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FLORIDA TRAFFIC CRASH

REPORT

D

SHORT FORM Ix I UPDATE

D

(Electronic Version)

Date

26, 2013

. _ ~

I

lll::::ll Hll

::

I

Time of Crash

11 :04 AM

I

Date of Report

JUNE 26, 2013

HIGHWAY

SAFETY

& MOTOR

VEHICLES

TRAFFIC CRASH RECORDS

NEIL KIRKMAN

BUILDING,

TALLAHASSEE,

FL 32399-0537

Reporting Agency Case Number

130600794

I

HSMV Crash Report Number

83950527

Code

ICity Code County of

Crash

40 ST LUCIE

I

Place or City of Crash

FORT PIERCE

Within City Limits

YES

I

Time Reported ITime Dispatched

11:04 AM 11:05 AM

Scene ITime Cleared Scene Completed

08AM

11

:30AM YES

I

Reason

(if Investigation

NOT

Complete)

Notified

By

MOTORIST

Occurred On Street, Road , Highway

IO

At Street Address #

At Latitude And Longitude

System Identifie r

Direction

s

I

At I

From Intersection With Stree t,

Road,

Highway

VIRGINIA AVENUE

Weather Condition

1 CLEAR

I

Type of Shoulder

3 CURB

'

Roadway Surface Condition

1 DRY

'

School

Bus

Related

1 NO

IO

Or From Milepost

I

Type of Intersection

1 NOT AT INTERSECTION

'

Manner of Collision

1 FRONT TO REAR

Type

I

First Harmful Event

14 COLLISION WITH MOTOR VEH IN

TRANSPORT

First Harmful Event Location

1

ON

ROADWAY

1 NO 1 NON-JUNCTION

With in Interchange First Harmful Event Relation to Junction

: Road

ICrash in Work Zone

Contributing Circumstances: Road

Contributing Circumstances: Environment

IType of Work Zone

Contributing Circumstances:

Road

Contributing Circumstances: Environment

I Workers in Work Zone ILaw Enforcement in Work Zone

Motor

Vehicle Type

1 VEH IN TRANSPORT

I

Hit and Run

1

NO

Veh License Number IState IReg. Expires Permanent Reg. IVIN

AQMH63 FL AUGUST 26, 2013 1 NO 1C8GJ253X2B599327

Style Extent of Damage jEst. Damage jTowed

Due

To Damage jVehicle Removed By Rotation

4t l: on

...........

. CO.

of Vehicle Owner (Business) D

. CENDEJAS

License Number State

:

License Number State

Reg. Expires

Reg.

Expires

S 25TH STREET

Current Address

874 SW HAMBERLAND AVE

Permanent

Reg

.

VIN

Permanent Reg . VIN

On Street, Road, Highway

Insurance Policy

Number

A9012101540

City & State

PORT SAINT LUCIE, FL

Zip Code

34953

Year Make

Year Make

I

At Est. Speed

I

osted Speed

40 40

Length Axles

Length

Axles

r

Total Lanes

04

Area

of

Initial Impact

Most

Damaged Area

I

T ailer Type (Trailer Two) 2 I 3 I 4 I 5 I 6 7 18 Undercarriage 18 ) I 3 I 4 I 5 I 6 7

r;; J 19 Overturn 19 ...... r;; J -

X d ~ 16 117 0

20

Windshield 20 X ~ ~ 16 1111 0

M a t R e ~ l e a _ s _ e _ T I H _ a _ z _ .

- a t - . - P ~ l a - c - a r _ d _ . . . . _ N _ u _ m _ b _ e r - - - - - - - - ~ - . . I C . . l a _ s _ s - - - - - - - - 1 /I

'

21

Trailer

21

/I

.

ICargo Body

Type

GVWR/GCWR

Trailer

Type

(Trailer

One)

JI

I 13

2

110 9

JI

I

3 2

110 9

Carrier Name

US

DOT Number

Carrier Address City &State

Zip

Code

Phone Number

Vehicle Body Type Vehicle Defects (one)

16 (SPORT) UTILITY VEHICLE 1 NONE

Vehicle Defects (two) Emergency Vehicle Use Special Function of MV

1 NO 1

NO

SPECIAL

FUNCTION

AHEAD 1 TWO-WAY, NOT DIVIDED 1 LEVEL 1 STRAIGHT

e Maneuver Action ITrafficway Roadway Grade Roadway Alignment

Most Harmful Event

2 COLLISION WITH

NON-FIXED OBJECT

I

Most Harmful Event Detail

14 COLLISION WITH MOTOR VEH IN

TRANSPORT

For This

Vehicle First

1)

Sequence

of Events

Second (2) Sequence of

Events

CONTROL SIGNAL 14 COLLISION WITH MOTOR VEH

IN TRANSPORT

HSMV90010 S

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IThird 3) Sequence

of Events

I Fourth 4) Sequence of

Events

7/26/2019 Miriam Mateen FPPD Crash Report 13-06-00794

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lnme of

Crash IDate

of

Report

IReporting Agency Case Number

I HSMV Crash Report Number

26, 2013

11

:04 AM JUNE 26, 2013 130600794 83950527

1

Motor Vehicle Type

IHit and Run

Veh License Number

State IReg. Expires Permanent Reg . I

VIN

1 VEH IN TRANSPORT 1 NO

7691NF FL FEBRUARY 2, 2014 1 NO JN8AS5MV5AW107307

Make

IModel

Style

IColor

Extent

of

Damage

IEst . Damage 'Towed Due To Damage

Vehicle Removed By Rotation

NISS 4D BLU/

4MINOR

$500 1 NO DRIVER

Company (Driver)

'Insurance Policy Number

CENTURY CENTENNIAL INSURANCE C 20537952

of

Vehicle Owner (Business) D

Current Address

City & State

Zip Code

MATEEN

2516 S 19TH ST 101

FT PIERCE, FL 34982

se

Number State

Reg. Expires Permanent

Reg

. VIN Year Make Length Axles

Number State

Reg . Expires Permanent Reg . VIN Year Make

Length Axles

:

Direction

On

Street,

Road,

Highway

'At Est. Speed

Posted Speed

ITotal

Lanes

N S 25TH STREET

40

04

ICargo Body Type

Area of Initial Impact

Most

Damaged Area

213141516 213141516

~

Trailer Type (Trailer One)

IT ailer Type (Trailer Two)

7

18 Undercarriage 18

-

t

16

IX

19 Overturn

19

1 lt

16

I

X

x

20

Windshield

20

x

Ma t. Release

IHaz . Mat. Placard

Number

I

Class

- -

14 I 13

112

I 11110 9

21

Trailer

21

14 I 13

112

111110 x

I

Larn

er

..ame

1 s f i e t i l l u m b ~

Carrier Addre

ss

City & State Zip Code Phone Numb er

m/Non

-Commercial

rehicle Body Type

Vehicle Defects (one)

Vehicle Defects (two)

I Emergency Vehicle Use

Special Function

of

MV

1 PASSENGER CAR

1 NONE

1 NO 1 NO SPECIAL

UNCTION

Maneuver Action

ITrafficway

IRoadway Grade

Roadway Alignment

I

ost Harmful Event

I

ost Harmful Event Detail

,_

....

t

.... ......_A::......

I">

,...,...,

1 ~ 1 n

.. 1

WITl I

1A

rnl

I

IC: lnM WITl - I MnTn l \/1=1-1

-

...

I

O N T LEFT TURN LANE

-

I

ITRANSPORTINON-FIXED OBJECT

Control Device For This Vehicle rrst (1) Sequence of Events I Second (2) Sequence of Events IThird (3) Sequence of Events IFourth (4) Sequence of Events

C CONTROL SIGNAL 14 COLLISION WITH MOTOR VEH

IN TRANSPORT

.

Description

'V

ehicle# 'Name

I Date

of

Birth

'Sex

IPhone Number

IRe-Exam

1 DRIVER 01 FRANCES G. CENDEJAS AUGUST 26, 1983 2 FEMALE (772) 353-0019 2 NO

~ s ~ -

Zin

rn o

SW HAMBERLAND AVE PORT SAINT LUCIE, FL 34953

Licen

se

Number

State Expires

IDL Type

Req. End. In

jury

Severity Ejection

FL AUGUST 26, 2019 5 E OPERATOR 3 NO ENDORSEMENT 1 NONE 1 NOT EJECTED

Systems

IAir Bag Deployed

relmet Use

Eye Protection

'Seating Location Seat 'Seating Location Row

Seating Location Other

AND LAP 2 NOT DEPLOYED 3 NO HELMET 3 NOT 1 LEFT 1 FRONT 1 NOT APPLICABLE

USED APPLICABLE

of

Crash (First) Drivers Actions at nme

of

Crash (Second) Driver Distrac ted By Vision Obstruction

IN CARELESS/NEGLIGENT 7 INATIENTIV E 1 VISION NOT OBSCURED

at

nme of Crash

(Third) Drivers Actions

at nme of

Crash

(Fourth) Drivers Condition

at

Time

of

Crash

77 OTHER (EXPLAIN IN NARRATIVE)

l Use 'Alcohol Tested

r lcohol

Te st Type

r lcohol

Test Result

BAC

ruspected

Drug

Use

Drug Tested

'Dr ug Test Type

IDrug Test Result

NO

of

Transport

to

Medical Facility

' EMS Agency Name or ID IEMS Run Number

Medical Faci lity Transported To

TRANSPORTED

son# IDescription

Vehicle# I Name

I Date

of

Birth

ISe x

I Phone Numbe r

'Re-Exam

1 DRIVER 02 MARIAM MATEEN FEBRUARY 2, 1989 2 FEMALE (772) 318 -9188 2NO

Address City

&

State Zip Code

19TH ST

101

FT PIERCE, FL 34982

License Numb er

State 'Expires

IDL Type

IReq . End.

Injury Severity Ejection

FL FEBRUARY 2, 2019 5 E OPERATOR

3 NO ENDORSEMENT

1 NONE 1 NOT EJECTED

Systems

'Air Bag Deployed

relmet Use

Iye Protection

reating

Location Seat

'Seating Location Row

Seating Location Other

2 NOT DEPLOYED 3

NO

HELMET 3 NOT

1 LEFT 1 FRONT 1 NOT APPLICABLE

USED APPLICABLE

at

nme of

Crash

(First) Drivers Actions

at

TI

me

of

Crash

(Second) Driver Distracted

By

Vision Obstructio n

CONTRIBUTING ACTION 1 NOT DISTRACTED

1 VISION NOT OBSCURED

Action

s at Time

of Crash

(Third) Drivers Actions

at nme of Crash

(Fourth) Drivers Condition at Time

of

Crash

1 APPARENTLY NORMAL

d Alcohol Use 'Alcohol Tested

'Alcohol

Test Type rlcohol

Te

st Result

BAC

15u

spected Drug

Use

Drug Tested

'Drug Test Type

I rug Te st Result

1 NO

ofTransport

to Medical Facility

IEMS Agency Name

or ID

'EMS Run Number

Medical Facility Transported To

HSMV 90010 S

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ITime

of

Crash IDate

of

Report

I Reporting Agency Case Number

IHSMV Crash Report Number

26,

2013 11:04AM

JUNE 26 2013

130600794

83950527

.. . .

'Description

3 PASSENGER

Vehicle# I Name

02 NUZHAT RASHID

I Date

of

Birth

MARCH 8, 1953

ISex I Injury Seve rity

2 FEMALE 1 NONE

IEjection

1 NOT EJECTED

Address

City State

Zip Code

SABAL LAKE DRIVE PORT ST LUCIE FL

34986

Systems

'Air Bag Deployed

'Helmet

Use

I ye Protection

reating

Location

Seat

'Seating Location Row

reating

Location Other

AND LAP 2 NOT DEPLOYED 3

NO

HELMET 3 NOT

3 RIGHT 1 FRONT 1 NOT APPLICABLE

USED

APPLICABLE

ofTransport

to

Medical Facility

'EMS Agency Name or I

'EMS Run Number

'Medical Facility Transported To

June 26, 2013 I responded

to Virginia Avenue and

S. 25th

Street for

a

report

of a non-injury traffic crash.

Prior

to

my

arrival both vehicles had

a private

parking

lot.

I

met

with

the drivers and

obtained

their

statements. St.

Lucie

Fire Rescue also responded

and

obtained refusals

for

1, a 2002

Chrysler

van was driven by Frances Cendejas. Cendejas stated she was traveling north on S. 25th Street and

did

not see traffic

in

front

of her. Cendejas stated she

was

distracted due

to

pain in her

right

hand

having

been slammed in the

sliding door

of her van.

entroute to the hospital to have her hand X-rayed. Cendejas did attempt to stop but could not and struck the rear

of

Vehicle 2.

injury.

2,

a 2010 Nissan

was

driven by Mariam Seddique. Seddique stated she

was

stopped in traffic

for

the red light

at

Virginia Avenue. She heard

squealing and then felt the impact

of

Vehicle 1 hitting the rear of her vehicle. Seddique and her passenger denied injury.

minimal to both

vehicles

and both vehicles

were

driven

from the scene.

was

veroa11y wdrnea.

l m 1

=

::I ll

I ank and Name

IDepartment

IType of Department

NO RANK

D.

DANIELS FORT PIERCE POLICE DEPARTMENT

2 PD

HSMV 90010 S

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