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i, <br /> ll.If thls dalm Involves a vehlde acddmqcol!Islon,provide your veldde Informatlon:__ '"/ � _______ _ __ <br /> Pla7e Nn. l�akc Mndel Ycar <br /> PrAr/sht�me Onvr�rLlmn:ch'o. VelildeOw�ne�(sJ�Adil/r�enfhwnO�Sa) <br /> o;vrtrrstnn.�ranmCompm;y PlroneNo. � N�ryKo. i <br /> I <br /> 12.I�ame;,adAresscs and lelephone numbcis ol all persons InvolveA In or wllness to thi:inddent: j <br /> i <br /> -- ----- '-'��� — ---- --- � <br /> ------- ' <br /> � <br /> 17.Mames,addresses ond Icicphone numbers oF all Clly of[vemtt employccs haviny knovdedqe a�out th1;Incident: I, <br /> _ pti/SGIc tvo,elc ,S o�F/�LE �1zS � zs7_8�$'°l� <br /> — — --- --- -- ___ ---- --- I <br /> lh. Names, aAdresses and telephone mm�bers of all IndNltluals not alrcady IAr.ntllled In pl2 �md q13 above who have knowlr.dge i <br /> regardin9 Ihe Il�b!Ilty I�:ucs Involved in lhls Inddenl, or knovded�c of the ClaiaNn!'S rP.;Wting Aanlagr.s, Please Indude a brlef � <br /> dr.;i��lptlon as to tte natwe and extu�t cF each pereods knotivleAge. Attach adAitlonal si�eeL•If necessary. � <br /> .D�NN� S � ct1SaN� PiPvPE2-r-YMh�/ER_�_ 36a - 333 � �ot5 � <br /> -�,-TNz�x T� s�w�� ,N rFSEM�NT � <br /> /3t�'r'J/ ✓i}NFeTJEN� TENA'/�r za6 -2H5- 9310� �yITN�SS Y.> Sf:w�Q ; <br /> --- -- �:F.-n�h�� <br /> 15. �escrlhe Ihe cause of Ne Injury or Jarc�a9es. Explaln ihe�eent of property loss or medlcai, physl�l or men�al Injudes. Altach i <br /> additlonal shcets If necessary. <br /> � S E� /q' rT/4 G E'f L�O �l -- --- <br /> 16.Has Ihis InciAent been repoiteJ lo law enforcement,sa(ery cr sccuriq�pe�scnnel7 if so,when and to whom? � <br /> yEf� rv c� r'�' o�_ ���,�� ��c �3t , c. =woR1<SJ oN 9�q��� , <br /> ]7. Nanms,addiesses and telephone nurc�bcrs of treaL'n9 medlcal providers. Attnc�oples of all med;cal reports and b!liings. <br /> � -------f-1�--------- - �—�-- ------- -- -- ; <br /> 10. Please aftach dncumenls Ihat suppur[lhe cla�m's.Itegotlons, <br /> 19. I dalni danta9i;s fium tlie Gly oT Everett hi Um sum o(S � 3 � 7, �j� � I <br /> 1 hls dalm f�im inusl 6e slyncd Ly cither t6r.Ciahnant ur on 6ehal(of Uie Clalmant by an altorncy-In�lact aho holAs a written Poe�er o( � <br /> attomey fm-Ihe Clalmant,or6y an altomey a[la�v admltted to pnclice In the Sla[e of Washing[on,or by a caurbappim'ed quardlan or <br /> puardlan ad litcm. <br /> I declare�penalry of pr.hwy under the luws of the State of 1Vasldngton lhat the(ore9oing Is�tiue and correcG <br /> 9_�6 -� 3 ��� �r, �� <br /> Signature of Claimant Oatc Place signed(ciry and stato) � <br /> Roo.m;o7 � <br /> I <br /> I <br /> � � � <br /> o f,; � i <br /> �,. , _ <br /> _- � <br />