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, <br /> ll.If tliis clalm Invofvc;t�vc:tldc aulden[/coillslon,provlJc your v�ilvdc Informaqon:_ __��__ I <br /> F/�1r hb. Flake Medrl 7ar � <br /> nii�r/sNamc ' D,i+iv's[/ancehb. � ✓c�ldrJ.�vrn,�fs)(i/da/cmuNiorndd✓n) I <br /> fA�SN5111fGId4:P(4'IyLib)' R100CNo, ___. _____,_.' PoIKYG'b. �— _ I I <br /> �2.��ames,addresses anA tdeplrone num6?rs of all Oersons Involved In or wltness to this InUd^.nt ! <br /> --G�1lelunr�r�vey-- -- 15�5 11o���- Pcvc i'vere{{- WA__N2S-z51_2�f2 � � <br /> - --- —�----- <br /> '_]�.Uf�C��l�°i �L1'� fl 1$IS 4-�0,�'��JC. (-VP.VC�� N1f� �.�Z1-].57 -7_V2{+ _ i <br /> 13. D:ames,adtlrc.,s aud lclephonC num6^rS ol all Gry ol EvMr.tt empioyees Itavino knmAeApe al;o�t ih,Inrldent: I <br /> Cn��Ci� Pu111io-�,la��'.S_Z�L(�`m_L ('L:�Sa...� $IJI(L'�_—_. ' ._— <br /> cc�L�('ef I��LI.� w:�ks 2y Iv--U='"° —123v-�+ti_ �'I 3 --- --- <br /> 14 '..unrs, adtlresses antl lelephan^ numbcrs of all Indiv:dual5 not alre�;fy Idc�4111ed In Nt2 anJ 7l13 a6ouc�.vho havc knnv,IM�r. <br /> reynrdiuy Ilie Ilahllll}• issurs lirvnlved In Ihl; InQdent, or Y.nov+leA9c of Ihe OalmanCS resultln9 darnage.a, Please I�;ludc a bdeF <br /> desulpllon is tu tlie nature and ertent ot rad�pr.rscn's Y.no'.�led3e ARac1�aAJittonal sheels If nr.cessary. <br /> l5, Describe lhe cause o!tlie In)ury or dama9es. Cxplaln the eatent of pm;ieity loss m n��edca�,physlcel er menlal InJuries. Attach : <br /> ad^Il'.onal shceLs If nIumssIary. <br /> �7L'C_ U:�`l.'_`,C.h illf�h'.���.-� .�/.��_. �I <br /> ._.__. . _'___ '__'-____.—___ _._ <br /> 1G.Has Uiis In:ident been repmled[o taw enforcement,salety or secudry 4cisonncl? I(ro,when and to�}*:,m7 <br /> �(�D��J4.�'yth�IL��)orf,s_r� 2_41�r �i.�« 8r31/ '� c�..t _��C�/�3 -- - -- <br /> 17.�dames,ad;Lesses anA Ielephnnr.nu�nLers of Ireatinp m^diwl providecc. Attach copies ni all mecllcal reputiv and blllln7s. <br /> � <br /> -N�Ft__ _ . . -_____--___- ______-__-____._�_ - _ <br /> --- _ ----- ---- ------- --- ... .--- <br /> 1 fl.Plr.asc altac h dnmrtmnix ihal a;upport lhr.d,Ini s:dicg�tlnn^.. ', <br /> 1��.I daim Aama9«f�om Ilir.Qly of t-vcrrtt In llic sum o15 ?_P.�----_-_.,- . <br /> I h.l;dalin(orrtl musl Lc slgnrd by eilhet lhe Clalmait[or on behaif of lhc Clalniunt Ly an atlorncy Imfa�.t v+hn hn!As a wriUen��wCr of <br /> nttcrney for lhe Claiinant,ur by an altornry n!IaW�tlmltted to pnclLe In lhe`.lale r,f V,'aslnn9mn,or hy a cm�rt-app�metl�uartllan oi <br /> 9unrd�un aA Ilt��.m. <br /> I <br /> i dedaie undet penallp o(perJur,y tmAer lhr.la:�s of lhe SLitc of lVa5hin4�on th [the(ete9oin915 Uue and conecL i <br /> -�V���h„�`"��- -(/ -- � _ _ _ <�-�rl�f.�''---- <br /> ---- 7 /io �.J_ t. �..�,�U i✓ - I <br /> Slynat�n�o ot Clalmant Datu Place signed(cily,nA state) <br /> aov,oriov <br /> I <br /> �`.�f (� � <br /> �' � i <br /> , _ _ <br />