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11, ff thts dalm InvoNes a vetilde auldenVwAlsion, praNdeyaurvrhMu Informatlon: "—' <br />Afafe Na AH:e NaJrJ Yur <br />! <br />�sumnsei.w YelkkOwx+7'sJ(dM�1enYM(Nmdd�e'J <br />OwrK/s7nrurdrcr�npmY ppnpµa —' �Y� _'_ <br />1z. Names, eddresses and [Mephone numbers ol eM persons InvoNed In orwltness ta Ws IndArnt: <br />/�.orf �T'/1�2�✓0,✓ ('Psrj zr7, ya,to u.i9 .J7t.ti,r.rr�/ <br />,ct�v�.c s'�r.�,r�,r,d G�ss I 'l�s• ��7.i. ?a�y �,��d,� <br />�a <br />13. Namas, addresses and telephona numbers of ap Ciry d Evaett empbyens having knowtedge a6out this Incldent: <br />Luo� • e�7�cco c��r or-��rnar/ �c•ts�co �„�.u� �a�,dr s'Ca.iK ovC7�Fl�.bV <br />2u�7 • Av4v.rY R9. 257- dBoo ��[ynct� rtt.-qri[r /icovnir�(' /N /.79'JM+G''✓J: <br />Z�/'1• S'CY'%�htld�e �^�. 2S7.8F2!•1Lwe4iNwYd-rjB�KkJik,.v � i1YY/%X/.•C41Mi ��f1%NN'L,fT <br />. �c1 <br />I4. Nmn�s, aJdresses and telephme num6en of ap hdivlduais nM atready Idmdtied in #12 and JI13 a5ovo wla hare knowledge p�` �nr <br />regarding the IuhlAty Iswes ImalveA In this Inddent, or knowl¢dge of Uc qalmnnl's rr_sulting Aamagec Pleasc indude a brlef/!'n �6 <br />desalptlon as to Ihe naWre and extent d each penon's knadedge. Altach addlNonal �eets If neaesrary. <br />.¢+�v�c7./'o0 /•� L!/�^�J /1 ?-r� /.f . <br />�ip„y�y . Gi`>�ow E�r.�7� ?��i �+-����ifd�2r, - <br />15, Desnl6e the wuse of the in)ury or damages. EMpialn the eMent of pmperty loss or mcdiwl, piryskal or mental InJunes. Attach <br />addlUonal sheels If necessery. <br />f,�..�t� v�.n�.., .,�. �n.� .nt„r-.�-� ,. �,-�r�rcc yir�r� <br />T� <br />Tb ./�f7�0/� FGev/L 7/GC � <br />�7l��T'J� , C.G[,%////�-f /Ia",b <br />rc 13h.1GA2C�y 7e rS�l C?tl3h <br />2 <br />�� <br />16. Has lhls Inddent bcen repated lo law enfrncemen4 sa(ely or saurity personnel7 If so, when aM to whom7 <br />C�%r� Of C'LL'�/�r%% �GML/(. C��O/'`��f . <br />17. Names, addmsxs and telephone numbers ot treating medlwl pnrvi�s. Auach coples o( all medluU mpotts and blllings. <br />! <br />SB, PIC35E 2II8CI1 CO[UIIIMCS HIaISIIp�Oti:I1C dllfll'SBIICgMI0f15. — WdY'YJA�, e N fl//9J, <br />19. I cFahn damag's from lhe CIM af EVerett In Me sum of �%� �. D. -��l,'�7/wf o7Y 8//>-/. .^ M-�J <br />'te /��C%�enY.� ,Bc+r��cin-.d u./ 1T/JC.E/"�a✓ P/4o�c to /J+�.y wo2_fa <br />Thk cWlm form must be slgned by elther tl�e qalmant or od Yehalf nf 1he Galmant 6y an attomey-In-faq who AoMs a wdtten power d <br />attwneV for Ihe tlalmant, a hy an attorney at law admltted to pradke In the State of WasMngton, or b} � wuthapproved guardlan ar <br />guardian ad Illem. <br />� 1 dnsJare undg penalryof <br />�D-7-v • .�L. <br />SI nature of CFaima <br />' RaV.07109 <br />unds tha laws af Ne SWte �d Washington lhat the (ntegobg ls true and mnect. <br />oy •� c• z�c.� cnm�'r, wq- , <br />Place signed <br />