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<br />State of Nebraska <br />2 <br />1 <br />HIT & RUN? <br />Total Number <br />1 <br />L14060028 <br />1 <br />X <br />X <br />of Vehicles <br />DATE <br />01 <br />OF <br />0553 <br />06/01/2014 <br />X <br />ACCIDENT <br />0554 <br />Hall <br />PLACE <br />OF <br />ACCIDENT <br />YESNO <br />PRIVATE <br />X <br />PROPERTY? <br />70 <br />ROAD ON WHICH <br />east bound I-80 mile marker 312 <br />YESNO <br />ONE-WAY <br />X <br />ACCIDENT OCCURRED <br />STREET? <br />NSEW <br />DISTANCE FROM <br />2 <br />MILEPOST <br />IF AT INTERSECTIONIF NOT AT INTERSECTION <br />X <br />1 <br />NSEW <br />NAME OF INTERSECTING ROADWAYFEETMILESOF NEAREST STREET, BRIDGE, RAILROAD CROSSING <br />10.00 <br />Mile Marker 312 <br /> X <br />01 <br />IF ACCIDENT WAS OUTSIDE CITY LIMITS, INDICATE DISTANCE FROM NEAR <br />NSEWNSEW <br />Grand Island <br />0.25 <br />2.00 <br /> X <br /> X <br />DOES ACCDENT INVOLVE DAMAGE TO <br />R.R1R2R3R4 S.S1S2S3S4S5-aS5-bS6-aS6-b <br />WORKPEDESTRIAN <br />STATE DEPT. OF ROADSÂ’ PROPERTY? <br />ZONECLASSIFICATION <br />1 <br />X <br />CODESCODES <br />2 <br />X <br />DRIVER <br />E825084216215 <br />MN <br />NO. <br />1 <br />LICENSE <br />651-269-3799 <br />Nicolle O Brethauer <br />1 <br />05/25/1991 <br />638 S Aspen Crt, St Peter, MN 56082 <br />17 <br />702-600-3027 <br />William J Brethauer <br />CITATION <br />X <br />2 <br />5719 Mellinger Drive, Saginaw, MI 48601 <br />LICENSE <br />PA2014 <br />538YJC <br />NV <br />PLATE <br />NO. <br />3 <br />2500 <br />2006Ford4 door Sedansilver / chrome <br />VEHICLE Focus <br />3 <br />1FAFP34N96W214073 <br />Geico <br />17 <br />Island Towing <br />Island Towing <br />4281-96-77-21 <br />75 <br />5 <br />DRIVER <br />NO. <br />LICENSE <br />1 <br />CITATION <br />01 <br />LICENSE <br />PLATE <br />NO. <br />1 <br />VEHICLE <br />01 <br />Complete this section for all injured persons 12345 <br />SEX <br />VEH. # <br />VEH. # <br />VEH. # <br />DR Form 40, Jan 09 <br /> <br />