20140225 Cross Isham (1)Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
PK2011
GZORQNL Page 1 of 6
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~ Reportable Accident I 0 On Emergency 0 Amended
I DOT Document Number
GZORQNL
I Document Override Number
Agency Accident Number Police Number
14022506 14022506
4-Accident Date 1 5 -Time of Accident (Military Time) 1 6 -Total Units 1 7 -Total Injured 18-Total Killed
02/25/2014 2030 02 00 00
2 -County I 3 -Municipality 11 -Accident Location
SAWYER-57 HAYWARD -06, TOWN NON-INTERSECTION
1~-On Hwy No. 114-On Street Name 114-Bu s/Frnt/Rmp 15 - Est. Dist I Ft/Mi 115 -Hwy. Dir
0.30 M SOUTH
~6 -Fr/At Hwy No.l16-From/At Street Name 116 -Bu siness/Frontage/Ramp
17 -Structure Type 117 -Structure Number 112 -Latitude I ~ 3 - Longitude
80 -First Harmful Event 1 93-Manner of Collision
MOTOR VEHICLE IN TRANSPORT REAR-END
112 -Access Control 1113 -Road Curvature 1113 -Road Terrain I Surface Type
NO CONTROL STRAIGHT LEVEL/FLAT BLACKTOP (BITUMINOUS)-2
115 -Traffic Way
NOT-PHYSICALL Y-DIVIDED-(2-WAY TRAFFIC)
117 -Relation To Roadway
ON-ROADWAY
114-Light Condition 1116 -Road Surface Condition 111 8 -Weather
DARK-NOT-LIGHTED ICE CLOUDY
9 1 9 0 Hit and Run D Government Property I 0 Fire I 0 Photos Taken I 0 Trailer or Towed
9
I 0 Load Spillage I 0 Construction Zone I &J Names Exchanged 0 Truck, Bus, or Hazardous Materials
101 1102 1103 1 79 -EM S Number 0 Supplemental Reports D Witness Statements D Measurements Taken
Operator/Pedestrian
Unit Status 1 81 -Most Harmful Event: Collision With I 23 -Dir Of Travel 1 24-Speed Limit
MOTOR VEHICLE IN TRANSPORT SOUTH 35
36 -Operating as Classified 1 37 -Endorsements I 35 D CLASS D Operating Commercial Motor Vehicle
29-Driver"s License Number 1 30 -State 1 31-Expiration Year 1 34-On Duty Accident
WI 2018
25-Operator/Pedestrian Last Name I 25-First Name I 25 -Middle Initial I 25 -Suffix
CROSS MARl PATRICIA
32 -Date Of Birth 1 33-Sex
08/19 FEMALE
26-Address Street & Number 1 26 -PO Box
27-City I 27-State I 27 -Zip Code 1 28 -Telephone Number
COUDERAY WI 548280000
39 -Seat Position 140 -Safety Equipment
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR) SHOULDER-BELT-AND-LAP-BELT-USED
38 -Injury Severity 141-Airbag 142 -Ejected 144 N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED 0 Medical Transport
43 -Trapped/Extricated I 92-Pedestrian Location I 92 -Pedestrian Action
NOT-TRAPPED
119 -What Driver Was Doing 1120 -Traffic Control I ~2 -No. of Citations Issued
PARKING-MANEUVER NO-CONTROL
64-1st Statute No. 1 64 -2nd Statute No. I 64 -3rd Statute No. I 64-4th Statute No. I 64 -5th Statute No.
122 -Driver Factors
NOT-APPLICABLE
88 -Driver or Pedestrian Cond I 89 -Substance Presence
APPEARED NORMAL NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
90 -Alcohol Test I 90 -Alcohol Content 1 91 -Drug Test
TEST NOT GIVEN TEST-NOT-GIVEN
Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
GZORQNL Page 2 of 6
PK2011
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91 -Drugs Reported
124-Highway Factors
SNOW,-ICE,-OR-WET
Vehicle
21 -Unit Type
AUTOMOBILE
I Vehicle Type
PASSENGER-CAR
I ~2 -Total Occupants
56 -License Plate Number 1 57 -Plate Type 1 58-State I 59 - Exp Year I 55-Vehicle Identification Number
AUT WI 2014 1 54316
50 -Year 1 51 -Make
2012 CHEV
1 52 -Model
IMPALA
I 53 - Body Style
4D
1 54-Color
WHI
I ~ 00-Skidmarks to Impact (Ft)
94-Vehicle Damage
REAR, REAR DRIVER SIDE
95 - Extent Of Damage 1 96 1 97-Vehicle Removed By
MODERATE 0 Vehicle Towed Due To Damage OPERATOR
123 -Vehicle Factors
NOT-APPLICABLE
Vehicle Owner
45
[8] Vehicle Owner Same As Operator
46 -Vehicle Owner Last Name 146 -First Name 1 46 -Middle Initial 146 -Suffix I Date Of Birth
CROSS MARl PATRICIA 08/19/
46 -Company Name
47-Address Street & Number 147 -PO Box
48 -City 148 -State 148 -Zip Code 149 -Telephone Number
COUDERAY WI 548280000
Insurance
63 -Liability Insurance Company I ~ PROGRESSIVE-CASUALTY-INS-CO Policy Holder Same As Owner
61 -Policy Holder Last Name I 61 -Policy Holder First Name
CROSS MARl
61 -Policy Holder Company
School Bus
Bus Travelling to/from I School Name 0 To 0 From
I Body Make I Seating Capacity
School District Contracted With
Operator/Pedestrian
Unit Status 1 81 -Most Harmful Event: Collision With I 23 -Dir Of Travel I 24-Speed Limit
MOTOR VEHICLE IN TRANSPORT SOUTH 35
36 -Operating as Classified 1 37 -Endorsements I 35 D CLASS 0 Operating Commer cial Motor Vehicle
29-Driver's License Number 1 30 -State I 31-Expiration Year 1 34-On Duty Accident
9901 WI 2013
25-Operator/Pedestrian Last Name I 25 -First Name I 25 -Middle Initial I 25 -Suffix
ISHAM MARl PATRICIA
32 -Date Of Birth 1 33-Sex
08/19/ FEMALE
Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
PK2011
GZORQNL Page 3 of 6
26-Address Street & Number 1 26 -PO Box
27-City I 27-State I 27 -Zip Code 1 28 -Telephone Number
COUDERAY WI 548280000
N 39 -Seat Position 140 -Safety Equipment 0 FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR) SHOULDER-BELT-AND-LAP-BELT-USED
z 38 -Injury Severity 141-Airbag 142 -Ejected 144 <( N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED 0 Medical Transport ii: 43-Trapped/Extricated I 92-Pedestrian Location ) 92 -Pedestrian Action .....
t/) NOT-TRAPPED w c 119-VI/hat Driver Was Doing 1120 -Traffic Control I ~2 -No. of Citations Issued w GOING-STRAIGHT NO-CONTROL a.. -64-1st Statute No. 1 64 -2nd Statute No. I 64 -3rd Statute No. I 64 -4th Statute No. I 64 -5th Statute No. 0:::
0 343.05( 3)(A) 344.62(1) .....
<( 122 -Driver Factors
0::: FAILURE-TO-HAVE-CONTROL w a..
0
88 -Driver or Pedestrian Cond I 89 -Substance Presence
APPEARED NORMAL NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
90 -Alcohol Test I 90 -Alcohol Content ) 91 -Drug Test
TEST NOT GIVEN TEST-NOT-GIV EN
91 -Drugs Reported
124-Highway Factors
SNOW,-ICE,-OR-WET
Vehicle
21 -Unit Type I Vehicle Type I !2 -Total Occupants
AUTOMOBILE PASSENGER-CAR
56-License Plate Number 1 57-Plate Type 1 58-State I 59-Exp Year I 55-Vehicle Identification Number
AUT WI 2014 06322
N
50 -Year 1 51 -Make
1996 DODG
1 52 -Model
INTERPID
I 53 -Body Style
4D
1 54-Color
BLU
I ~ 00-Skidmarks to Impact (Ft)
0 94-Vehicle Damage
w FRONT, FRONT PASSENGER SIDE ...J 0
:I: w > 95 - Extent Of Damage I 96 I 97-Vehicle Removed By
MODERATE 0 Vehicle Towed Due To Damage
123-Vehicle Factors
NOT-APPLICABLE
Vehicle Owner
45
N D Vehicle Owner Same As Operator
0 46-Vehicle Owner Last Name 146 -First Name 1 46 -Middle Initial 146 -Suffix I Date Of Birth
0::: MITCHELL LEO c 04/01/
w 46-Company Name z ~ 0 47-Address Street & Number
> 48 -City 148 -State 148 -Zip Code 149 -Telephone Number
WINTER WI 54896
Insurance
Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
PK2011
63 -Liability Insurance Company
N NONE
GZORQNL Page 4 of 6
lo Policy Holder Same As Owner
0 61 -Policy Holder Last Name I 61 -Policy Holder First Name
(/) z -61 -Policy Holder Company
School Bus
N Bus Travelling to/from I School Name I Body Make I Seating Capacity 0 0 To 0 From
(/) =» School District Contracted With
al
Occupant
~ Address Same As Operat or
65 -Unit No 1 66 -Occupant Last Name 66 -First Name I ~-Middle Initial 1 66 -Suffix
01 CROSS DENISE
68 -Address Street & Number 68 -PO Box ..... 0
68 -City 68 -State I 68 -Zip Code .... COUDERAY WI 548280000 z <t 67 -Date of Birth 69 -Sex
fl.. 01/01 /FEMALE =» 0 71 -Seat Position 1 72-Safety Equipment 0 FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER) SHOULDER-BELT-AND-LAP-BELT-USED 0
70 -Injury Severity 73 -Airbag I 75 -Ejected
1 77 N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED 0 Medical Transport
76 -Trapped/Extricated 78 -Agency Space
NOT-TRAPPED
Occupant
0 Address Same As Operat or
65 -Unit No 1 66 -Occupant Last Name 66 -First Name I ~-Middle Initial 1 66 -Suffix
01 RASMUSSEN BEVERLY
68 -Address Street & Number 68 -PO Box
N 0
68 -City 68 -State I 68 -Zip Code .... COUDERAY WI 548280000 z <t 67 -Date of Birth 69 -Sex
fl.. 11/03 FEMALE =» 0 71 -Seat Position 1 72-Safety Equipment
0 SECOND-SEAT-LEFT-SIDE-(MC/BIKE PASSENGER, TRAIN BREAKMA SHOULDER-BELT-AND-LAP-BELT-USED 0
70 -Injury Severity 73 -Airbag I 75 -Ejected 1 77 N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED D Medical Transport
76 -Trapped/Extricated 78 -Agency Space
NOT-TRAPPED
Occupant
0 Address Same As Operator
65 -Unit No 1 66 -Occupant Last Name 66 -First Name 1 66 -Middle Initial 1 66 -Suffix
02 ISHAM MICHAEL J SR
68 -Address Street & Number 68 -PO Box
M 0
68 -City 68 -State I 68 -Zip Code .... COUDERAY WI 54828 z <t 67 -Date of Birth 69 -Sex
fl.. 06/26 MALE =» 0 71 -Seat Position 1 72-Safety Equipment 0 FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER) SHOULDER-BELT-AND-LAP-BELT-USED 0
70 -Injury Severity 1 73 -Airbag I 75 -Ejected
1 77 N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED 0 Medical Transport
Wisconsin Motor Vehicle
Accident Report MV4000e 01/2005
GZORQNL
PK2011
'l:t 0
..... z <( a.. =» 0 0 0
Lt)
0
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76 - Trapped/Extricated
NOT-TRAPPED
Occupant
0 Address Same As Operat or
65 -Unit No 1 66 -Occupant Last Name
02 REFUSED
68 -Address Street & Number
68 -City
67 -Date of Birth
71 -Seat Position
SECOND-SEAT-RIGHT
70 -Injury Severity
N-NO APPARENTINJURY
76 - Trapped/Extricated
NOT-TRAPPED
Occupant
[8] Address Same As Operat or
65 -Unit No 1 66 -Occupant Last Name
02
68 -Address Street & Number
68 -City
COUDERAY
67 -Date of Birth
78 -Agency Space
73 -Airbag
NON-DEPLOYED
78 -Agency Space
Page 5 of 6
66 -First Name 1 66 -Middle Initial 1 66 -Suffix
68 -PO Box
68 -State I 68 -Zip Code
69 -Sex
1 72-Safety Equipment
SHOULDER-BELT-AND-LAP-BELT-USED
I 75 -Ejected
NOT-EJECTED 1 77 0 Medical Transport
66 -First Name
68 -PO Box
68 -State I 68 -Zip Code
WI 548280000
69 -Sex
FEMALE
0 71 -Seat Position 1 72-Safety Equipment
0 SECOND-SEAT-LEFT-SIDE-(MC/BIKE PASSENGER, TRAIN BREAKMA NONE-USED-VEHICLE-DRIVER/OCCUPA NT 0 70 -Injury Severity 73 -Airbag I 75 -Ejected 1 77 N-NO APPARENTINJURY NON-DEPLOYED NOT-EJECTED 0 Medical Transport
76 - Trapped/Extricated 78 -Agency Space
NOT-TRAPPED
Diagram and Narrative
105 -PHOTOS BY
Wisconsin Motor Vehicle GZORQNL Page 6 of 6
Accident Report MV4000e 01/2005
PK2011
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Ba$ed on operator $latement
Not drawn to scale
UNIT# 1 WAS PARKED ALONG THE SHOULDER OF THE SOUTHBOUND LANE OF CTH K, UNIT # 2 WAS SOUTHBOUND ON CTH K,
OBSERVED THE VEHICLE STOPPED, BUT DID NOT SEE HAZARD FLASHING. OPERATOR STATED THAT THEY WERE UNAWARE IF
THE VEHICLE WAS STOPPED OR MOVING. UNIT # 2 CONTINUED SOUTHBOUND TOWARDS THE UNIT# 1 WH ERE IT COLLIDED WITH
THE REAR END OF UNIT# 1.
Officer Information
125 -Officer Last Name 1125 -First Name 1125 -Middle Initial 1131-Officer ID
RIPCZINSKI GREG 326
129 - Law Enforcement Agency No. 1130 -Law Enforcement Agency Name
5700 SAWYER COUNTY SHERIFF
126 -Law Enforcement Agency Address Street & Number
15880 EAST Fl FTH STREET
127 -City 1127 -State 11 27 -Zip Code 1 128-Telephone Number
HAYWARD WI 54843 (71 5) 634-4858 EXT.
132 - Date Notified 1133 -Time Notified (Military Time) 134-Time Arrived (Military Time) 1135 -Date Of Report
02/25/2014 2031 2041 02/25/2014
Agency Accident Number I Police Number 19 -Special Study
14022506 14022506
18 -Agency Space