HomeMy WebLinkAboutCC 10 CLAIM #88-20 08-15-88~ ~'~.; ~ ........
/ 'Inter.-Com
DATE: JULY 29, 1988 ..
FRO~:
$ USJ ECT:
~HONORABLE MAYOR AND CITY COUNCIL
CLAINANT: REGGIE RAINEY; D/L: 12/2/87; DATE FILED
W/CITY: 3/14/88; CLAIN NO: 88-20; CARL WARREN FILE
NO: .~a~nT.~
After investigation and review it is recommended that the above-
referenced claim be rejected and the City Clerk directed to give
proper notice of the rejection to the claimant and to the
claimant's attorney.
City Attorney
JGR (F4. se)
Enclosure:
Copy of Claim
· CLAIM AGAINST THE CI~ii.~ TUSTIN
('For Damages to Per ~r Personal Property)
Received by
',.S. Mail
nter-office Mail
Over the Counter
The law provides generally that a claim must be filed with the. City Clerk of
the City of Tustin within 100 days after which the incident or event occurred.
Be sure your claim is against the City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify informa-
tion by paragraph number. Completed claims must be mailed or delivered to thc
City Clerk, The City of Tustin, 300 Centennial Way, Tustin, California 92680
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the. following claim and information rela-
tive to damage to'persons and/or personal property:
1. NAME OF CLAIMANT: Reqqie RaineY
a. ADDRESS OF CLAIMANT:
b. PHONE NO: ( c. DATE OF BIRTH:
SOCIAL DRIVERS
.
d. SECURITY NO: e. LICENSE NO:
·
2. Name,. telephone and post office address to which claimant desires notices
to be sent, if. other than above:
Todd W. McWhorterr E.sq.r 207 W. 20th S't., .Santa Aha, CA 92706
· This claim is submitted against:
a·
The City of Tustin only.
The following employee(s) of the City of Tustin only:
C · XXX
The City of Tus~in and the following employee(s) of the
City of Tustin only:
see attached report
4. Occurrence or event from which the claim arises:
a. DATE: 12/2/87 b. 'TIME: 10:30 p.m. c. PLACE (Exact
and spe'cific loca%ion): Edin~er Ave., Irvine, Ca.
d. How and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use additional paper if necessary).
RaiD~V way stoDDed without probable cause, was detained for
an .~nreasonable period of time~ and was beaten.
e.. What particular action by the City, or its employees, caused the
alleged damage or injury?
beating, clubbing, kicking, etc..
'5. Gi~e a description ' the injury, property da a or loss so far as is
known at the time of this claim. If there wer~ no injuries, sta%o "no
injuries# .
~e~ attached medicals
6. Give the name(s) of the City employee(s) causing the damage or injury:
see attached
7. Name and address of any other person injured:
·
none
8. Name and address of the owner of any damaged property:
9. Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs:
c. Total amount claimed: .~n_nn~ n~
d. Basis for computation of amounts claimed ('include copies of all bills,
invoices, estimates, etc.: ~see attached report and medicals
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
ao
c.
, _
d.
Any additional information that might be helpful in considering this claim:
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM.' (Penal Code
Section 72; Insurance Code Section 556.0)
I have read the matters and statements made in the above claim and I know the
same to be true of my own knowledge, except as to those matters stated to be
upon information or .belief and as to such matters I believe the same to be true.
I certify under penalty of perjury that the foregoing is TRUe. AND CORRECT.
,
Executed this llth day of March ., 19 88 , at Tustin, California.
Office of the City Clerk,
Tustin, California
" CLAIMANT ' $ SIGNATURE
Revised 8/05/81
JGR:se :R:8/5/81 (A)
INITIAL REPORT
Patient's Name: Re,glo R~iney
Claim/Policy #:
Employer: ~o~ai ~-3~
Date of Injury/Onset: ~-','Z.x~87
1. Incident of Injury: On 12/5/87 at approximately 10:45-~1:00 ~atl~nt
reports ~h~t he: "was $tJpped by ~olice and h~ reoeated]y ~ith ~,~]~', ~]ubs
on this. ~a~e(12/3/87) coming home from work."
2. Patient's Complaints: "Stiffness a-~d sore muscles, sore rib, ', ·
toe, wrist, shoulOer, back , leg, arms." The patient also complai~'~-~-, c~
inguinal 'pain on the left side.
5. Objective Findings (Examination): Initial consultation and
examination was performed on 12/7/87 which was followed by recommended
emergency evaluation for trauma sustained: Decreased cervical rang~', o~
motion in ail ranges with severe attendant pain. Decreased lumbar range
of motion in all ranges with severe attendant Dain. Foramina Compression
Testing is positive bilaterally. Positive Kemos test on the Le~t.
Positive Kemps test on the right. Shoulder Depression testing is positive
~-~ the left. Lasegue's Sign is positive bilaterally. Positive Goldwaits
t bilaterally. ~abere-Patrick°s Test is positive bilaterally. Positive
~_lsalva test. Positive Cough- Sneeze test. Positive Milgrams test.
On 12/18/87 after medical evaluation was performed at Chapman Medical Center
the patient reported that they diagnosed a left shoulder separation and a
ie~t inguinal hernia, also it was brought to our attention that the patient
was suffering from left lateral bone bruises and left side thoracic rib
bruises.
4. X-Ray Analysis Summary: CERVICAL SPINE Cervical Hy~olordosis.
The patient°s head is tilted to the le~t. Cervical curvature is
on the left. The radiographs suggested the presence of mild myospasm
·
the 'cervical paravertebrai musculature. Multiple views of the cervical
Spine revealed no conclusive radiographic evidence of recent fracture or
gross osteopathology as visualized. LUMBAR SPINE: Lumbar Hyperlordosis.
The ilium is high'on the.~ight. Radiographic analysis of the lumbar
spine was negative for recent fracture or gross osteopathology as
visualized.
5. D£agnosi.s - ICDA #:
847.0 CERVICAL SPRAIN/STRAIN, +847.2
LUMBAR SPRAIN/STRAIN
&. Alternate Summary (Comments): The examination and radiographic
finOings support a causal relationship ~ith the history of the
a~cident.y
T. Disability Data: T~-,~ ~atien~ can perform light work with minimum
2
ture
Precision ChiroDrac~ic
2950 N. ~lassell S~reet
Orange, CA e26a5
Cent~-
Date
Completed ,By
ATIENT · INSURED (SUBSCRIBER) INFORMATION
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90020 NF' Ir,' ,~.,.. < c, ) ~-;¢
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'~NT NAME
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4 1'1 70130
e D 70150
70 70160
90 702OO
10 O 70210
11 O 70220
12 ~ 70240
13 ~ 702~
16 ~ 70330
17 ~ 70360
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25 ~ 71010
2~ ~ 71020
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30 ~ 71120
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C ~EMmES
- "" '!GE MEDICAL DIAGNOSTIC ~'
293 S. MAIN,. .,.;ET. $1J~TE 1 O0 · ORANGF_,C~LIFOR. N'~
L./~.~/ ~ - ---.:- ~ _
NECK AND CNE~I'
F~I ~ ~ (O~) ....
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ODt,C F~m~ ~ ~
Skull ~e
Tem~romandi~r Jt~ B~L
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Ril~ BiisL
Sternum
Sterno-Cisvicuisz
AND PELVIS,
C-S43irm, com134ete
IncL Fisv. & ExL
~uml~r JunCt.
8~ ~ 74000 A~?~~gtl ~ (KU8)
83 ~ 74020 ADdomet~.Com~te
87 ~ 74220
88 ~ 74~41 UGI. with KUB
91 ~ 74270
92 ~ 742~
g3 ~ 74~0 Ch~st~m~ Omi
'" 111 O 76535 Thy~<l Reel Time
112 r"~ 7~45 ~llst Reel T~ma
113 ~ 767~ ~m~m~e
' 118 O 7~5 ~~lC~e Si~e
' 119
Seoaoll Slue/
L-S Some. limited ~
L-S Same. ~e (Ommu~l
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Pmv~ Coat,em ~
Sacroiliac Jt~ Corollate
Sic, mm&Coccyx
57 O 73~30 Ctmvicle
63~ 73~ EI~ . ' /
64 73~ F~a~
65 ~ 731~ W~[Limff~
66 ~ 73110 W~[C~te
67 ~ 73130 Hand
68 ~ 731~ Fi~er{s)
69 ~ 73510 Hi~ Unil. Com~tete
70 ~ 73520 Hi~Bi~L~Petws
72 ~ 73550 Femur. In~. Jr. ~
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73 ~ 73562 K~eComolete
' .... 73581 Knee Annr~ra~y. Com01ete
~3590 TiDe & FiOula
-~ _ 7~0 An~le. Comolete
77 ~ 73630 F~ot. Comolete /'
78 ~ 73~ F~&Ankle
~: -:: ~3663 Toes
;;:; -- 75821 Ven~m~ UniL Complete
~02 -- 75~23 Ven~ra~ BilaL Complete
!'1 76815 ~ Lo=a~iz. ation
123 ~ 7~370 T~t~a~z Utt~nd
O NUCLEAR MEDICINE
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127 E3 78215 LNer & Spleen
128 O 7~223 Hel~toDilmry Ductal
129 O 7~ ~ ~n L~e~ u
1~ ~ 7~ ~~flComp~te
131 ~ ~ ~c B~ Poohng
1~ ~ 7~18 ~ I~&. R~,on. P~ .....
~2 ~ 7~24 ~ Im~ R~ Peri. (Re~) .....
.~ 6 ~ 787~ ~lm~i~On~
~; 1~ ~ 787~ ~ Fu~mon Stu~
124 ~ 7~ ~U~l~eOn~ ....
125 ~ 7~7 ~ Imgi~ MultL ,,
126 ~ ~ T~hn~ium Thyr~ ~n ....
H ~RDIO/~ONARY
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139 ~ ~
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J~ ~ ~15 ~ Stre~ Test (TreaOmill}
,- L: ~42 ~ ~274 H~ter MOmtor ECG
· ' ~ _ ...~3 ~ ~ M-M~eEc~o
· 145 ~ 93~9 2-D. M-Mooe Ec~o:z':~;raOny
~46 ~ 937~9 2-D. M-Mo=e Do==.'e' ,
152 ~ ~010 Somromet~-Vit~t C~: =,o~ --
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148 ~ 93870 Caret;0 Ima; ~Spec: A-.z ..
149 ~ 93890 Anermal StuOy-UoDer Exire~
150 ~ ~910 A~e, ml SluOy-Lower Ex;rem
151 ~ 9395G Deed Venous Evaluahon
MEDICARE Fq:IOVtDER eW9992
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· (714) 771-2281 f'~ %
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DATE OF SERVICE
F
j blIICEL.LANEOUI,,
100 O 74741 Hyena
lO3 ID 7~xx)' ~
105 !"9 7~O62 O~ Suwey. ComPete
1~ O 7~ Xe~~m~ Unit
107
156 ~ ~70 Sm~e Troy CT. ~n
K ~I~L ~E~PY
157 ~ g71~ 1 A~/1M~.ln~Min.
15g ~ g7101 ~~15Mi~
RELEASE AND ASSIGNMENT: I beret
authorize ORANGE MEDICAL DIAGNOSTIC
'I'ER to retea~e any information aCcluireO Ouring ti-
course of my examination or treatment. I
hereDy authorize Dayment to ORANGE MEDIC.~
DIAGNOSTIC CENTER for the me(tic, al beneh
otherwtse DayaDle to me for ~rvices as
herein, but not to exceecl the reasorml~e aaa cu
ternary charge for tnmr 8ewices. I uncierstand tha
am financially r~lx)rmible for ail charges
cov~'ecl by this authorizatiort.
_
S~gn~tt (Plaint. ~ Parent d Manor) Date
DIAGNOSIS CODE:
·
· . '*~/~-.~
DIAGNOSIS: [~' '''! '" ' :' ~ ['"'~
!
,
Reterrmg Physicmn ~' ' ~'~ ?' '-' '-'
A(~lr~s
TODAY'S CHARGES
AMOUNT RECEIVE~
E) CK ~ CR CD
O CASH
ADJ U STM E NT
AMOUNT. OWED
s _ (
, o
HA~k 3UDI~ 0157K1¢
COUl,iTY OF OI,L^NGI.L; STATE OF CALIFOI<NiA,
..
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CuU;~'i iV: O{, u{ ~l~out 12/2/;.;7,
and ~iv~, lcl~a, ~i~d poascss ~l~ ir~ru~',~unl ~nd weapon ol :l~e kin~ cummu~Hy ki~own ~s
~,.,bi(i' V; O~, ur about 12/3/J7, ~aia dclc~,aan:, in viul~:iu~, ol Section i~3 ol ~1,= P~l~al
Co~e, a M15D~M~ANOic, did w~llully and unlawlully re~, dc~y, ~ld obstruct a pubhc
oliic=r in lh~ dbch~rg~ ~d ~ttempt to-di~ci~arae a du~y oi his o~lic~.
COUNT Vh On or a~ut i2/2[37, ~i~ det~r,~n[, ~ vioa~ion oi Section ll~7(b) oI the
ti~lti~ h~d 5~tety Coa~, a ivIIS~,~EANOt(, did williully ~d u.l~.lully po~&s~ not lnor~
~h~n'onc uvoir~upois ounce of mariju~.
C;IT^,~.~,~ ,.,~,. ~..~.0771t. L~ ^TTACIikD l-ial4E'l'O ^i~{.) INCOiLPOtV. A'rED Hl-~iiii~ BY
~a~'~'~.i.,, 'L ,-',~ ADGITONAi. VIOLATiON.S, COUNT(S) 1~ 11, a: III.
tt, c oulc~Gapt(l)'h~reili n~rnuu, m~d :{~l ~id ~eienaants(~) be dealt with ~ccor~na to the
1~'.
I declare u~.acr p=,~lt>, of perjury that :t~u IUrcisoin~ is true ,md correct.
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...-;' ;~7-22601
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OR J/,!L USE ONLY
Er BOOKING
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PLEASE c. .,,'-'E ' PRE-BOOKING RECOR[
[ ~ ESC ~ VID ~ ~, ~ OTHER
Ir-"] WARRANT
~ME
r'-] OR,S£Lr JD OR/OR
D COURTORDER
D OR/TR - DATE'
COM.!.'~ - TIME FINE: $
J J'""""] BOOK AND RELEASE
,
SPECIFY
D ENROUTE
D LINE UP
ARRESTING OR TRANSPORTING OFFICER COMPLETE
LAST FIRST MIDDLE
lNG AGENCY
BIRTHDATE
b - t6-~"1
)DITIONAL A.K.A.
OR ,NJURED J TYPE OF ,LLNESS OR ,NJURY
YES ~NO
!
JRISpICTION J WARRANT AND/OR CASE NUMBER
!
~ARGE 1 ~'~/'"~..~'~v' 4,~-.v ~ CHARGE 4
lARGE 2
-tAR C,,1LE 3
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:ARS. MARKS. TATTOOS. AMPS
JEYES BUILD
CHARGE5
CHARGE 6
OC.~UPATION
COMPLEXION J MARITAL STATUS
)DRESS
--XT OF KIN: NAME
,'7'/V~ ~t~. , ,,.~'i,-.l CiTY
:)DRESS ....~,,,,,,,~ ~') ~.- · j
L~..CITY
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·
jSOGIAL SECURITY NO.-
ELEPHONE NO.
97'-
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STATE ' · J ZIP
STATE J ZiP
4PLOYED BY J BUSINESS ADDRESS
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:FICER'S ADDITIONAL INFORMATION/CHECK BOX IF YOU BELIEVE THE INMATE WILL REQUIRE SPECIAL MANAGEMENT.
~ MEDICAL D MENTAL ~ INTOXICATED ~ PROTECTIVE CUSTODY D HIGH SECURITY r"""} OTHER
·
I I I II I I
III
'ERMIS$ION TO USE TELEPHONE AFTER ARREST (pursuant to penal Coae ~echon 8S~.~)
nave been g~ven the opportunity to make three (3) FREE telephone calls within the LOCAL DIALING area, or at MY OWN EXPENSE
tJTSIDE me Io:~ chaHncJ area. RECORD OF TELEPHONE CALLS:
DESIRED /' Telephone calls COMPLETED
-
S;GNATURE
~o~e: ~: .. ,;: (, ,,eT, ~Js.aoo o OFFICER .'
COURT COPY
IRVINE POLICE DEPART;,'~ENT
("' NOTICE TO APPEARt-
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II;X,~..CIJTI;Q JT INVINi ON TN' OATir SHOWN &OOV' IN OII&#Gr C:OI.~NTT, ¢&GIprOftNl&
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OR OTHE:R LOCATION --
[' wRECKED' ipPEo' HAVE YOU ENTERED MISSING,
__ i='lABl-I= PARTS IN SVS?
,~ Es n,,o c:]..,,,,o.,, E3''
ITEMS ITEMS NO t ITEMS ITEMS CONOIT ION
t EMS TRANSMISSION
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CARIURITORISI
sI&T (FRo#TI IGNITION KEY ~ SPIED I i lIGHT FRONT
ALTERNATOR
SEAT tREARI GISTRATION 4 SPE£O I I LEFT REAR
DR. LIBHTSIR ) GENERATOR
NUB CAPS IR ) RIGHT REAR
I,. Mil AG WHEELS
_~, RECOVERED, STORED OR
.,
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~ D&T[ &ND CASE NOMI[N OF N[pONT IN6 &6[NCY
OWN[
~~~~ CONDITION AND INVENTORY
TAPE DECK
II | RILL _.----i-------
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1.0. HUMBER ARAGE ffTM DA A( kT YEH {SIGNATU!
OFFICER ORDERING VEHICLE STORED (SIGNATURE]
·
i,-~,,~L.,,,L I/C-- ' APPRAISAl-, REI-F. ASE,
IFOR OFFICE USE ON]..Y)
TELETYPE (DATE AND ~..r.:._.,~£0 NOTICES %EN-~~~ ~(o' iNDICATE N~ASON ~jAVA pROGRAM
~TORAG[ AUT)~OR ITT/CONC£Rk'
T IRE AND
'
C~RTIFICAT lO · _ .......... ~t~ TO TAKE pOSSESSION OF
.
7~-g~ Ur~gina~' Reco~as
~. ?,,~ COov: Tow Comp~nv
·
;I:OLEN BICYCLE (PARTS)
IROPERTY RECEIPT
)EST_RUCTION
I
C, OF OCCURRENCE
,TIM L/F/M
III · lelI I ~ II~/ ii. ...... ~
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f') F~ ,ICYCLE (PARTS) Case #_ ,,
[~ FOUND MISC. PROPERTY
r-I RECOVERED PROPERTY
DATE/TIME OCF..:JR RE D "
/~'~
.;'~.~[ DESCRIPTIOE: ~
';:: ' Other __ Banana Color: ~ ~. ,...
.... -'"' ~~ "S BIKE LOCKED:
RLS BRAKES "'--"-"'"-' ~ ~ ~ '
~ e --'--' -- - Back Rick - '
~ Knobby BIKE LOCKED ,.....Chain Guard ~
__Racing White Wall DYES r'lNO __Basket
-- Racing Black Wall
__ OTher Type: .__.i....-
BRAND
MODEL
LIC. '
~GE OF BIKE
COLORS:
FRAME
TRIM
GRIPS
CH. GUARD
OTHER
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ETAILS OF OCCURRENCE or PROPERTY DESCRIPTION
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· ,~ ' E'TIME REPORTED
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BUS. PHONE D,O.B.
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TAPE
ADDITIONAL SERIAL NBR.
JEWE LR Y
PREC.
METAI~
$
A B
OFFICE
FURS EQUIP.
$
C E
HOUSE- ~n~_~ ~u LIV~ ......
'~ I~~"1 ~AA;~ I M,SC.
GOODS
TOTAL VALUE
H I j K
WAS OWNER NOTIFIED?
Pp~-~=.RTY ,c..~TU~:';ED TO OWNER
ADDRESS "~' ~;,) ~
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PH 0~ E
UPVP.
IPROPERTY BOOKED AT IPD
! r-!FOUND -~-'~E",,~DE:;~E --":,:~--Z::'---=~:":~
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'_J DESTRUCTION
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[~YES
! ~_EC.ARATiCJ:..
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' ".":;E POUCE DEPARTMENT
;/.,C.-2CI2600' ' lCF Icg~2.O
,,~.~RREST
M
INCIDENT '\
DAT[ TIME O~ OCCURRENCE I ? DATE/TIME REPORTED TO P.D. I .L;OCATION OF OCCURRENCE
l,,V-.=-~7 'z:~ ~ / 1/'~- ~.-o~, ~=z4 ~-O~-,~ ~- ,/~' /~.-~-'~"~'Y,
VICTIM OR MSG PERSON'S NAME--LaSt, Fwst. ~ (FIRM IF BLI~NES~) 10 RESIDENTIAL ADDRESS '1 11 RES. PHONE
,,X--RACE 114 AGE 15 DOB 16 BUSINESS ADDRESS ($CHOO:. IF JUVENILEI ~? IqU$ PHONE X
CODES FOR BOXE$ 20 & $0 V VICTIM P ,= PARENTILmaamd~u~.a,,~aeat DC = ~OVEREDC~EOFINCIDENTI~8 CHECK IF MORE NAMES ON PAGE 1AA[)
W: WITNESS RP ~ REPORTING PARTY MIP ~ MISSING PERSON
I
1~ NAME--L~I. Fff$1, M~aOle
2:3 OCCUPATION 124 SEX -- DOB
21 NAME-H,a~t, F~rst, I~badie
33 OCCUPATION [ 341 [;EX ,~F '3S~&GE.., 13' DOB
MISSING PERSON (SEE INSTRUCTIONS}
MENTAl. CONDITION
20 CODE
21 RESIDENTIAL ADDRESS
27 BUSINESS ADDRESS (SCHOOL IF JUVENILE}
l.~'~,o p,~,~ P~
131 RIE~NTI~d. ADDRESS
40 PROBABLE CAUSE OF ABSENCE
37 BU~INF, S~ AODRE'"'~ (SCHOOL IF JUVENILE)
41
22 RES. PHONE
· J2~ BUS. PHONE
I
38 RES. PHONE
38 BUS. PHONE I X,'
42 IDENTIFYING MARK,S~CHARA~T~RL~"TIC~ OF M/P
43 VEHICLE DRIVEN BY MIS~ING PER~ON, - [44 WHERE LOCATED ON PRIOR OCCASION
JUVENILE
__ARr""'TEE (SEE INSTRUCTIONS) ~;~,ADULT [~4& DATF, rrlME ARREb-i F,D 147 LOCATION OF ARREST ' 1481PKG'AREA a ' IREPT.' DIST i
4,5 OF ARRESTEE-,-Last, F~St, Mmlaie
?/_.~//%~g~/' P~.,(x'6I~ /~::V~I~I~' t_9. LOCATION BOOKED ACTION T~,,.~N/ 51 BOOKING NUMBER Is2SOC. SEC. NUMBER ..
4i DA~~u .....
53 CHAR~(S~~ WARRANT NUMBERS. COURT. JUDGE ISSUING ENL. AND DATE ISSUED -
/~,~oo,, ~ - ~r,,,.,a ~,,,.,.,,, c,.,,,~_, /,(Pg. - ~.~,~.~,..<.-/ ~,'~,~,,,-,.~-
e~ H*aaC,0LOR I" EYECO~OR Is2 COMP~ 163 P[.ACE OF BIRTH
$? RESg::~4TL~L ADDRESS - I ~ # [ 68 DESCRIP¥iON AND D~POSITION OF ARRESTEE'S
$~ WAS aDMONITION OF CONSTITUTIONAL RIGHTS GIVEN'/ YE.,%,~- BY WHOM? DATE/TIME GIVEN
MODUS OPERANDI (SEE INSTRUCTIONS) REQUIRED FOR ALL: FELONIES, SEX CRIMES, NARCOTIC CASES. 488 P.C.
DESCRIBE CHARACTERISTICS OF PREMISES AND AREA WHERE C~I-~-N~E OR INCIDENT OCCURRED
71' DESCRIBE BRIEFLY HOW OFFENSE WAS COMMITTED
'172 DESCRIBE WEAl=ON INSTRUMENt. TRICK. DEVICE OR FORCE USED -
:73 MOTIVE -- TYPE O; PROPERTY TAKEN OR OTHER REASON FOR OFFENSE
ESTIMATED LOSS VALUE AND/OR EXTENT OF INJURIES--MINOR, MAJOR
·
--
WHAT DID SUSPECTIS) SAY-NOTE PECUUAt:b't,
~ -- ~'S N:;TIVITY JUST PRIOR TO AND~OR DL;A;NG OFFENSE
·
~-~-RADEMARK--OTHER DISTINCTIVE ACllON OF SUSPECTtS)
~ BY SUSPECT--I-K;. NO., ID No.. ¥®~r, Ma~e. I~:~tei. ~s (Other iD ~ter~ttcs)
Su~ECT ~. I (~T ~STED~t. F;~. ~ ~
~DCNU~
ADDRESS· CLOTHNG. ~D OTHER ID M~KS OR CHARACTERISTICS
SUSPECT NO. 2 (NOT ~RESTED~L F~st. Mm~e ~ ~
FBI. OR DL NUMBER
ADDR~. ~O~ING. ~ OTHER lO ~ OR CH~TER~TI~
~ UNFOUND
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Conaum- Livestock
able Gels. ~
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DATF..,'TIM[
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1
PART II
CRIME[
eel~ I ~1., VI-,
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·
~- ;TINUATION ~ SUPPLEMENTAL
C'--C .CTION OF ORIGINAL C;'.;k'.[' ~.'~ INCID[N~ 2 ~..~!ME OR iNCIDENT
\ 0 cl;riZEN STA'~EMENT
RE PORTED LOSS:
~AME OF PERSON MAKING STATEMENT--4.a~t, F~rst, M~Ome ADO~ESS n RESiD. t-~ BUS. PHONE NUMBER
DATF'TIME STATEMENi WR~T'~rc'.~ .~~1 LOCATION STATEMENT WRITTEN
RECOVERY; ADDITIONAl. LOSS: UNFOUND LOSS:
DESCRiPTIOZ ~ PROPE RT Y VALUE
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Cu~ency Jewelry Clothing/ Autos Office TV, Radio, Flr~s Household Consum- Livest~k Misc. PART II
~~ NED
~ T~G OFF~E R
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27
REPORTING OFF1CER~5i [$ER. NO.I
'iNE POLICE DEPARTMIr. N i '""~ ~ Nu~aEJ~ I D^Tr-J'rI~E REPCmT
2 'INUA~ON ~ SUPPLEMENTAL X D CITIZEN STATEMENT
~AME OF PERSON MAKING STATEMENT--I~a-.t,
ADDRE.~S n RESID. ~ BUS
ADDRESS D RESID. ~ BUS.
PHONE NUMBER
~AT=.:TIME STATEMENT WRII'rEN j 11 I,.UgAIION ~TATEMENT WRI'FrEN
1
REPORTED LO,~: RECOVERY: ' ADDITIONAl. LOSS. UNFOUND LOSS: DR NO.;
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:
Currency
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Jewelry
Prec. Metals
Ce
Clothing/
Furs
Autos
F-
Office
Equip.
F.
TV, R,.dlo, Firearms
Camer&~
Ho
Household
Gooas
L
Consum-
aisle Gas.
Ko
Misc.
PART II
'CRIMES
)tE$ TO:
INVi
D.A.
', Omer
t R=~ORTING OFFICE Fi
·'
J SU~ERV_I, SJ~ / '
RECEIVED
DATE/rIME J PRO
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tREPORTINGOFFICER(S! {SER NO )
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·
I~ SUPPLEMENTAL
2 CRIME OR INCIDENT
NTINU&TION
,:CTION OF OP, ICalNAL CRIME OR INCIDENT
· Z_ gr~rlZEN STATEMENT
, ;~ C, * .L...;ICATION
T P
VICTIM'S N*,AMuE--La~t, Frst, ~ (FIRM IF BUSINESS)
[$8 ADDRE~ ~ RESID, L, ~U$ [ I PHONE NUMBER
ADDRE~ O REStD. ~ BUS. 0 PHONE NUMBER
NAME OF PERSON MAKING STATEMENT--Laat, F~'M, ~
DATE;TIME STATEMENT WRII IEN
i l 1 LOCATION STATEMENT WRIT'TEr~
2 fl~:POHTEU LOSS: RECOVERY: ADDITIONAL LOSS: UNFOUND LOSS:
DR NO.:
Currency Jewelry Clothing/ Autos Office TV, Radio, Firearms Household Consum-
I Pre~. Melal: Fur~ Equip· Cameras Goo~s able GUs.
P.S./ i
LOSS)
UNF.
2 ~)PtE5 TO
iNV.
D.A.
~ Orner
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ISUP£RV~SOR ~ '
SEn. NO. I RECF..'WEO
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·
Livestock Mtso, PART 11
· CRIMES