Date of Crash
Time of Crash
09ltL/2012 14 10 24HR
Com monwealth of Massachusetts Motor Vehicle Crash SPRINGFIELD Police Report City/Town
AT II.ITERSECTION:
Lirnit 3 0
Speed
State
Local
Police tr Police
MBTAPolice Other:
tr tr
I\OT AT INTERSECTION:
APPLETON ST Name of Roadway/Street
Name of Roadway/Street
M3Til|lw-l
.
or Mile
Name of Intersecting RoadwayiStreet
-r..t
Also at Intersection with
or
Marker
Route#
Exit Number
Intersecting Roadway/Street
Name of Intersecting Roadway/Street
[l #
License
sex
F
v.nicte t
S9LL93622 Lic
1 st
[l
#occupants
MA
L2-2905-AC
uirinuo
DoB/Age 07
/ 29 / L97 3
classFTIII Lic RestrictionsllT| cDL-
ORTIZ / SYLVIA L nddress 70 APPLETON ST
01108-2902
State
Direction' INXJE
Responding to Emerg ency? 2
Ch/Sec/Sub I Please
Name (-ast First
city
19
Reg Type
93
veh Make
fill
Reg state
MA
veh config.
ORTIZ , SYLVIA L
SPRINGFIELD
State
M[,
zip
ffi
0LLOS-2902
Damaged Area Code: (Circle Up to Three)
Event Sequence
Most Harmful Event
Drivercontributingcode underride/override
Viol.4: Ch/Sec/Sub
Et] EIE
out for operator and all occupants involved
Middle)
Pc
cHEvRoLET
Vehicle Action Prior to Crash
lwl Citation # (If Issue$ R2 I I5141 110 viol.2: Ch/Sec/Sub viol. 1:Ch/Sec/Sub 90 Viol. 3:
veh year
owner
Insurance Company Vehicle Travel
# 1ww7 5 0
tnr:lorsement
operator
SPRfNGFIELD
Reg
ro*.d
2
E
27 Safety System
Address
BAYSTATE
MEDICAI
[l
v.nicte
20
#occupants
St-
fxoo.MotoristATypeilEActionilHLocationEflConditionffi
DOBiAge
Reg
#
953DL3
vehvew
operator
Driverless
M.
V.
State-
city
Zip
CTTIZENS vehicle Travel
Direction'
fWdwl
2OL2
owner EWEN Address
Reg Type veh Make
f.l
PC
uirnoo
Reg State
HONDA
veh
l'IA
conrrg
l-,
11
2ol
l.
I
r DAVID K
88 APPLETON
ST
SPRINGFtrELD
State
MA
Zip
Vehicle Action Prior to Crash Responding to Emergency?
2
Event Sequence
t
,1
)1
)7
)1
Citation # (If Issued) 1: Ch/Sec/Sub
Viol.2: Ch/Sec/Sub
Drivercontributingcode
Viol. 3: ChiSec/Sub
Viol.4: Ch/Sec/Sub
Underride/override
Viol.
Please Name Q-ast First
fill
EE
[38 To*.d
2
8
out for operator/non-motorist and all occupants involved
Middle)
OperatorA{on-Motori st
Address
Medical Facility
.)= Direction E
ie: ')fr
- vehicle 1 ff
= vehicle 2
+lrl
I
ft =
Pedestrian
-)R
If
Crash Did Notoccur on a Public Way:
App{eten,
"St
IIJST
T#
.SilALE 12-A*rl5*4f;
..
t
n
Offl-street Parking Lot
n
Garage
il
MalVshopping Center
il
Other Private Way
i:'
..-."*' i: t .."":ilf *<
i.
-!:',-:,ii."
North
l,t/V #L S on Aplleton St by #90 when collision occured. Oper #1 :rnhgt3t'egy at scene, suffering from pre-existinq medical condition prior to condition and transported to Baystate Nedical. via Al4R 4t6.
M/v *2 Parked, unoccupied in front of 90 Appleton St when collision occured.
Name (Last,First, Middle)
Owner (Last,First,Middle)
Description of Damaged Property
Registration #
(From Vehicle Section)
Carrier Name
Carrier Issuins Authoritv Code
US DOT #:
cargo Body rype
St-
Ciry
Address
Issuing
State Number
code
ffi
Gross Vehicle
Trailer Reg #:
Reg
weight
State-
ICC
#:
Zip
terstate
Effi
Type
Reg
State
Reg
Year
Trailer Leneth
Hazmat Information:
placardff
Officer
Material
EDT,iliUlD
Police Ofticer Name (Please Prin| cDPl
11-2J-00
l digit#
ffi
MateriatName
N HIIIEY
Material 4 digtt
H490
Sierature
IDlBadge #
#+elease
code
sprinsfield Po].ice Departnent Departrnent
Precinct/Barracks
09/1112012 Date