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. <br />` 21101 <br />9946 <br />State of Nebraska <br />Investigator's Motor Vehicle Accident Report Sheet _ of 1 <br />OOtaI, <br />Number <br />of Vehicles <br />=Cr <br />L11051557 <br />Case ncy <br />No. <br />HIT & RUN? <br />`)YES :.:N.) No <br />INVESTIGATION MADE AT SCENE? <br />`) YES (X NO <br />L <br />1 <br />A/1 <br />04 <br />DATE <br />ACCIDENT <br />M M / D D/ Y Y Y Y (In Military Time) <br />STATE USE ONLY <br />' <br />05-12-2011 <br />• • • • Fli • • A c ED FN-r <br />_ <br />2057 <br />PLACE <br />OF <br />ACCIDENT <br />COUNTY <br />Hall <br />No i ED <br />2057 <br />LATITUDE <br />CITY <br />Doniphan <br />- -- ----- ---------- - - - - -- YES � NO <br />P RIVATE ? `', %� <br />B, <br />LONGITUDE <br />ROAD ON WHICH STREET/ <br />HIGHWAY NO. Highway 281 ONE-WAY YES NO <br />ACCIDENT OCCURRED STREET? `� <br />C <br />5 <br />L-- <br />DISTANCE FROM <br />MILEPOST <br />FEET <br />N <br />+ S <br />E <br />W <br />OF <br />MILEPOST <br />HIGHWAY NO. SHOULD LOCATION HAVE <br />ENGINEERING STUDY? <br />D -- <br />1 <br />— <br />IF AT INTERSECTION <br />IF NOT AT INTERSECTION CD YES �NO <br />- NAME OF INTERSECTING ROADWAY <br />CX FEET `)MILES <br />N <br />I S <br />E <br />W <br />OF NEAREST STREET, BRIDGE, RAILROAD CROSSING <br />500 <br />X <br />Cedarview Rd <br />vvim <br />01 <br />IF ACCIDENT WAS OUTSIDE CITY LIMITS, INDICATE DISTANCE FROM NEAREST TOWN <br />MILES <br />N <br />S <br />E <br />W <br />AND <br />MILES <br />N <br />S <br />E <br />W <br />OF NEAREST <br />CITY OR TOWN <br />V2/M <br />- <br />R. WORK Rt R2 <br />R3 R4 S PEDESTRIAN Si S2 S3 S4 S5 -a S5 -b S6 -a S6 -b <br />DOES ACCIDENT <br />INVOLVE DAMAGE TO <br />OF ROADS' PROPERTY? <br />(X) NO <br />ZONE <br />CODES <br />1 1 <br />J <br />1 <br />J <br />CLASSIFICATION <br />_ <br />r <br />L <br />f <br />I <br />STATE DEPT. <br />CDYES <br />E <br />2 <br />- -- - -- <br />VEHICLE NO 1 <br />F <br />2 <br />DRIVER <br />LICENSE NO. <br />H12741222 <br />STATE NE <br />(0f License) <br />SEx `) FEMALE <br />MALE <br />DRIVER <br />BRIAN K BOMBERGER <br />PHONE LOCAL NO. <br />(308 ) 258 -0345 <br />"1/N <br />01 <br />DRIVER AD 2R CITY STATE,. ZIP <br />864 FRIE RD, , ST PAUL, NE, 68873 <br />DATE OF <br />M BIRTH <br />(M /DD /YYYY} <br />vv, <br />17 <br />v2/N <br />tiK�AN K BOMBERGER , <br />(308 ) 258 -0345 LOCALNO <br />V1/2 <br />'� <br />OWNER ADDRESS CITY, STATE, ZIP <br />864 FRIEND RD, , ST PAUL, NE, 68873 <br />CITATION ED YES CITATION NO. <br />C) PENDING (X.) NO <br />V1/3 <br />LICENSE PA N O . <br />49E203 <br />(Pa Expires) <br />(01 P a e) <br />H <br />1 3 <br />YEAR <br />VEHICLE 2004 <br />MAKE <br />Chevrolet <br />MODEL <br />XLS <br />BODY STYLE COLOR <br />1 4 door Sedan BLK <br />ESTIMATED DAMAGE <br />C)TOTALED $ 5000 <br />VI /4 <br />vvo <br />2 <br />V2/O <br />No' M <br />1G1ZT64884F224033 <br />INSURANCE COMPANY <br />Allstate <br />V15 <br />17 <br />TOWED TO - <br />TOWED BY P t i 2599 <br />V1/ <br />65 <br />VEHICLE NO. 2 <br />1 - <br />5 <br />DRIVER <br />LICENSE NO. <br />1 <br />STATE <br />(0! License) <br />SEX J FEMALE <br />C) MALE <br />DRIVER <br />PHONE <br />( ) <br />LOCAL NO. <br />V1 /P <br />1 <br />V2/1 <br />DRIVER ADDRESS CITY, STATE, ZIP - <br />DATE OF <br />(MM / B DD YYYY) <br />V2/P <br />vvz <br />OWNER <br />PHONE <br />( <br />LOCAL NO. <br />L 01 <br />OWNER ADDRESS CITY, STATE, ZIP <br />CITATION . cD yEs <br /><_) PENDING C1) NO <br />CITATION NO. <br />V2/3 <br />LICENSE <br />PLATE NO. <br />1 <br />1 YEAR <br />I (Plate Expires) <br />- <br />STATE <br />(0f Plate) <br />. I <br />VV4 <br />vvo <br />4 <br />VEHICLE <br />I YEAR <br />MAKE <br />MODEL <br />I BODY STYLE <br />1 <br />COLOR <br />ESTIMATED DAMAGE <br />) TOTALED $ <br />vva <br />VEHICLE ID <br />NO. (VIN) <br />INSURANCE COMPANY <br />` <br />01 <br />V2/e <br />TOWED TO <br />TOWED BY <br />POLICY NO. <br />Complete this section for all injured persons <br />(Complete a continuation report, if more than three were injured) <br />DATE OF BIRTH <br />(non/ DD / YYYY) <br />1 <br />2 <br />3 <br />4 <br />5 <br />SEX <br />M F <br />Seat <br />P tt <br />Eject <br />on <br />I CY <br />Trans. <br />VEH. # <br />NAME ADDRESS <br />LOCAL NO. <br />MEDICAL FACILITY NAME <br />EMS SERVICE NAME <br />EMS RUN REPORT NO. <br />VEH. # <br />NAME ADDRESS ,. <br />LOCAL NO. <br />- <br />MEDICAL FACILITY NAME <br />EMS SERVICE NAME <br />EMS RUN REPORT NO. <br />VEH. # <br />NAME ADDRESS <br />LOCAL MD. <br />MEDICAL FACILITY NAME - <br />EMS SERVICE NAME <br />EMS RUN REPORT NO. <br />DR Form 40, Jan 09 <br />THIS FORM REPLACES OR FORM 40, .IAN 02 <br />PREVIOUS EDITIONS WILL BE DESTROYED. <br />