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<br />COL4FtAD0 pEPARTME�'T C1F' PUBLIC AND ENVIRONMENT
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<br />� �TAT�s �7F L.'"OLQRALND .: STA7E FILE NUMBEFi 4
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<br />, t. �ECEOENT'S NAME (First, Mmdfe, Last� , '�;, � . � R. SEX 9. DA7E OF DEA7H (A4antn, 0ag Ysa�
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<br />Micha�I. '? 3ames MCCf�,RF�I ': ' ' > Male June 23` 2Q09
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<br />E 6114hda BafB) (�1A nM, y�Yb 1' ����� Cau 1ry)
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<br />Tnterst,ate 76 Mile Marlcer 152 Croolc Lo an
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<br />Owner/Ope�atar ,�'����.r� Marriecl Shanda Wobig
<br />13a. RESIDENCE-37ATE 136- C UN� ' 13�, C1TY;- . N•QR: �. M49 . r-. ���.) ' TREBT AN� NUMBER
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<br />N�braska Hall: '... -. '�� � anc� . :, �2�::Pi.onee�' Blvd.
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<br />James • McClaxsi� - . , �'�t `',' I�.cme. ��a McClaren - Wi�e
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<br />a ' June 25, 2009
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<br />David E. Tennant, T:;�g�n County. A�pu�y Corcrner PO Bvx .]:547, S�r1i:i�g,C�ia: 80751
<br />31. NAMEOFATTEN�INQPHYSICIANIFOTH�RTHANCERTI RI yps/PAnp , , �� ���
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<br />� 4 � �2. MANN�ER OF qEqTH .' �� 33a �ATE (iF INJURY` �� TIM 0 � �37a.�y�uRY A7 �J . .DESCRI � HOW INJ1�qY OGCURp§D � � � � �
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<br />.. . � � � (Montli;DaY riah ;�: � INJ�RY 1i WORI�'?: ... , . , � . .
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<br />g mveat17a11on .JlItl2 23,2a0 8:OOPM ° Vari an� Semi-trailer Truck Collision
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<br />• � caiMuJ.ti. 7.� Trauma: F`rac�ure-dislocation vf atlanto.-occi itala s
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<br />$YA71NG THE . �Intarvgl 6atWRen aneet
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<br />Fractured Lefti �ibs and Left �`erntar Yes �Yes
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