence
First
Violation 1: Ch______Sec______ Violation 2: Ch______Sec______
Driver Contributing Code
Violation 3: Ch______Sec______ Violation 4: Ch______Sec______
Underride/Override
25
Age/DOB
See Above
Please Select One
of the Following:
X Vehicle 2
q
1
___#
Occupants
q Non-Motorist A
Type
MA
M Lic. Class D
Sex____
8
1
18
Lic. Restrictions
1
19
CDL ________
Endorsment
14
2
3
4
1
9
10 Undercarriage
5 11 Totaled
8
7
O
24
Y
Towed ____
27
28
--- --- 1
15
Action
22
29
30
31
32
33
99
4
16
Location
0
0
5
17
Condition
q Hit/Run qMoped
JWA1278
PAS
PA
Reg # _____________________________
Reg Type____________
Reg State__________
NISSAN
2015
Veh Year______________
Veh Make______________________
Veh Config.
2
20
TAYLOR
KYLE
Operator ______________________________________________________
EAN
HOLDINGS
Owner __________________________________________________________________
51 SPRAGUE AVE
Address _______________________________________________________
6929 N LAKEWOOD AVE
Address _________________________________________________________________
MA Zip ___________
BROCKTON
02302
City _________________________________
State______
OK
74117
TULSA
City ___________________________________________
State______
Zip ___________
ENTERPRISE
Insurance Company______________________________________________
Vehicle Action Prior to Crash
Last
Vehicle Travel Direction:
First
N S E W
X
Middle
Responding to Emergency?____
Citation # (If Issued)______________
Last
Event Sequence
1
Most Harmful Event
First
22
1
Driver Contributing Code
Violation 3: Ch______Sec______ Violation 4: Ch______Sec______
Underride/Override
Operator/Non-Motorist
See Above
24
18
--------
Sex
22
24
4
Y
Towed ____
26
Age/DOB
Middle
Damaged Area Code: (Circle Up to Three)
21
23
25
Please fill out for operator and all occupants involved
Address
1
22
22
Violation 1: Ch______Sec______ Violation 2: Ch______Sec______
Name (Last First Middle)
3
11
1
12
6
Seat Safety Airbag Airbag Eject Trap Injury Transp.
Pos. System Status Switch Code Code Status Code
Medical Facility
Sex
--------
S77052000
License # __________________________
St ______ DOB/Age __________
18
10
Damaged Area Code: (Circle Up to Three)
21
24
1
26
Address
Middle
23
1
Please fill out for operator and all occupants involved
2
1
22
22
22
1
Most Harmful Event
Operator
2
20
Address _________________________________________________________________
Name (Last First Middle)
7
1
58 MARLBORO ROAD
Address _______________________________________________________
Middle
Citation # (If Issued)______________
6
TOYOTA
2013
Veh Year______________
Veh Make______________________
Veh Config.
(Same as operator)
Owner __________________________________________________________________
First
9
673ZX8
PAS
MA
Reg # _____________________________
Reg Type____________
Reg State__________
TOOMEY
SCOTT
Operator ______________________________________________________
Last
2
Case Number 1500001341
Endorsment
5
NOT AT INTERSECTION:
q Moped
MA
2
>
State Police q
Local Police X
q
MBTA Police q
Other:
HAMMONDSWOOD RD
WEST
______ ________
_____________________________________________________ _____ _________ __________ ___________________________________________
Route#
Direction
Name of Roadway/Street
Route#
Direction Address #
Name of Roadway/Street
_________________________________________________________________________
__________________________________________________________________________
At
___ ___ ___ l ___ or __________________
________Feet N S E W of
HAMMOND ST
SOUTH
______ ________
_____________________________________________________
Mile Marker
Exit Number
Route# Direction
Name of Intersecting Roadway/Street
_________________________________________________________________________
________Feet N S E W of
Also at Intersection with
_______ _______________________________
Route#
Intersecting Roadway/Street
________Feet N S E W of
______ ________
_____________________________________________________
___________________________________________
Route# Direction
Name of Intersecting Roadway/Street
Landmark
S95074676
License # __________________________
St _____ DOB/Age ___________
4
RMV Document Number
Number Speed Limit 25
Injured Latitude
Longitude
0
City/Town
27
28
2
O
3
4
O1
9
10 Undercarriage
5 11 Totaled
O
8
7
6
29
30
31
32
33
Seat Safety Airbag Airbag Eject Trap Injury Transp.
Pos. System Status Switch Code Code Status Code
--- --- 1
2
99
0
0
5
Medical Facility
1
13
= Direction
ie:
Crash Diagram:
1
= Vehicle 1
1
2
=Vehicle 2
= Pedestrian
2
If Crash Did Not Occur
on a Public Way:
r Off-Street Parking Lot
r Garage
r Mall/Shopping Center
r Other Private Way
Indicate North by Arrow
Crash Narrative:
__________________________________________________________________________________________________________________________________________________
Operator of MV 1 stated he was traveling south on Hammond St and was struck by MV 2 who was coming out of
__________________________________________________________________________________________________________________________________________________
Hammondswood Rd. going across Hammonds which intersects with Hammonds Street.
MV 1 had moderate drivers side
damage and no injuries were reported.
All valuables were removed
__________________________________________________________________________________________________________________________________________________
MV 1 was towed by tody's to their lot.
__________________________________________________________________________________________________________________________________________________
from the vehicle prior to the tow.
__________________________________________________________________________________________________________________________________________________
Operator of MV 2 stated he was traveling west on Hammondswood Rd. and as he was traveling across Hammond
__________________________________________________________________________________________________________________________________________________
Street he collided with MV 1.
MV 2 stated that he
could not see the stop sign at the intersection because
__________________________________________________________________________________________________________________________________________________
as he came around the corner the stop sign was obstructed by a tree.
I inspected the stop sign and as you
__________________________________________________________________________________________________________________________________________________
come around the corner it is difficult to see the sign right away due to
obstruction.
MV 2 sustained
__________________________________________________________________________________________________________________________________________________
moderate front end damage and no injuries were reported.
MV 2 was privately towed from the scene.
MV 1 had
__________________________________________________________________________________________________________________________________________________
(Continued on next page)
__________________________________________________________________________________________________________________________________________________
W itnesses:
Name (Last, First, Middle)
Address
Phone #
Statement
Property Damage:
Owner (Last, First, Middle)
Address
Phone #
34-Type
Truck and Bus Information:
Registration # ___________________________(From Vehicle Section)
Description of Damaged Property
35
Carrier Name ___________________________________________________________________________________________ Carrier Issuing Authority Code
Address___________________________________________________________ City________________________________
St________
Zip___________
US DOT #: ______________________ State Number________________________ Issuing State ________ ICC #:_____________________ Interstate
Cargo Body Type Code
37
Gross Vehicle Weight
36
38
Trailer Reg #:_______________________ Reg Type__________ Reg State _________ Reg Year__________ Trailer Length
39
Hazmat Information:
Placard
40
Material 1 digit #
41
Material Name______________________________ Material 4 digit # _____________ Release code
42
MATTHEW W COLELLA
12/15/2015
_________________________________________________________________________________________________________________________________________________
Police Officer Name (Please Print)
Signature
ID/Badge #
Department
Precinct/Barracks
Date
NEWTON POLICE DEPARTMENT
CDP1 11 . 24. 00
= Direction
ie:
Crash Diagram:
1
= Vehicle 1
1
2
=Vehicle 2
= Pedestrian
2
If Crash Did Not Occur
on a Public Way:
r Off-Street Parking Lot
r Garage
r Mall/Shopping Center
r Other Private Way
Indicate North by Arrow
Crash Narrative:
__________________________________________________________________________________________________________________________________________________
the right of way.
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
W itnesses:
Name (Last, First, Middle)
Address
Phone #
Statement
Property Damage:
Owner (Last, First, Middle)
Address
Phone #
34-Type
Truck and Bus Information:
Registration # ___________________________(From Vehicle Section)
Description of Damaged Property
35
Carrier Name ___________________________________________________________________________________________ Carrier Issuing Authority Code
Address___________________________________________________________ City________________________________
St________
Zip___________
US DOT #: ______________________ State Number________________________ Issuing State ________ ICC #:_____________________ Interstate
Cargo Body Type Code
37
Gross Vehicle Weight
36
38
Trailer Reg #:_______________________ Reg Type__________ Reg State _________ Reg Year__________ Trailer Length
39
Hazmat Information:
Placard
40
Material 1 digit #
41
Material Name______________________________ Material 4 digit # _____________ Release code
42
MATTHEW W COLELLA
12/15/2015
_________________________________________________________________________________________________________________________________________________
Police Officer Name (Please Print)
Signature
ID/Badge #
Department
Precinct/Barracks
Date
NEWTON POLICE DEPARTMENT
CDP1 11 . 24. 00