HomeMy WebLinkAbout06- Ingram - Notice of Claim - 11-20-06
LAW OFFlCES OF
WALTER H. MADDEN and KARL KNUCHEL, P.C.
A Professional Corporation
Attorneys at Law
116 West CaUeoder
P.O. Box 9!3
Llvtnpton, MT g(M7
Telephone: 4061222-O13!
Facsimile: 4061222-8!17
e-mail: knuchel@wispwest.net
NOTICE OF CLAIM
November 6, 2006
THE HONORABLE JANET KELLY
DIRECTOR, DEPARTMENT OF ADMINISTRATION
MONTANA STATE GOVERNMENT
P.O. BOX 200101
HELENA, MONTANA 59620-0101
and
BRIT FONTENOT, CLERK OF COMMISSION
CITY OF BOZEMAN
CITY HALL
411 EAST MAIN STREET
BOZEMAN, MONTANA 59715
Re: Kayle Ingram
Dear Ms. Kelly and Mr. Fontenot:
With your permission, please note that we represent the Estate of Kayle Ingram
who sustained severe injuries, including partial severance of the right arm, experienced severe
pain and ~uffering over several hours and ultimately died following a traffic accident at
occurred on North 19th in Bozeman, Montana, on October 18, 2005. Pursuant to MCA fi2-9-
301, please accept this correspondence as the Notice of Claim for the following:
\i....r...
11/17/2006
Page 2
Claimants: Estate of Kale Ingram. by his personal representative, Cole Ingram;
Cole Ingram individually; Jackie Ingram; Capri Ingram; Michelle Ingram;
Date of Loss: 10--18-2005;
Accident Location: North 19m Street, just north of its intersection with Dead
Man's Gulch/Cattail Drive in Bozeman, Montana;
Attorneys: Walter Madden and Karl Knuchel at P.O. Box 953, Livingston,
Montana 59047;
Enclosures: 1. Crash Investigator's Report (this investigation was handled
predominately by the City of Bozeman Police Department); 2) Attorney/Client Fee
Agreements: 3) State of Montana standards applicable to height of medians;
Claim Facts: Kayle Ingram, a then high school junior, was a right front seat
passenger in a vehicle operated by David Cherry on the afternoon of October 18, 2005, in
Bozeman, Montana. Mr. Cherry was driving a 1984 Toyota. At the time in question there
were two northbound lanes on North 19m. The City of Bozeman contracted with Thomas,
Dean & Hoskins of Great Falls for the engineering work on the North 19th project including
overseeing the operation and creating engineering design and specifications. The City also
contracted with JTL of Belgrade, Montana to do the construction work.
On the afternoon in question, JTL suddenly funneled traffic from the right (or
east) northbound lane to the left (or west) northbound lane in such a manner as to prevent a
reasonable opportunity for motorists to merge over from the right northbound to the left
northbound lane.
After David Cherry maneuvered his 1984 Toyota from the right northbound lane
to the left northbound lane, his vehicle came into contact with the median on North 19m just
north of its intersection with Dead Man's Gulch / Cattail. The median was unmarked and was
at that time at least 8 1/2 inches high contrary to the Montana State Department of
Transportation's own standards for medians. Medians are to have a height of no higher than
15Om.m (6 inches) with a face no steeper than 1 horizontal to 3 vertical. The unmarked median
which the Cherry vehicle encountered was at least 8 1/2 inches high.
The design speed called for a maximum of 70 kIn per hour (approximately 43
mph). The posted speed limit on North 19m at the'time was ~5 mph with a 35 mph speed in
work zones.
When David Cherry's 1984 Toyota came into the contact with the 8 V2 inch high
median, the impact tore asunder the undercarriage of the Toyota causing the driver to lose
control and resulting in the vehicle going over the median making contact with the roadway on
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11/17/2006
Page 3
the driver's side of the vehicle and sliding on its left side northbound now in the southbound
lane of oncoming traffic. The Toyota made contact with a truck which sheered the roof from
the Toyota. There were no warning signs of the unmarked median or of its 8 V2 inch height
contrary to state and national standards.
The Montana Department of Transportation and herein the City of Bozeman
have a duty to exercise ordinary and reasonable care in maintaining and improving the
roadways. They breached this duty by creating an unsafe highway condition by virtue of the
negligent design, engineering, construction, maintenance and inspection of the project. This
resulted inclusively in the presence of an unmarked 8 Y2 inch high median which was way
beyond the national and state standard for heights of such medians, to wit, being no more than
6 inches. The low clearance of the 1984 Toyota simply could not accommodate contact with a
median that high. The State and the City left the median at that 8 1h inch height level for many
months after the accident in question. Ultimately, the roadway surface of the area in question
recently underwent asphalt paving thereby raising the surface of the roadway some 2 Vz inches
in an effort to bring the median within the state and national standards of no more than 6
inches in height.
Separate and apart from the incktent in question of October 18, 2005, other
motorists voiced grave concern about the height and concomitant dangers of the median as
well. As a result of the above described negligence, Kayle Ingram sustained serious and
severe injuries including the partial severance of his right arm along with massive internal
injuries from which he suffered and ultimately died several hours later.
In addition to Kayle's horrific pain aml suffering, his loss of future earnings
reduced. to present value approximates 1.4 million dollars alone. Based on the above, the
claimants make the following demand: consistent with the provisions of MCA ~2-9-108(3),
and the March 17, 2003, contract between the City of Bozeman and Thomas, Dean & Hoskins,
Inc. and the contract of May 19, 2005, between the City of Bozeman and JTL Group, which
incorporate liability insurance, the total demand on behalf of all claimants to resolve all claims
is $7 million.
If there is any other governmental entity(s) that may be liable to the claimants
either in full or in part, please provide us with the name, address, and agent for each such
entity. Also, please provide a copy of this Notice to such potentially responsible party. This
Notice is submitted in compliance with the provisions of ' Montana's Tort Claims Act, MCA
~2-9-101 et seq. including MeA ~2-9-301.
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11/17/2006
Page 4
Lastly, as an accommodation to you, you are invited to an initial exploratory
"
meeting concerning the matter to be held at the Wingate Inn Board Room on Thursday,
December 14, 2006, beginning at 10:00 a.m. Please confirm that date and time at your earliest
opportunity. Thanking you for your courtesy and attention. I remain,
;2d~~
Walter H. Madden, Esq.
Enclosures
xc: Cole Ingram, Personal Representative of the Estate of Kayle Ingram
~'\. [-,:
Repoltinf Officer.
Bozeman Police Department ON FI 0 ENTIAL
Fatal Crash Report
THIS INFORMATION IS FOR LAW
Sgt.MarkJohnson ENFORCEMENT PURPOSES ONct
ANY UNAUTHORIZED USE IS
0501211411002 STRICTLY PROHIBITED.
Crash Report # :
Date of Report:
November 29,.2005
SynQpsis: This was a two vehicle, sideswipe, opposite direction collision involving a Toyota
passenger car and a d1evrolet pickup auck The Toyota was traveling north on North 19th Avenue
and had two occupants. Th.e Chevrolet was traveling south on North 19th Avenue and had one
occupant. The Toyota failed to negotiate a lane change, strock the median, rolled onto the'driver's
side and slid into the lane of the Olevrolet, striking the driver's side of the Chevrolet.
CJriI;n:1tion of Call: The call came into the Gallatin County/City of Bozeman 911 Center at 1734
hours on October 18, 2005. I was dispatched to this accident at 1735 hours.
Environment21 Conditions: The weather conditions at about the time of the accident were in the
mid 60's degree Fahrenheit with clear skies. Wmds rnnged from 6 miles per hour out of the north to
7 miles per hour of the southeast.
Date/Time/Location: October 18, 2005 at 1734 hours on the 2800 to 2900 blocks of North 19dt
Avenue in Bozeman, Gallatin County, Mr.
Initial Observations qpon Aniv.d: I arrived on scene at about 1742 hours and obsexved a number
of vehicles parked along both sides of the straight roadway and people st::mrling on the southbound
lanes of North 19th Avenue. This section of NOM 19th Avenue was currentlywithin a construction
zone, .with po~d speed limit signs of 35 miIes per hoW'. A Bozeman FireDe~m truck and an
Amencan Medical Response (AMR) ambulance were alSo sceJJe. I observed a maroon, Toyota
passenger car on the inside, southbound lane of N. 19th, on its driver's side~..facing north. As I
approached the Toyota, a witness informed me there was an~ther victim to the south of me. I
turned around and obsexved a dainaged silver Orevrolet pickup parked on the outside, southbound
lane of N. 19dt facing south. Sitting to the west of this pickup was an adult male who appeared to
have blood on th~ back of his shirt and left arm. The license plate on the To}Ota was Montana
license 6-A91621 and the license plate on the Chevrolet Wo1S MOntana license 6T-E4107.
On ~ene Medical PelSonnel:
Bozeman Fire Depa.rtment
Muk Criner
Jeb Fisher
Kurtis Bushnell
Jason Kolman
Orris Dubay
Graver Johnson
Travis Batton
Cody MnmTTlPY
Central Valley Fm Department
Jason Wheeler
Tun Anderson
Kevin Striclder
American Medical Response (AMR)
Aaron ShUltZ
Holly Helstrom
Vehicles/Occqpants:
Vehicle # c
Year/Make/Modeh
VIN:
License:
Registered Owners:
Driver:
Name:
Address:
OOB/OIN:
Issuing State:
Endorserrents:
Restrictions:
Restraint:
AleohoVDrugs:
Injwy:
E jeered:
Entrapment:
Extrication:
Passenger.
Name:
Address:
DaB:
Location:
Restraint:
AlcohoVDrugs:
Injury:
Ejected:
Entrapment:
Extrication:
1984 To~ta Celica
Jf2RA64CSE6229220
6-A91621
Geoffrey David <l1eny & James Edwa.rd Oleny
259 Evening Star Lme
Bozeman, Mf 59718
Geoffrey David <lteny
259 Eve' Star~ Bozeman,MT59718
Montana
None
Provisional
None
Yes-alcohol and marijuana
Fatal injuries
NlA
N/A
N/A
\
.A,
Kayle L Ingr.un '.
1000 North 1rt> Avenue, II 120 Bozeman, Mf 59715
-Front right seat
None
Yes-alcohol and marijuana
Fatal injuries
N/A
NlA
N/A
Insurance:
Property and Casualty Insurance Company of Hartford
Policyll 55 PHJ514375-264401
2
Vehicle # 2:
Year/Make/Model:
VIN:
License:
Registered Owner.
Driver.
Name:
~s:
DOB/OIN:
Issuing State:
Endorsements:
Restrictions:
Restraint:
AlcohoVDrugs:
Injury.
Ejected:
Entrapment:
Extrication:
Instmloce:
Allstate
Policy# 048710577
2005 Otevrolet pickup
lCXJHDC23215F855218
6T~E4107
Jared A Schroeder
147 High K Street
Be~e.~59714
Bozeman, Mf 59715
Montana
None
None
Lap and shoulder belt
None
Non-incapacitating evijent injwy
NlA
NlA
NlA
Crash SceDC Investiption: On-scene forensic mapping and speed estimates were conducted by
the Montana Highway Patrol (MHP). to include Troopers Jay Nelson, Kenneth Klapan. Pat
MeT "1~lin) and J2Son Hoppert. Photographs of the scene \\'ere taken by Deputy QUef Bill Dcwe
and Detective Trent Schumacher of the Bozeman Police Depa.mnent. Biood ~ws of Ingram and
Abbott were conducted by Bozeman Deaconess Hospital Phlebotomist JallleS Knight at the request
of Bozeman Police Department Officer K.a~e Anderson. GaIIatin County Deputy Coroner Roger
Layton was responsible for coUerring blood draws of Clleny:
Witnesses:
John A Laing
1045 5th Avenue East
(406)755-6025
Stephen G. Sparks
705 Stonegate Drive
(406)522-0884
Janrs G. Sparlts
705 Stonegare Drive
(406)522-0884
K2lispell, Mf 59901
Bozeman. Mf 59715
Bozeman, MT 59715
3
Allison Levy CONFIDENTIAL
1011 River Drive, # 301 Livingston, Mf 59047 THIS INFORMATION IS FOR LAW
(406)570-0940 ENFORCEMENT PURPOSES ONL'f.
Trechell Y. Schroeder ANY UNAUTHORIZED USE IS
1203 Guiser Lane Belgrade, Mf 59714 STRICTLY PROHIBITED.
(406)924-6052
Derek C TlSdel
65 East Kimberly Coun Bozeman, Mr 59718
(406)585-2763
Margaret J. Lewis
7340 Fowler Lane Bozeman, MT 59718
(406)587-3066
Drew R McDowell
1230 Candlelight Drive Bozeman, MT 59718
(406)388-2046
Richard R Ridenour
229 Painted Hills Road Bozeman, ill 59715
(406)586-0425
Brett L. Layman
9100 Trooper Trail Bozeman, Mf 59715
(406)585-8569
Herbert C Homan \
153 Pathfinder Trail Bozeman, MT 59718
(406)388-0634 /\
Judith K. Franzak
153 Pathfinder Trnil Bozeman, MI' 59718
(406)388-0634
Marianne E. Baumberger
1013 East Silverbow Avenue Belgr.ule, MT 59714
(406)3887263
Andrew W. Beland
29 Annette Patk Drive Bozeman, Mf 59715
(406)585.-0001
4
Robin L. Stoddard
99 Frank Road, # 7
(406)539-3999
Lacie J. Sikes
1814 West Beall, # A
(406)209-4817
Be~,~59714
CONFIDENTIAL
THIS INFORMATION IS FOR LAW,
eNFORCEMENT PURPOSES ONL'f.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
Bozeman, Mf 59715
Robert E. Poublon
1707 Rainbow Road
(406)522-8453
Bozeman, Mf 59715
Evidence: Measurements, digital photogr.lphs, toxicology results, taped interviews.
Contribut:in& Factors: Driver # 1 was exceeding the posted speed limit of 35 miles per hour and
per some witness accounts, was driving in a careless manner. Driver # 1 had bo~ alcohol and
marijuana in his system. The street was under coIlStl'UCtion and only one northbound lane was open
to traffic.
Namltivc: This crash was a twO-vehicle, sideswipe, opposite direction collision. Vehicle II 1 was
traveling north on North 19th Avenue. Vehicle II 2 was traveling south on North 19th Avenue.
Vehicle II 1 was traveling in the east lane of a posted, 35 mile per hour constIUCtion zone and
approaching a section of the roadwa.ywhich redUected all northbound traffic, via orange traffic
barrels, into the west side, northbound lane. As Vehicle II 1 attempted to change lanes from right to
left, driver /I 1 lost control of his vehicle and stnlCk the 1J11dd1e concrete median with the vehicle's
front undercarriage. This caused vehicle /I 1 to roll onto the driver's side of the vehicle. Vehicle # 1
then slid northbound on its side into the southbound lane and struCk vehicle II 2 in the west side,
northbound lane. Vehicle II 1 then sheared off of vehicle II :2 and skidded to a rest, facing north, on
the inside, southbound lane of North 19th Avenue. This narrative is based on in'frviews conducted
with the above--listed witnesses. (Refer taped interview tnlDScripts).
Upon fwther inspection of vehicle II 1, MHP Trooper McI~l1ghlin noted ~ rear tires were studded
but the front tires were not. Mclaughlin said vehicles with only two studded tires tend to skid more
on dry surlaces, such as pavement. Mclaughlin said most authorized tire installation businesses will
not place only two studded tires on a vehicle.
MHP Troopers Nelson, Klapan, Mclaughlin, and Hoppert conducted measurements of the accident
scene as well as their own skid test of the roadway. Per their findings, the minimum speed of
vehicle II 1 MS approximately 73.34 miles per hour prior to impact with t.he concrete median. (.Refer
MHP repents)
Conclusion: In conclusion, this accident oc~d due to driver # 1 failing to negotiate a lane
change while traveling at a high rate of speed and while having a detectable amount of alcohol and
marijuana in his system. Vehicle # 1 then stIUCk a concrete median, thus resuhing in the vehicle to
roll onto its side. Vehicle II 1 then slid into the southbound lane of traffic, striking vehicle # 2.
5
End of Repo.tt,
Sgc~~
Bouman Police Department
/
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
\
A
6
.""-'l'-' -_"'
CONFIDENTIAL
THIS INFORMATION IS FOR tAW
ENFORCEMENT PURPOSES ONLY.
MONT ANAHIGHW AY P ~~THORIZED USE IS
CRASH RECONSTRUCTION RJfi1ljitJf-Y PROHIBITED.
On October 18, 2005, at 1835 hours, I was notified by the Montana Highway Patrol
Communications Center and Captain Keith Edgell of a two-vehicle fatality crash on
North 19th in Bozeman, MT. I was in off-duty status at the time of the notification and
was advised that I needed to respond to reconstruct the crash. I called Trooper Ken
Klapan of the Montana Highway Patrol and had him obtain the Total Station Forensic
Mapping Device from the Butte Patrol Office and meet me while enroute to the crash
scene.
Trooper Klapan and I arrived at the crash scene at 2020 hours and were met by Trooper
Pat McLaugWin, Trooper Jason Hoppert, and Captain Keith Edgell, all of the Montana
Highway Patrol. Sergeant Mark Johnson of the Bozeman Police Department also met us
on scene. Trooper McLaughlin walked Trooper Klapan and I through the crash and
advised us that the Bozeman Police Department would handle all aspects of the fatal
crash investigation except for the Forensic Mapping and speed estimates.
Trooper Klapan and myself made the following initial observations of the crash scene.
The scene was located within the 2900 block of North 19th in Bozeman, MT. This
location is within the city limits of Bozeman and located in Gallatin County. The crash
was within a construction zone that included a reduced speed zone and traffic barrels that
directed northbound traffic from two lanes down to one lane. The traffic was directed
into one lane by the use of orange traffic barrels. The roadway itself was comprised of
two lanes for northbound tnlffic and two lanes for sovtllbouDd traffic with a eel\ter turh
lane for both northbound and southbound traffic. The center turn lane w~ separated by a
raised cement median. The traffic lanes and turn lanes were comprised oInew
bituminous asphalt and showed no apparent defects. Dashed white liJles separated the
two northboWld lanes and the two southbound lanes. The center turn lane near the crash
scene had a painted double yellow line that separated the two southbound lanes from the
turn lane.
Initial observations of vehicle number one was that ofa maroon Toyota Celica with two
occupants that had been traveling northbound on North 19th. The vehicle was resting on
its driver's side and the top of the vehicle along with the occupant area was fully
exposed. Vehicle number two was that of a silver Chevrolet pickup truck with one
occupant that had been traveling southbound on North 19th. The vehicle was parked in
the right lane of the southbound traffic. There was a yaw mark in the right and left lanes
of the northbound traffic adjacent to the driveway of Bozeman Ford at 2900 North 19th.
There were two tire marks that extended from the center median divider to the point of
impact. There were two short tire marks that extended south from the point of impact.
There was a distinct debris field that consisted of vehicle parts, human tissue, and gouges
that extended from the point of impact north in a cone shaped pattern to the final position
of vehicle number one.
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLV:
ANY UNAU~O~I ·
Trooper Klapan and I set up the Total Station Forensic Mappin'fm~ USE IS
of the southbound lanes in between vehicle number one and two. Trooper oppe .
Trooper McLaughlin assisted in positioning the prism as Trooper KJapan and I triggered
the instrument from the position of the Total Station. All evidence points were
diagramed including: Final positions of the vehicle number one and two, all tire marks,
debris field and gouges, traffic lanes. turn lane. median divider. traffic islands, roadway
edge and driveways at the scene of the crash.
Upon completion of the Total Station Forensic Mapping Trooper Klapan, Trooper
McLaughlin, Trooper Hoppert, and I measured the yaw mark in the northbound lanes.
We measured the first one third of the right front tire mark of vehicle number one. We
measured the chord of the yaw mark that measured 46.0 ft. from inside of the yaw mark
to inside of the yaw mark. We then measured the middle ordinate from the chord to the
inside of the yaw mark. The middle ordinate measured 0.5625 ft. Trooper Klapan then
disabled his antilock brake system in his patrol car and performed three skid tests in the
left lane of the northbound traffic near the yaw marks. The skid tests measured as
follows: #1 112.0 ft. at 49 mph, #2 106.0 ft. at 50 mph, and #3 113.0 ft. at 51 mph.
These skid tests gave an average drag factor of 0.76. With the chord, middle ordinate,
and drag factor a minimum speed of73.34 mph was calculated.
In conclusion, through the training and experience of Trooper Klapan and I it is are
findings that vehicle number one was northbound in the 2900 block of North 19th.
Vehicle number one entered a construction zone that included a reduced speed zone and
redirected traffic from two lanes into one lane. The lanes were redirected into the left
lane. This redirection of traffic was made with the use of orange traffic barrels. Vehicle
nUIllbsr one entered this area at a high rate .fspeed ahd as ttae vehicle neared the
driveway for Bozeman Ford located at 2900 North 19t\ the driver lost con\I'ol of the
vehicle. The vehicle yawed counterclockwise and struck a raised center m~dian divider
with the vehicle's oil pan and undercarriage. When the vehicle struck)he median divider
the vehicle was facing northeast. Due to the angle of the collision, the 'area of the vehicle
that struck the median divider, and the speed of the collision vehicle number one rotated
on to its left-side tires. The vehicle then traveled at an approximate 45~degree angle
across the turn lane into the left lane of the southbound tmffic on its left tires. This is
consistent with the two tire marks on the roadway leading to the point of impact. Vehicle
number two was traveling southbound in the 2900 block of North 19th. Vehicle number
two was traveling in the left lane. Vehicle number one sideswiped vehicle number two.
TItis collision had enough energy to rem(}ve the top of vehicle number one and cause
fatal injuries to both occupants of vehicle number one. Post collision, vehicle number
one continued northbound in the southbound left lane of North 19th sliding on the
vehicle's driver's side. Vehicle number one came to rest on its driver's side in the left
lane of the southbound traffic. Vehicle number two did have two short tire marks near the
point of impact consistent with evasive action. Vehicle number two continued
southbound moving into the right lane and stopping the vehicle across the road from the
Bozeman Ford driveway.
rooper Ja~ M. Nelson (MHP266 / ID # 1493)
Montana Highway Patrol
Crash Reconstructionist
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONL'(.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
\
/,
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY;
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
DASHED CEN
MEDIAN DMDER
SED TRAFF1C ISlAND
\
/.
*
~
CRASH I Of51018OO13
DAlE OF CRASH 1CH8-Q!5
lOCAnON NORlH 10lH BOZENAN, MT
IN\GnGA TED BY SERGEANT MARK JOHNSON BOZEMAN POlICE OEPARlMENT
TOTAl.. STAnON lEAt.f WHP 1ROOPER NELSON. TROOPER KLAPAN, lftOOPER MCLAUGHLIN, TROOPER HOPPERT
DRA~NQ BY MHP TROOPER KLAPAN, TROOPER NELSON
......... BEGIN SPEED CALCULATION .........
Comment:
Input values:
..............
min radius = 472.601429 feet
max radius = feet
step radius "" feet
minimum coef of friction = .76
maximum coef of friction =
step in coef of friction >=
e, superelevation = 0 degree
o degree
= tan(O) slope
'"" 0.000000 slope
The input values after conversions:
..................................
min radius = 472.601429 feet
max radius = 472.601429 feet
step in radius = 0.000000 feet
minimum coef of friction = 0.760000
maximum coef of friction - 0.760000
step in coef of friction = 0.000000
m. roadway grade = 0.000000 slope
S, speed
= 3.87 · sqrt(R · (f + e))
where e is the road superelevation in slope (rise/run)
coef of friction "'" 0.760000, distance = 472.601429
-= 3.87. sqrt(472.601429.. (0.760000 + 0.000000))
= 73.344116 mile/hr
Recap
........
min radius = 472.601429 feet
max radius :::: 472.601429 feet
step in radius "" 0.000000 feet
minimum coef of friction = 0.760000
maximum coef of friction = 0.760000
step in coef of friction = 0.000000
In, roadway grade = 0.000000 slope
S,speed
= 3.87 · sqrt(R · (f + e))
CONFIDENTIAL
THIS INFORtJlATION IS FOR LAW
ENFORCEMENT PURPOSES ONL'f.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
\
.,z
where e is the road superelevation in slope (rise/run)
coef of friction \ radius -~-> u 472.601429 feet
I
0.760000 --> 'U 73.344116 mile/hr
-............... END SPEED CALCULATION .............
CONFIDENTIAL
THIS INFORMATION IS FOR lAW
ENFORCEMENT PURPOSES ONL'Y.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
\
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CRASH 'VESTIGATOR'S REPORT
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Refer attaChed diagram.
01
ill
00
'~~~;~~;~~:~V:~'~'~.\.:;~.;"~.l.~~ ~ :/
ABBOTT DANIEL BERYl
---...-
13525 BRIDGER CANYON RD
BOZEMAN MT
If
00
......,.-
(U8710m
lIl>Codo
MT 59714
--- ..---
JT2~$4C5E6229220 1 GCHK2321 SF855218 6TE4107
--
TOTOTA CHEVROLET
--- .... -~
-- -8=0- .......
~- ... ~?
:. """"""'-.."''''''- -,.Oooooogod ..--
o-w_ ---
01?oI NONE NONE
_000010 --..
~ -
...~ .-..0 ~~ _,__"- No_ ~D~.. '-''''''''~
:;"'o..~ . I:.... BeST RATE ~o.:=. :::- MR.rs
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COMMERCIAl EHICLE AND FAT" ACCIDENT JPPLEMENT
~ 'FAT'w:ACCIDENT,:ONL:'Y': ' ''. ' ; ( ;; ::,L r: .;~:,.""J,';.
NoUftoatlon TlrM !MS Arrival TIIM EMS
(mlUtefy tImll)
??oo _not notlllecl
;17:34 I 17:42l
NarM of~. Involved SAC TMt OJqn Method of A1c:oho1
o.tarmlnltlOl\(~}
'.'1' ..;."i'"
'," ,.'".;"""""
ISMS t1nw at hotlfJltal of
uo.t S.vw.ly Injured
I 17:~9
EjactIon Path
ABBOTT, DANIEL BERYL
~~ER~~~~9f'=:~ ~~y'I~_
INGRAM, KAYLE L
._-~-~-~~~.-._~ ----~-
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y
y
1 EvIdentIIl Tilt (8tatI1, Blood, Urlne 1 Not ejected I not appllolble
1 EIIIo18lUI TeIt (BrMth. Blood. UrIM 1 Not..1IlUd I not appIIeablll
--....-..------.---....--~~- ~--- -
1 ~l Tilt (8rHIh, tllood. l..lrtne 1 Not ejected I not ttppIcabl.
._ _~__..............-~~, _~ ~'.r'_.._~___.
~-_.
Rqadway Surface Type
2 Blacktop (blb.Jmlnous)
I
V.h1 Veh2
E8t 6pMd: n
Number ofTrafllo Lanea: .Ci
CONFfDENTIAL'
THIS !NFORMATION IS FOR LAW
EM~OACEMP!.NT PURPOSES ONLY.
ANY UNALJit--IORIZEO USE IS
IfftlfJfl.V PROHIBITED.
\
~A,
Calla For Service Report CaIlID: O~10180090 Printed: October 19,2005
1. Ao-ncy 2. PelllOll Received 3. O-.m.... Received S. 11me ArrIved 7. Cu.'"
BPD Complaint 10/1812005 17:34 17:39
4. 11.... Dlapatched e. 11.... Complete 0510-180013
17:35 01:49
8. Nature Of Incident Mva Reported Injuries
9. Location Of
Incident N 19TH AVB/BURKE ST,BOZEMAN MT
ALLTEL 866-S20-0429
10. VIctim or Caller 1121 MANDEVTI..J...E LN: NW SECf
4063219216
11.Clualflcatlon 12. How Received 13. Disposition 14.otfIcer 16. Dat. Submitted
TRAFFIC ACCIDENT 'ANI/ALf lICAD REPORT TAKEN Johnson, Mark 10/18/2005
Notes: CAILBK-(406)209-408iv~1l1.0S9224 +4S.71167S 1709...2 VEH INVOLVED. MRN CAR.. LOI searoh completed at
10/18/05 17:34:48 .. Recommended unit AMR. for ~ AMR(O) (2.64 mi) .. Reoommendod unit BOZFD for
requirement BOZF'D\O) (3.36 mi) Duplicate EventLocation:a N 191H A VFJBURKE ST BOZE, Cross Street 1 m N
19TIl A VB -ONE VEHICLE ROIL OVER. PEOPLE LAYING IN THE STREET BURKE ST, Cross Street 2 -
BURKE ST, Typo - MY A - MY A, Subtype - INJ - REPORTED INJURIES, Alann Lovel- 0 End of Duplicate Event
data 141 IN RT ADV SIREN NOT WORKnil"G 636 ADV 2 PATIENTS ON SCENE ADV 1 OOA 1 EXIREML Y
CRITICAL BOZ ENG 1 REQ CORONER.. LAYTON PAGED. 636 ADV 115 BODY MA'ITER IN THE ROADWAY
NEED TO KEEP PEOPLE AWAY FROM 115 RESP PARKING AT SUBWAY.. Cross Referencod to Event #
c2ooS00090 at: 10/18/0S 17:40:37.. >>>> by: NICOLE SMITH on t.crminal: firecms2141 REQ ANOTHER.
AMBULANCE 2ND AMB PAGE SENT 650 PAGED REQ BELGRADE FIRE AMB TO RESPOND TO
TRANSPORT. III. Cr088 Reforenccd to Event # L200500S95 at: 10/1S/0S 17:45:59 .. >>>> by: NICOLE SMITII on
terminal: firccms2 132 132 REQ MHP FOR FATAL ACCIDENT RECONSTUCTION 297 WILL RESPOND AND IS
CALLING OUT A PARlNER TO ASSIST.'" LOI search completed at 10/18/05 18:19:06.. LOI search completed at
1O/18/0S IS:21:48 .. Case numberbOSl01S0013 has been assigned.. >>>> by: BROOKE M. LANNON on terminal:
citylaw.. PER search completed at 10/18/05 18:45:58 III. PER search completed at 10/18/05 18:46:30 .. PER search
completed at 10/18/05 18:46:51 .. PER soarch completed at 10/18/05 18:48:15 .. LOI search completed at 10/18/05
19:31:37 NEXT ROTATIONAL WRECKER. CHEVY TK FRONT END DAMAGE TO A&D AUTO BODY. MR T'S
REQ BEST RATE FOR TIlE OTHER VEHICLE - ON IT'S SIDE WilL NEED A FLAT BED 141 ADV ROAD IS
OPEN IN AlL DIRECTIONS
141- Vehiclc 1 (passenger car) wastra.vcling northbound on North 19th, when tho driver drove over the median. rolled
onto thc driver's sidc and sideswiped vchicle 2 (pickup truck), which was traveling southbound. One juvenile in
passonger car was dcccascd upon police arrival Other juwnile puscngerwas transported to Bil1.ing8 hospital via
helicopter and was deceased upon anival. Adult male in pickup truck was transported to BDH and subsoquently
released. Montana Highway PatrolassiBted with investigation. Investigation to continue.
CONfIOENT\A\..
N \S FOR LAW
T\-\\5 \NFORMAT'~UR?OSES ONLY.
ENFORC.EMENO:TR'lEO USE \S
UNAUTH t
ANY PROH\etTEO,
STR\CTLY
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CONf\DENT\AL
N IS FOR LAW
1\-\\5 \NFORMAT\~URPOSE.S ONLY.
ENFO~~~~~~6R\ZEO USE \5
~~\CTLY PROH\B\TED.
\
( AI.<<IC'JNllIIIC - OCA
N Bozeman Police Department INCIDENT IINVESTlGA TI,- .4 0510180013
c OR! REP~~~-\. ~~\. 0..:" / Time Reported
( ** C - _ -:f+
0 ~~ . WE Oct 19. 2005 02:50
E Crime IncldCllt ,~ JRl ~w JUt \~~ ~'~m List Known Secure
N #1 OiliER TU Oct 18. 2005 17:34
T
Crime IDcident .\fc 'l~~' . ~lS.E \5 DAn At fouod
0 #2 1F~' i Deom TUOct 18,2005 17:34
A ~~~.
T #3 Crime Incident t;.'J :l' DAn
A A o CoIn
LocatiDn oflncidCDl N 19th Ave / Burke St, Bozemon. fjJ ;\1\ '" 1 PJa:uise Type Hillhwav/RoadIAllev ~
How Attacked or Committed
(0 Fon;ibIc EPtry 0 Yes 0 No rt:I NI A
Wmpou I Took
#I VICtims 2 I Type Iodividual Injury None I Raridcocy Status Residant
Vic1:irnlBusilloss NlIDUl (Lut. Finlt, Middle) Victim of Crime II ~: Sell:
V VI 1
Cherry. Geoffrey David JUVENILE
I RdUiomhip to Oft'codcn M
C
T Home Addn:n Homo Phone
I 259 Evening Star Ln, Gallatin county. Ml' (406) 585-7876
M Employm Namo'Addfea Bus PboDc
~~4 I~h I~ I~ I~ I ~1621 MT I vrNmlU64C5E62292220
::> cc 0fI..5: V- Y' . V2 Y3) 0" other R- p-.. {if othcI' l- Ived
r Code NaIll" (LaIt, Ft.nlt, Middle) Type: V]o~ of Aac I DOB
Ingram. Kayle L JUVEimE Crime i#
fI VI2 I W M
Ii
R Home Addfta Home
S LOOO N 17th Ave Apt. 120, Bozeman. MI' 59715 (406) 587-5602
Bmployar" NlIDIO' Ado:huI BUlIi_ Phone
I
"l Code N.me (Ust, FiIst, Middle) Victim of I Aie I DOB Race Sell
V 101 Abbott. Daniel Beryl Crime #I 1!!IIJll
) W M
L Homc Addten me PC
V 13525 Bridger Canyon Rd. Gallatin_county. MT
S liUijilOyer DC
!) Gallatin J"alley Homes
Statui L - Lost S - Stolco R - R.ocovertd D .. DamI&cd z.. SeIzed B - Burned C.. Counterfeit I FOIled F - FOUDd U" Unknowu
CHI_ le VlCk .or column if fur.... .
~ UCR StatuS - Date Value OJ QTY Property Description MaktIModel Sma! Numb<<'
~
l
)
;)
~
't
r
'{
NumberofVehick4 Stolen 0 Number V~ Rcoovend 0
0 Officer (141) JOHNSON. MARK Ollie<< Slpature ISupcmsor~"OHNSON. MARK
Complainant Signature ~ SWUlI: Cue Disposition:
Further InVQ/JfaJion
October 19.1005
'rinted at: 11/2912005 23:00
Page: 1
Incident I Investigation Report
I OCA: 0510180013
, .&-'iit.i<..t';',4f1"~';: "Ai.W;\J~";;
':~'! .~~I<I~'11'~:'6r',~~~~~~~'~~:',~ "I,~~.~.1'~LI
louman Pollee Department
L"Lost
StalWl
Qu4ntity
TyPe Masuro
Swpectcd 0Iu& Type
o
R
U
o
S
S
U
S Scacs, M
P
E
C
THat
Jacket
Wu Suapect AImed?
Offmd~.) Suspectc:d OfUlIlng OOend... 1 Oft'_der 2 Off_d<< 3 ~Offcada
Age: Race: Sex: Ap: Race; Sell: Aj~ Race: See ResidMt Status
o Drup (if Nt A RtlIidtnt
o Akohol OOeader .- O<<tIIlder 5 Off_der , Non-Relidcat
o Comput<< Ap: :0/ R.oc: Sex: At,c: Race: Sell: Ap:. Race: Set: Uabowa
DOS. t Ale
Build
Hair Style
en acoCIllt, \'0
fWr Color
Hair l..cmIth
. )
VYR
SWlpoot Halo I Bw Motivated:
r Name (lut, Flnt, Middle)
T Laing, John Arthur
'0{
E Home Addrosll
~ /045 5th Ave East. Kallspell. MT 5990 1
Assisting Officers
: (115) ANDERSON, KA YCEE
l (636) PETERSON, DON
l (MHP)MTIDGHWAYPATROL
i (160) PANKRATZ, ADAM BENJAMIN
I
o y~ It! No
Socks
Shoa
Mode ofTravd
0.0.8.
-
Homo Phone
~ Race S&
57 W M
EllIpIoycr
Ekroth Musk
Phone
; V I was driving Vehicle I, and V2 was a passeoger in V chicle 1. V ohiclo I was northbound on 19th
Avenue when it erossed over the concreto median and sideswiped Vowelo 2. 10 was driving Vohicle 2
southbound on 19th Avenue. VI was deceased upon officer arrival. V2 was transported to a hospital
in Billings via holicopter and died onroute. 10 was transported to Bozeman Deaconess Hospital and
subsequently roleased. Montana Highway Patrol officers responded and conducted accident
investigation.
Related to:Abbott, Daniel Beryl- INVOLVED OTHER
2005 CHEVROLET PICKUP - SlL \fER
tinted at 11/2912005 23:00
Page: 2
Incident I Investigation Report
Owner I BCHROBDBR, JARED ALLKN
VIM I 1~3215F855218 Licanae: MT/6TK4107
PURPOSES ONL'f.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
~v
\
Printed at: 11/29/2005 23:00
Page: 3
Incident I Investigation Report
Bozeman Police Department CONFI~0013 I
THE INFORMATION BELOW IS CONFIDENTIAL - FOR usN~IAtT+B~EiSbNNEL ONLY
y
\
Printed at: 11/29/2005 23:00
Page: 4
Incident I Investigation Report
Name (Lan, Flnt, Middle) bee S..
Name Sparh, Stephen Gray 56 W M
Address 705 Stonegate Dr, Gallatin_county, MT H: (406) 522.JJ884
Employer Wingate Inn B: (406) 5824995
Name Sparks, James G ~ 15 W M
Addren 705 Stonegate Dr. Gallatin_county, MT 59715 H: (406) 587.3665
EmpJ.yer B:
Name Levy, A.llison - 19 W F
Adllren 1011 River Dr Apt. 301. Livingston, MT 59047 Ht
Employer B:
Name Schroeder, Trechell Yevette - 35 W F
y'
AdcInn 1203 Cruiser Ln, Belgrade, MT H:
EmpIeyer \ Bt
Name Tisdd, Derek Carvelle 30 W M
Add.... 65 E Kimberly Ct, Gallatin_ ccunty, MT 59718 HI (406) 585-1763
Employer BI
Name lAwis. Margaret Jones .... 67 W F
Addret. 7340 Fowler Ln, Gallatin_county, MT 59718 Ht ,,106) 587.3066
ElIIpIoyer B:
Name Mcdowell, Drew Randall - 17 W M
A...... 12JlJ CtmtJlfl/ig/tt Dr. GdlItJitIIJOWlty, NT 5'7118 H: (416) ~IH6
Employer B:
Name Ridenour, Richard Ross 17 W M
Addren 229 Painted Hills Rd, Gallatin_county. MT 59715 HI (406) 586-fHIJ
Employer B:
Name Layman, BreU Leasure - 17 W M
Addren 9100 Trooper Trl, Gallatin_county, MT59715 H: (406) 585-8569
EnIpIoyer B:
Name Hollran. Herbert C - 60 W M
Addr_ 153 Patlifinder Tr/, GalJatiTU:OJUfty,MI' 59718 H: (406) 3u..0634
Employer Bozeman Senior High &hool BI
NlUJMI Frarttak, Judith K - 41 W F
Adllres. 153 Pathfinder Trl, Gallatin_county, MT 59718 H: (406) 388-06J4
Employer 81
Name Baumberger. Marianne Evelyn - 46 W F
Addnl. /013 E Silverlx1wAve. Belgrade. MT Ht (406) 388-716J
EPIpIoyer B:
Printed at: 11/29/2005 23:00 Page: 5
Incident I Investigation Report
Name
Na_ (Last, Flnt, Middle)
Beland, Andrew Westerlund ENf~~ ~~ - ,'-
. ~.~ ~'lE\ .
29 Annette Park Dr, Gallatin county, MI' 59715 ",~"f ~.~ , ...:"'.'r'I\~' - .
- S't\i\C1"\.:" . I ~.
Ale Raee Sex
Name Stoddard, Robbin Lynn
.A.ddr... 99 Frank Rd Apt. 7, Belgrade, MT 59714
EnIpIoyer Mt Lines
Name Sikes, lAcie Jo
AlId.-- 1814 W Beall St Apt. A, Bozeman, MT 59715
EJIpIeyer Montana Lines
N.... Poublon, Robert Eugene
Addreu 1707 RainbowRd, Gallail:, county, MT59715
17 W M
H: (406) SIJS..(}()(}}
B:
_ 46 WF
H:
BI
Addren
Empleyer
EPIpIoyer
_ 23 WF
H:
B:
_43WM
H: (406) S11-84J3
BI
\
Printed at: 11/29/2005 23:00
Page: 6
200S-l0wn 112:38
F ror'lt hp cor ldt.r
+
MONTANA-HIGHWAY PATROL
FAT AUTY CRASH REPORT
Date:
# Vehlclt*:
200&1018 Time: 1730
COt.Inty: GALLATIN
2
# KilI9d: 2
,J
# InJuRK1: 1 L P
C10HSt CIty or TO'NI1: 80ZEMAN
Highway: NO 19TH & BURKE
AlCOhol a Factor: NO
Road ConditIcJM: DRY
MPM:
Speed. Factor:
UNK
Commerc al Vehicle:
Haz. Mal Involved:
NO
MotorCycle: NO Bicycle: NO
Out-of-SUtte Vehicle Involved: NO
Pedestrian: NO
Occurred Outing OayUght Ho\n: YES
NO
,,~, 1 MakelModel: 1884 TOYOTA CST
Driver: CHERRY, GEOFFREY OAVlD OOB: _
Addt..: 259 EVENING STAR LANE BOZEMAN MT 69716
AGE: 17
MorF M
condition: FATAL Seat Belt U"': NO Hospital: OO.A
Paaerlgc 11': INGRAM,KAYLE'v' OOB: AGE: 16 MorF M
-....-
Addren: 1000 NO~ 17TH AVENUE #170, BOZEMAN MT 68716
COMmon. FATAl Seat Belt Usod: NO Hospital: at Vincente Bmlngs
passengnr. DOS: AGE:. MOI'F
Address:
Condition Seat Bait Used: Hospital:
Vehicle # 2 MakalModel:
I1rfver. ASSarT, DARREU.
2005 CHevROLET TRUCK
008:. -
AGe. 44
MorF !L-
Address:
13S25 BRIDGER CANYON ROAD, BOZEMAN MT 89715
COndiUon Minor Injuries Snt Bolt UMd: NO
PaaungfJr. 008:
Ac:ldfess:
Hospital: BoHman Deaconess
AGE: MorF
Puaeng'u:
Address:
Condldon:
DOB:
Hospltal:
AGE:
MorF
COndfUon:
SNt Belt Uaad:
Seat Belt u..d:
Hospital:
Commen:s: DO NOT RELEASE
Next of K n Notified: YES Dlstrtct Office Notified: YES
NARRATIVE FOR pRESS ReLl!ASE:
. VEHICLE 1 WAS NORTHBOUND ON 19TH AND CROSSED OVER CONCRETE MEDIAN WHERE IT
: . SIOESW!PEO VEHICLE 2 SOUTHBOUND ON 1QTH. BOTH OCCUPANTS 01= VEHICLE 1 WERE FATALlY
INJURer.. ORNER OF VEHICLE 2 sustAiNED MINOR INJURIES.
Inveatige1ing Offtcer: BOZEMAN pouce DEPARTr4ENT
CFS# 101806w22B
Received: 20081010 TIma:
CSO: JERRY FOX
0167
HQ 1087
INVOLVED:
REPORT OF INVFSTIGATlONC~~~~N~W'W
~,&.t\~J~fQ~~fc.c:.(,)bllY.
December 7, 2005 lH~'I'.!';:;;r~~~~~l'
E~_~~g~
Fatality Motor vehicle Crash ~~~Tu{'rR~~~ .
DRIVER 1984 TOYOTA CAR ~ Deceased
IIiiiiiiiiId Cherry
259 Evening Star LaDe, Bozeman, MT
585-7876
DATE:
SUBJECf:
PASSENGER 1984 TOYOTA CAR ~ Deceased
~
~120, Bozeman, MT
587~S601
DRIVER 1005 CHEVROLET TRUCK
Daniel Abbott
Brldeer Canyon Road, Bozem.aa, MY
539-6931
REFERENCE:
ponce Case # 051018-0013
REPORTING:
Lieutenant Rich McLane
DETAILS OF INVESTIGA'90N:
On October 18, 2005, at about 9:00-p.m. I was informed that numerous patrol officers, MHP troopers,
Gallatin County Deputies and various first responder.J had responded to a fatality accident on N. 19dt,
located in the city limits of Bozeman, MT. The Fire departmont bad already contacted the coroner prior
to law enforcement arrival.
On October 19, 2005, at about 07:00 a.m. I met with Sergeant Mark Iohnson, Deputy Chief Mark
Lachapelle and Deputy Chief Bill Dove. I was updated on the status of the investigation and it was
determined that I w<JUld assist by holping conduct related. follow-up interviews and help facilitate
gathering any related reports documenting this accidC2lt investigation.
I learned the below listed Bozeman Police Officers and Gallatin County Sheriff Deputies responded and
assisted with this accident or it's investigation:
Sergeant M. Iohnson Bozeman Police Department
Officer K. Anderson Bozeman Police Department
Officer A. Pankratz Bozeman Police Department
Sergeant C. Schumacher Bozeman Police Department
Officer T. Schumacher Bozeman Police Department
Detective C. Gappmayer Bozeman Police Department
Deputy ChiefB. Dove Bozeman Police Department
Deputy Chief M. Lachapelle Bozeman Police Department
Deputy ChiefM. Kent Bozeman Police Department
Lieutenant R. Mclane Bozeman Police Department
Deputy T. Quillen Gallatin County Sheriff's Office
Page 10f5
,
......~
--.
i' \
- ,
\. ;'
-./
t ..
C'~
Deputy D. Peterson Gallatin County Shcriff.~CON FIDE NTIAL
Chaplain W. Hiebert Gallatin County Sh . cn9FORMATION IS FOR LAW
l'FfcEMENT PURPOSES ONL'f.
On October 19, 2005, I collected all existing digital recordings &it" Jr.J~Y~4mi~a .!&1ected
all existing digital photographs done at the accident location. I ~~HYe ~ draw from
Ingram and Abbott had been submitted into Bozeman Police Evidence. I received and secured a video
tape showing the traffic conditions and signage as Officer Anderson approached the accident on October
18,2005.
On October 19, 2005, I spoke with Derek Carvelle Tisdel. Tisdel indicated on October 18,2005 at about
5:30 p.rn., he had just left Cost-Cutters near Radio Shack, located on the west side of N. 19th Avenue,
when he heard a vehicle crash. Tisdel looked to the road and saw a car (1984 Toyota) sliding northbound
on the road on its side and going at a fast rate of speed. Tisdel went back inside and called 9-1-1 and
reported the accident. Tisdel approached the car and saw two bodies inside, neither of which appeared to
be alive. Tisdel said one of the persons appeared to start to breath with some typo of body reaction
occurring. Tisdel said people present kept saying the airway needed to be opened, but everyone appeared
to be in shock and the male (Ingram) had severe injuries to his face. Tisdel said he tried to help with
traffic Wltil officers mrived. Tisdel said he didn't see the truck involved in the accident at all, until he
looked aroWld after awhile. (Refer taped interview)
On October 19, 2005, I contacted local news stations and gave them an updated report of the accident.
On October 19, 2005, I spoke to Robbin Stoddard. Stoddard works for ''Montana Lines" and helps with
signage and controlling tmffic for the construction occurring on N. 19m. Stoddard indicated her primary
work area during the day was near the intersoetion ofN. 19th and Valley Center road, controlling traffic
onto Valley Center road and southbound traffic onto N. 191h. Stoddard had completed her dutiosand was
getting in her vehicle parked in the west lot on N. 1911I near Burke Street. Stoddard had a second
employee with her, Lacie Sikes. Stoddard said she was getting into her vehicle when she heard a crash.
Stoddard looked up and saw a).~ (1984 Toyota) coming to rest in the southbound lane ofN. 19th, facing
toward the North and on its side. Stoddard did not see the truck get hit, but saw it sitting on the west side
of the road. faCiing tQ tJle 8Quth. StQlidard IJW .lw driva:- JitPq ~rt"i~ of t.bo v4Aig}t; with blQOd. on his
ann. Stoddard indicated none of the cones, signs or markings had changed on the road for several days
and the medians had been in place for most of the summer. (Refer taped interview)
On October 19, 2005, I spoke to Herb Hotban. Hothan was driving northbound on N. 19th and was
stopped near Burke Street. Hothan indicated the right (eastern.) lane had eroded with cones running at a 45
degree angle into the existing northboWld (western) lane. Hothan said he saw a red car (1984 Toyota)
going fast in the western lane. The car cut directly in front of him, striking the median. Hothan was
unsure if the car rolled over or hit the truck (2005 Chevrolet), but saw it slide to a stop, facing north in the
southboWld lane. Hothan indicated prior to him stopping, he was going 30-35 miles per hour. Hothan
described the red car as passing "at a flash" and was going a lot faster than he was. (Refer taped
interview)
On October 19, 2005, I spoke to Judith Franzak. Franzak was a passenger in Hothan's vehicle. Franzak
said the red car (1984 Toyota) came out of nowhere, flying past her at an angle and cut in front of
Hothan's vehicle. Franzak said there was nowhere for the vehicle to go but into traffic and the car hit the
median going into oncoming traffic and hit a truck (2005 Chevrolet) and flipped onto its side. Franzak
said none of the other traffic was moving fast. Franzak said at the timo the rod car passed in front of
Hothan's vehicle, Hothan's vehicle was only a few feet from the point where the eastern lane ended and
was basically ''the front-of the line". (Refer taped interview)
On October 19, 2005, I spoke with Treche11 Schroeder. Schroeder said on October 18, 2005, at about
Page 2'of 5"
. ....
.r- --
I
'CONFJDENTJAl
5:30 p.m. she was getting into her vehicle parkod near Subway. 31m T .~al3 tiUUtAW
She heard a loud acceleration and looked to the south and saw the ~L'I.
fast and then driving on only its two driver side wheels, prior to hi H ~blSliit ISo
middle median, landed onto its side and slid into a southbound :r~~JBSE6&eder said
tho truck plowed through tho car, peeling off the top of the car. (Refer taped interview)
On October 19, 2005, I spoke with School ResoW"CC Officer Trent Schumacher. Schumacher indicated
there were rumors circulating in the schools that Cherry and Ingram may have been drinking earlier that
day and may have been racing in vehicles. I conferred with Officer Anderson and determined it was
necessary to re-interview the mends that wore last with Cherry and Ingram.
On October 19, 2005, I was able to reach either the youths or their parents that wore last with Cherry and
Ingram. This included Andrew Beland, Richard Ridenour, Brett Layman and Drew McDowell. All four
youths came to the L&J Center. Officer Anderson interviewed Layman and McDowell and I interview
Beland and Ridenour.
On October 19, 2005, I interviewed Richard "Ross" Ridenour. Ridenour indicated all six above named
males were initially at KMMS at a radio show meeting. After tho meeting, they all went together to
Wendy's. After being at Wendy's, they went to their vehicles parked in the N. 15th parking lot. Cherry
and Ingram were in one vehicle, McDowell was in a 2114 vehicle, and Layman, Beland and Ridenour were
in the 3id vehicle. Cherry, McDowell and Ridenour were the respective drivers. Ridenour said they were
going to 10 to eheny's house to hang out. Ridenour said he was initially in front of Cherry going North
on N. 19 and was in the western lane. Cherry accelerated to pass and merge in front of McDowell, when
Ridenour said he saw a tnJ.ck (200S Chevrolet) get hit. Ridenour didn't initially know it was Cherry's
vehicle, until he started passing by the accident location. Ridenour pulled into the Border~ s parking lot
and the three of them got out to observe what had happened. Ridenour indicated he thought he was
driving 35-40 miles per hour and that Cherry was &,oing about 45 miles per hour when Cherry passed.
Ridenour denied anyone had been drinking in any of the three vehicles or that anyone had been racing.
(Refer taped interview) >.
On OQtobcr 19. 2005, . ~_ Andrew:Qttl'lD4 ~ pvc, a ailni1ar aecoUDt as given by
Ridenour. (Refer taped interview)
On conclusion of interviews with Beland and Ridenour I conferred with Anderson. AndCfSOn related
similar responses had been given by both Layman and McDowell. All four youths were given a ride
home by their parents.
On October 20, 2005, I verified with Evidence Tecbnician Tom Weigbtman that Abbott and Ingram's
blood would be sent the next day to the Montana Crime Lab for a toxicology screen.
On October 20, 2005, I met with Trooper McLaughlin. I verified which MHP Troopers had responded to
assist in the accident and ensured the extent of investigation we were doing was consistent with that
necessary to investigate a fatality accident. M4-augblin BlX'ced that our investigation was consistent with
those done by MHP troopers and indicated tho below officers from the MHP were pI:csent to investigate
the accident:
Trooper Pat McLaughlin 297
Trooper Jason Hoppert 205
Trooper Jay Nelson 266
Trooper Ken Klapan 327
On October 20, 2005, I interviewed Lacie Sikes. Sikes gave a similar account as given by Stoddard.
(Refer taped interview)
Page 3 of5
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.(_.~,
I,,.,,,, '<-CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONL'f.
On October 20, 2005, I spoke with Assistant Coroner Roger Layton. ~~
been sent in for toxicology analysis and gave mea copy of pictures ~~'PROHIBITED.
On October 20, 2005, I went to Best Rate Towing. I retrieved a copy of the registration and proof of
liability insurance card from the business. I. verified the following tires were on tho vehicle:
Front: Cooper Lifesaver P185/70R14 Classic STE
Rear: Pacemaker Radial ST12 P185/70R14 878
I knew the left tires bad not been photographed and took a photo of these.
On October 20,2005, I received copies of the Ccntra1. Valley Fire and AMR ambulance reports. I later
received a copy of the Bozeman Fire Department report. The following were first responders for medical
attention at this crash:
Jeb Fischer Bozeman Fire Department
Mark Criner Bozeman Fire Department
(5 other Bozeman Fire Departmcot pc:sonnel)
Aaron Shurtz AMR
Holly Helstrom AMR
Jason Whocler Central Valley Fire
Tim Anderson Central Valley Fire
Kevin Strickler Central Valley Fire
On October 20, 2005, I received copies of all medical recoros for Daniel Abbott from Bozeman
Deaconess Hospital.
On October 20, 2005, I spoke briofly with Daniel Abbott and obtained his insuranco information.
).
On October 24,2005, I intcrviewedjLobcrt Poublon. Poublon indicated he.was traveling southbound on
N. 19th, about three cars behind the 2005 Chevrolet truck. Poublon said the southbound traffic was just
starting to accelerate faster than 25 miles pel' hour. Poublon said he saw the northbound car (1984
Toyota) launch off the median onto its side, hit the 2005 tru.ck and slide mnthbound on N. 19th. Poublon
said he tried to call 9-1-1, but the phone lines were jannned.
On October 27,2005, I received a CD copy of all 9,..1-1 phone calls of this accident and all radio traffic
during the time period of the accident.
On November 1, 2005, I forwarded. an email to all Bozeman Police and Gallatin County employees
present to complete a supplemental report of their involvement in this investigation.
On November 2, 2005, I received the coroner report on Geoffrey David Cherry.
On November 3, 2005, I forwarded a CD copy of all photographs to Trooper Jay Nelson, Montana
Highway Patrol.
On November 15, 2005, I spoke with Deputy Chief Dove and Deputy ChiofK.ent. Both indicated they
were at tho accident scene, but did not conduct any investigation or speak: with any witnesses. Deputy
Chief Dove said he took some additional photographs of the accident; which he bad already given to me.
Deputy Chief Kent said he assisted with some traffic control.
Page40fS
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On about November 18, 2005, I spoke with Cole Ingram. the father of Kayle. I explained to him the
investigation and that we were still waiting on reports from the MHP and crime lab.
On November 30, 2ooS, I received a copy of the MHP report. I spoke with Trooper Nelson and asked
him to add a narrative explanation on the report, which he agreed to and is forthcoming.
On December 1, 2005, I received facsimile copies of toxicology reports from the Montana Department of
Forensic Science in Missoula, MT. I gave copies of these to Coroner McNabb. On December 1, 2005, I
received the coroner report on Kayle Ingram from Deputy Coroner Roger Layton.
On December S. 200S, I forwarded toxicology reports to Sergeant Mark: Johnson and asked he complete
the fatality report.
On December 6, 2005, I "met with Jn1i8nnaand Jim Cherry, the guMdi.ans for G. David Cherry. I
explained the results of our investigation and the toxicology findings on David. I also explained the
reasons for delays on completing the investigation and that it would be done shortly.
This concludes my involvement in this investigation through December 7, 2005.
~
Lieutenant Rich McLane
CC~\F~:)::~!T'Al
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
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Page 5 of5
r.: N\\~\..
REPORT OF IHVESTIGATIOH r.OlWl~fi~'ir~tA\J';
~~\~~;~J:~Nl1.
DATE: October 30, 2005 ~~~~'USE. \5
~'(C~rlI:;9 .:,~ol-'n8rrEr
SUBJECT: Fatal Motor Vehicle Acddent SlRICi\.. .
REFER: Case #0510180013
VICTIM 1: Geoffrey David Cherry
OOB:
OLN:
VICTIM 2: Kayle L. Ingram
OOB:
SSN: Unknown
REPORTING OFFICER: Officer' Kaycee Anderson, 115
OET AILS OF COMPLAINT:
On October 18, 2005 at approximately 1734 hours, my Communications Center
dispatched me to an injury accident at 19th Ave and Burke St. While enroute,
Communications informed us the Injuries sounded severe. Deputy Don Peterson
arrived on scene before l:dld and said over the radio one of the persons Involved was
DOA (dead on arrival), and the other was in critical condition. As I arrived on scene
at approximately 1139 hours, rSeputy Peterson told me where to park and to try to
avoid driving over the human debris between my patrol vehicle and the wrecked
vehicle.
OET AilS OF INVESTIGATION:
I approached the vehicle and observed a body covered in a blanket (later
identified as Geoffrey David Cherry), and I observed a male (later identified as Kayle
l. Ingram) near the body. Ingram had a severed right arm and several people were
providing medical attention to Ingram. I asked a witness if only one vehicle had been
involved, and the witness said he had only observed the one vehicle as it was rolling
over. The witness fdentified himself as Derek Tfsdel.
There were several vehicles backed up in' the scene of the accident and I tried
to get those vehicles to move along. I began to identify wftnesses of the accfdent.
One of those witnesses was Steve Sparks. Sparks told me he observed the accident
and was one of the first people on scene. Sparks told me the passenger car had hit a
truck that was now stopped south of the location of the car. Sgt. Johnson had
contacted the driver of the truck (identified as Daniel Abbott), and we requested
medical attention fo~ Abbott from the medical ~rsonnel on scene. While I was With
"
\
-~ CONFIDENTIAL
THIS IN~ORMAT/ON IS FOR LAW
Sgt. Johnson, he informed me an arm was left on the fron~~~~g~ERrrOSES ONLY
relayed that information to a fireman on scene. STAiLY Pl1 ,12 TO USE IS
I photographed the scene, and at 1821 hours, I went to ~zeman~rto~~ss
Hospital. Whfle I was at BDH, I requested a legal blood draw from Ingram to
determine the presence of drugs or alcohol. Before Ingram was airlifted to Billings, a
phlebotomist, James Knight, under the direction of Dr. Blend was able to get a blood
sample from Ingram. The blood sample was taken at 1925 hours, and Knight
immediately gave the sample to me. The blood sample was retained in my vehicle
and by me until 2230 hours, at which time I placed the blood sample in Evidence.
I contacted Abbott, and asked him about the accident. Abbott said he
remembered seeing a vehicle come flying at him out of the corner of his eye. Abbott
said the top of the car hit the side of his truck, and his truck then continued down
the road. Abbott said he got out of the truck and sat on the curb, where Sgt. Johnson
found him. Abbott said he was not wearing his seatbelt and had not consumed any
alcohol before the collision. I did not have any indication that Abbott was under the
influence of alcohol, but because of the seventy of the accident, I read the Implied
Consent Advisory to Abbott. Abbott agreed to give blood and he agreed to complete
a Medfcal Release Form. (For'complete interview, refer to Abbott's Interview).
Knight took a blpod sample from Abbott at 2025 hours, and Knight immediately
gave the blood sample to me. The sample remained in my vehicle and in my custody
untfl2230 hours when I placed the blood sample in Evidence. Evidence Technician
Tom Weightman later gave me copies of the Blood Analysis Request for both Ingram's
and Abbott's blood samples, which were sent to the MT State Crime Lab for analysis.
On October 19, 2005, I assisted Lt. Rich Mclane in interviewing witnesses of
the accident. I contacted Peggy Lewis. We had received info~matfon from Lewis'
son-in-law, Joe Johnson, thatlewfs told him she had seen some Idds playing
uchicken" on N 19th Ave right before the accident. I asked Lewis what she had seen,
and she said she had driven up N 19th Ave shortly before the accident, but had not
seen anyone racing or playing uchicken." Lewis said she had no idea where Johnson
had received information like that, but she said she did not tell him any such thing. I
later contacted Johnson, and Johnson said Lewfs had told him that while she was
Southbound on N 19th Ave, she met a couple of cars headed Northbound that caused
her concern. This would have been a few minutes before the accident occurred.
That same night, I assisted Lt. Mclane in interviewfng the juvenile witnesses
who were traveling behind Cherry and Ingram at the time of the accident. Student
Resource Officer Trent Schumacher had informed us that there were some rumors in
the Bozeman High School about the juveniles all racing down N 19th Ave at the time of
the accident.
I interviewed Drew McDowell. McDowell said a group of them were headed to
Cherry's house. McDowell said, he was driving his own car, and did not have any
passengers. McDowell said Cherry and Ingram were in Cherry's car, and Brett
Layman, Andrew Beland, and Richard (Ross) Ridenour were in Ridenour's truck.
McDowell said that he was headed Northbound on 19th Ave, and was in the right lane
ri
"'.,,~
'"
-,
',QONFIDENTIAL
f~l~ INf=5MMAT/ON IS FOR LAW
ENffiFtSEMENf~Q~ES ONL'f.
when he stopped at the traffic signal at 19th Ave and B~fIW ~'fl4t\ ''M!EY IS
was a couple cars back in the left lane. McDowell said hi1*jl\M~mftmto the
left lane, and that was when Cherry had evfdently pulled Into the right lane and
McDowell said Cherry just kind of "ripped by" in the right lane and was trying to get
ahead of the group of vehicles in the left lane. McDowell said he didn't know how
fast Cherry was going, other than to say "too fast," and that McDowell thought
speeding was a factor. McDowell said Cherry merged too late, and McDowell thought
Cherry had panicked and overcorrected, and then hit the median. McDowell said, to
his knowledge, neither Cherry, Ridenour or McDowell were racing or playing any
games. McDowell said they never race, and in addition, Ridenour was about 4 or 5
cars back from McDowell at the time of the accident. (For full interview, refer to
McDowell's Interview).
I also interviewed Brett Layman that night. Layman said he was In Ridenour's
truck, and they were headed out to Cherry's house. Layman said they were back in
traffic a ways and he did not actually see the accident or how it happened. Layman
said he just recognized Cherry's car as they drove by the accident. Layman also said
there was no racing or other type of games being played by the drivers. Layman said,
"we've never raced before, and we weren't racing." Layman said he would tell us if
they had been racing S9 Cherry's and Ingram's parents would know. (For full
interview, refer to Layman's Interview).
That same night, I interviewed Marianne Baumberger. Baumberger said she
was also Northbound at the time of the accident. Baumberger said she had started in
the right lane at 19th Ave and Baxter. Baumberger said she merged into the left lane,
and another white car alsQ merged Into the left lane in front of her. Right after that,
Baumberger said a reddish, maroon car (Cherry's car) came "just flying by" on the
./' '
right side. Baumberger said sfie was thinking that Cherry's car was just going to force
its way in and was trying to get ahead of the vehicles In the left lane. Baumberger
said she saw Cherry's car miss the orange pylons and miss a car in the left lane before
veering to the left. Baumberger said Cherry's car then hit the cement median, hit a
silver pickup, and continued north and landed on Its side. Baumberger said she
pulled over to the side of the roadway, and tried to help direct traffic for a while.
Baumberger said she also spoke with the people In the white car that Cherry's car
had cut In front of. Baumberger said a police officer (Deputy Chief Lachapelle) came
over and spoke with them. Baumberger estimated that she was going about 35 mph,
and she said it didn't take very long for Cherry's car to go around her. Baumberger
said she was unsure of the speed of Cherry's vehicle, but estimated the speed at
about 45 - 50 mph. (For full interview, refer to Baumberger's Interview).
This concludes my involvement In this investigation.
END OF REPORT
1(~
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f j
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StlPPLBMBNTARY
CONfioeNTIAl
.iFtls INFt)~MATION IS FOR LAW
RBPOR"ENF@~~EM;NT PURPOSES ONl'l
AN~ YH^YfMO~iZEO USE IS
stRlctL\" pf\C~H'1'TED.
CASBz BPD * 0510180013
DATE O~ REPORTs November 2, 2005
REPORTING O~~ICBRs D. Peterson 636
DBTAILS O~ RBPORT ~
On October 18, 2005 at about 17:35 hours I was southbound on
19th street, croBsing the I-90 overpass when I was flagged down by
a northbound vehicle. The female advised me of a vehicle on its
side in front of Subway and she thought that one person was dead.
I noticed the vehicle in the roadway and advised dispatch
that I would be out investigating. I approached the vehicle, which
was on its driver'S side and noticed two male passengers partially
within it.
Due to the inj urias of one male I detennined him to be
expired and covered him with a blanket that was wi thin the car.
The other male was unconscious but still had a pulse and was
breathing but seemed to be somewhat obstructed. One male
approached and advised that he was an EMT and asked if he could
help. I advised him that he could and he retrieved a bag and
attempted to clear the airway and give the victim medical
attention.
A passerby pointed out to me that there was a second vehicle
that was involved just south of my location. As Officer 115 was
arriving from the s9uth I instructed her to stop near the second
vehicle that was involved and block the scene so that vehicles
would Rot disturb it. ./
Fire and Medical units began to arrive and I attempted to
direct them to the scene and around traffic. As medical units
began to work on the patient, a passerby approached me and pointed
to a group of juveniles and stated that they were following the
involved passenger car. I approached the males and questioned if
the new anything of the incident. They stated that they did and
went to school with the two males within the passenger car.
As I began to get information from them, more Bozeman
Officers arrived and began to speak with them as well. At about
the same time I was requested to clear the scene as 800n as
possible to respond to county calls that were backing up. I
advised Officer Schumacher that I had to clear and that I had not
gotten any names or addresses from the juveniles. I then cleared
the scene and did not return.
End Report.
~D. peter.on.636
~~~,~
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DATE:
GONFiDE,'iTIAL
REPORT OF INVESTIGATIT~ INf=t1FiMA TION IS FOR LAW
11-14-0S $N~~@eMeNr PURPOSES ONL'f.
ANf UN~\.Jtl=-KmIZEO USE IS
Snll€tL y P?l'Ot1'~TEO,
SUBJECT:
Fatal Vehicle Accident
REFERENCE:
PROS1018-OO13
REPORTING:
Detective Trent Schumacher
DETAILS OF INVESTIGATION:
On October 18, 200s at approximately 5:30pm I was working at the Law and Justice
Center preparing to leave for my residence. At 5:34pm Dispatch advised there was a
vehicle accident on 19t1a street. Radio traffic by omcers arriving at the scene indicated the
possibility of injuries or fatalities.. Sgt. Colt Schumacher and I went to the location to assist
with the Investigation.
Sgt. Schumacher and I arrived at the 2800 block ofN. 19th at 5:42pm. I spoke with Sgt.
Mark Johnson and advised him I would start taking df&ital photos of the scene. I
photographed the involved vehicles as weD as the debris areas and impact points. The
vehicles Involved were a silver Chevy picknp and Maroon Toyota Celies. I observed the
passenger of the pickup receiving medical treatment oear IUs vehicle. Schumacher advised
me that the driver and passenger of the Toyota were believed to be high school students by
witnesses he had spoken with. The driver of the Toyota had suft'end severe head trauma
and was dead at the scene. :ne passenger was tnuuported by ambulance to Bozeman
Deaconess HospitaL I checked the wanet of the driver and Identified him as Geoffrey
David Cherry by his drlver'l ~ Calls to the hospital and ltitbais iIlfonnadon
confirmed the passenger from the Toyota to be Kayle Ingram. After photographing the
scene I contacted HIgh School Principal Godfrey Saunders and advised him that two High
School students were involved in the accident. I informed. Saunders of their identities to
reduce any confusion since several students were at the ,cene and word of the accident was
passing quickly by cen phone. I spoke with Sgt. Johnson aDd Deputy Chief Lachapelle
about what needed to be done nert. They..bel me to go to Bozeman Deaconeu Hospital
with medical release forms and usut OMcer Kaycee Anderson. Andenon had gone to the
hospital when Ingram had been transported from the location.
On October 18, 2005 at 8:03pm I arrived at Bozeman Deaconess Hospital I provided
medical release fol'JlUl to Aadenon. I spoke with. Jaclde Inp'am (Kale Ingrul's mother)
and eIplained the circum8tances of the accident. She thanked me for the information and
left for Billings where Kale was being Down to by air ambulance. I left the hospitalat"9:39
pm. This ended my involvement in the inveltigation~
T~ent SchumaChe:/. / . _{
~~
1
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0--'
,~J CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.
PHOTO LOG ANY UNAUTHORIZED USE IS
BOZEMAN POllCE DEPARTMI!ImICTLY PROHIBITED.
\ i
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Pollce Report:0510184)013:
Date: 11-14-05
Subject: Fatal Vehicle Accident
Location: 2800 North 19th
Time of Photos: 1743-1920 Camera: Olympus C-740
~enae:l:2.8-3.7
Film: Digital Format"
Flash: X
Fstop: Auto
Frame #
1.
149C
2
149D
3
149E
4
149F
5
149G
6
149H
Daylight:X
Nipt: X
Other:
Shutter Speed:Auto
Number of Photos: 51
Descriotion
Bv:
. Driver of struck silver pickup - Daniel B. Abbott 149
Facing N/B-struck Silver Chevy tnlck in SIB 149
Outside lane.
).
Facing NIB-Debris trail to Toyota Celica Location 149
./ r
Facing NIB-location of 1984 Toyota Celica from 149
pickup location
Facing NIB-Toyota Celica from estimAted 149
impact point
Facing NIB-Location and Position of Toyota Celica 149
7 1491 Treatment/transport prep of Kayle Ingram 149
8 149J Facing FJBwLocationIPosition of Toyota Celica 149
9 149K Facing S/BwLocationIPosi1ion of Toyota Celica, 149
10 149N Facing FJB-Damage to undercarriage of Toyota 149
Celica
.-----
, , , '"_,,ICONFIDENTIAL
!"
ll.:r..,~..,....
THIS INFORMATION IS FOR lAW
ENFORCEMENT PURPOSES ONLY.
11 149M Facing EIB- Treatment/transport OfKa~}h~UTIM!RIZED USE IS
SiRI TLY PROHIBITED.
12 149Q Facing NIB-Impact point on median by Toyota 149
Celiea.
13 149P Skid mark of Toyota Celica from median to 149
impact point
14 149U Front let\: passenger compartment area of Chevy 149
pickup
15 149T . Dash board of pickup - severed hand from Ingram 149
16 149X Pacing SIB - Driver's side of Chevy pickup 149
17 149W Pacing W IB-Close up - damaged side of Chevy 149
truck
18 149AA Pacing SIB-medical treatment of Chevy 1ruck 149
driver Daniel Abbott.
19 149Z Facing NIB..cloBe-Up of passenger side of Chevy 149
truck
20 149AC Pacing W/B..close-up of underside of Toyota Celica 149
).-
21 149AE Pacing SfB..close-up of oil pan of Toyota Ce~ca 149
./
22 149AD Same as above. 149
23 149AH Close-up of severed hand on Chevy trock dashboard149
24 149AG Dashboard and steering column of Chevy truck 149
25 149AL Pacing FiB-passenger compartment of Toyota 149
Celica
26 149AK Pacing N/B..close-up of Toyota Celica top under 149
Chevy truck UP tire
27 149AO Facing FiB-passenger and rear compartment of 149
Toyota Colica
28 149AN Same as above - no flash 149
29 149AR Foot/Leg position of driver of Toyota. 149
~. "~~ON PI OShlTjAL
,-- THIS INFOAMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.
Celiea (Cherry). ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED,
30 149AQ Facing NIB-position of driver of Toyota Celiea 149
31 149AV Facing E/B-rear passenger compartment of Chevy truck 149
32 149AU Facing NIB-drivers area of Toyota Celica 149
33 149A Facing N/B-position/location of Chevy truck 149
34 149AX Dashboard close-up of Chevy truck 149
35 149AY Close-up ofairbag and floorboard of Chevy truck 149
36 149B Facing NIB-front of Chevy truck 149
37 149AW Passenger compartment area of Chevy Truck 149
38 149AT Foot po,sition of Cherry in Toyota Coliea 149
39 149AS ,Position of Cherry in Toyota Celiea - note photo 149
is rotated counterclockwise. Bottom of photo is to
the left.
40 149AP Facing FiB-position of Cherry prior to removal from 149
veJUcle
41 149AM Facing N7B-passenger and engine compmtment ef 1~9
Toyota Celica
42 149AJ Close-up of Toyota Celica top under front end of 149
Chevy truck.
43 149AI Facing W IB-wing window area and windshield 149
of Chevy truck. Rotated 90 clockwise
44 149AF Facing SIB-from approximate Celiea location to location 149
of Chevy truck. Rotated 90 clockwise.
45 149AB Facing N/B--close-up of Toyota Celica rear-end 149
46 149Y Facing SIB-right rear and side of Chevy truck. 149
4T 149V Facing West-profile of Chevy truck. 149
48 1498 Close-up of driver's airbag in Chevy tmck. 149
49
50
51
149R
1490
149L
f~-'j
f\.....__
~
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\-...,.........
Chevy truck passenger compartment thru driver's
window.
149
Facing NIB-passenger area of Toyota Celica
149
Treatment/transport of Ingram
149
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONL~
ANY UNAUTHORIZED USE IS
SmlCTLY PROHIBITED.
)..
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1:.
Date:
Subject:
Refer:
Driver 1:
DOB:
Passenger:
DOB:
Driver 2:
DOB:
SQ))plemental Report
11/2/05
Fatal Crash., North 19"'/Burke
0510180013
_frey David
.
illiiliyle L
Abbott, Daniel Beryl
Reporting Officer: Colton Schumacher
DETAILS OF COMPLAINT:
crash.
Officer.> responded to the lltea of North 19'" and Burke for a .teport of a traffic
DETAILS OF INVESTIGATION:
On 10/18/2005 at approximately 1735 hours, Detective Trent Schwnacher and I
were leaving the Law and Justice Center after completing our shift when we overheard a
report of a possible fatality crash on North 191h neu the inreuection of Burke. Detective
Schumacher and I immediately realized that the combination of the location and the fact that
it was the peak of the rush hour traffic would tmke it imperative that we respond to assist
the officers on the scene.
Deputy Chief Lachapelle, Deputy Chief Dove responded ahead of Detective
Schumacher and myself in separate vehicles. Upon our arrival of the scene, I began an initial
walk through of the scene to determine what resources we had available. As I walked north
on 19d1 through the scene, Deputy Chief Lachapelle shouted to me and gestured to a group
of juveniles that were standing near the parking lot in front of Radio Shack adjacent to the
crash scene. Deputy Chief Lachapelle told me that the juvenile were witnesses and that we
needed to contact them.
I approached the group of boys and I noticed that Deputy Peterson of the Gallatin
County Sheriffs Department was already talking to them. The first male that I contacted
was identified as Richard Ridenour. Ridenour told me that he was driving his trock: north on
19d1 behind the T oyata. Ridenour advised me that he did not see the actual crash. The
~ ~~.l\.
second male that I contacted was identified as Brett Layman, DOB 11/13/1987. Layman
told me that he was riding in the back seat of the trUck driven by Richard Ridenour. Layman
told me that they were coming from the high school Layman told me that he did not see
the actual collision but he did see the pickup that was involved and saw the Toyota was
tipped over. Layman told me that he was friends with the driver of the Toyota and he
identified the driver as David Cherry. I then interviewed Drew McDowell who was driving
his own vehicle north on 19lh behind the Toyota that was involved. in the crash. McDowell
told me that he was traveling north on 19lh coming from the high school parking lot and had
merged into the left lane with traffic when the Toyota involved in the crash passed by him
on the right going "too fast". McDowell told me that he observed the Toyota merge to the
left, strike the curb, flip McDowell told me that the driver of the Toyota was a friend of his
named David Cherry. -McDowell told me that the passenger of the Toyota was a male
named Kayle (he did not know a last name). The conversation with McDowell and part of
the conversation with Layman was digiWly recorded with my pocket recorder.
I advised McDowell and Ridenour to go to their vehicles and stay warm and that I
would returo to talk to them some more later. I then contacted Chaplain Heibert of the
Gallatin County Sheriffs Department and directed him to where McDowell, Layman and
Ridenour were located so that he could talk to them.
At approximat~ly 1911 hours, Officer Pankratz and I cleared the scene and were
available for calls. This .concludes my involvement in the inves' cion.
~~
Serg... Colton Sch1Qll8Qker
CONf\Oe..\lTIAL
"nUl tN~OAMA ilON IS FOR LAW
ENt!OJ'\C!M!NT PURPOSES ONL"
ANV UNAUTHOR\ZED USE IS
sf~\etl\f fl~OH'8lTEO.
____AJ""'""&<l
;~ N."i9"~A';;':;.='lS~"'n ~~@,(-f~(.
Herbert C. Hothan (Driver)
. 153 Pathfinder Trail
Bozeman MT
ooB:_
Phone~34bm
(406) 522-6237 wk
WITNESSES:
Hothan Vehicle: Mf - ACI473
I~ith (Judy) Franzak (Passenger with Hothan)
. 153 Pathfinder Trail
Bozeman MT 59718
DOB:_
Phone: ~0634inn
M~e Evelyn Baumberger (Driver)
1013 Silverbow Avenue
Belgrado-MT 59714
DOB:_
Phone:~1263 inn
(406) 522-2549 wk
Baumberger Vehicle: Mf -6A75807
REPORTING OFFICER: Mark Lachapelle, Deputy Chief
-..,."-':f"'1I"'I, .A. ....... CI_
DATE:
CCQNEt~ij'N"A~L
BOZEMAN POLICE DEPARTME~19"l'Q8(3~fJi1~"f~fS ~R~\i\f'.~
SUPPLEMENTAL REPORT ENl!t.jAOe~t4u~~8S~~J~.
AN~NDN~U~~~~EOs~~S IS
Friday, November 11, 2005 ST$~l:."t~~f1~~tfED
INCIDENT:
North 19t1a Ave I Barke Street FataUty Accident
REFERENCE:
0510180013
DRIVER(S):
GEOFFREY DAVID CHERRY
DOB:_
DANIEL BERYL ABBOTI'
D08:
REPORTING OFFICER: Officer Adam Pankratz
, .
DETAILS OF INVESTIGATlON:
On October 18,2005 I was assigned patrol duties in a marlced patrol car in the City of
Bozeman. At approximately 1734 hours patrol was informed of an injury accident at
North 19th Ave and Burke Street. Initially, Sgt. Johnson, Officer Anderson and I
responded to the scene.
Upon arriving at the scene I observed a passenger car to be on its side and blocking the
southbound lane of North 19th Avejust south of Burke Street. I obsetVed Sgt. Johnson
and Officer Anderson to be on'icenc dealing with those in.....olved in the crash. lobserved
members of the Bozeman Fire Department to be attending to the injured people involved
in the crash.
I realized the southbound lane ofNortb. 19th Ave needed to be shutdown and traffic
diverted to protect persoIUlel on scene and the evidence relating to the crash. I placed my
patrol vehicle at the intersection of North 19th Ave and Burke Street at an angle to block
all southbound traffic. All emergency lights were activated.. I then began to divert
southbound traffic on North 19th Ave, west onto Burke Street. I continued to do so until
approximately 2030 hours when I was replaced by Deputy Chief Kent. I then cleared
from the scene with Sgt Schumacher and began answering calls for service unrelated to
the crash.
END OF RE
~
Page 1 of 1 - Supplemental Report
BPD Officer Pankratz
8r'-".
..
:t:--'"
STATE OF MONTANA
DIVISION O!!~~~~C SCIE-NCECCJ.:aN'Fl1J6NmAL
....-.~~ Street nll:llSN~OOMM<<\I)NSlS=<B1ID13tlWN
MiuouIa. --- ......... (406) 728-4970 Ett~~WsfNWlffiWRB6SESl9NlY.
UllHSlBIiIEDJOOeslS
Y 'f?AOOJESHED.
CORONER'S
REPORT FORM
SUBMITTING AGENCY: Gallatin Co Coroaer COUNTY CORONER'S omCE
County: Gallatin CoronerlDeputy: Layton
DECEDENT (Full Given Name): Geoffrey David Cberry
Addr~ag Star Laae 8ozetaaIl, Mt. 59718
D.O.B.: ~ Gender. Male Race: WhIte
OccupatIon: Stadellt .
OATE & TIME LAST SEEN ALIVE 0; OR IF KNOWN DATE & TIME OF DEATH [81: 10-.18-05 1715 bra.
DATE & TIME FOUND IF TIME OF DEATH UNKNOWN:
PlACE OF DEATH: 2900 North 19- Street Bcn;MU... Mt. 59715
IF DEATH IN HOSPITAl, DATE & TIME ADMITTED: Dr.'a NaTle:
AUTOPSY? NO IF YES. BY DR.
TOXiCOlOGY SPECIMENS TAKEN? YES IF YES. CHECK WHICH: 181 Blood D VItreous [8J Urine
ANGERPRINTS TAKEN? NO PHOTOGRAPHS TAKEN? YES IF YES: [81 Scene 0 Autopsy
DEATH CERTlACATE (D.C.) CERTIFIED BY: [8J CoronerIOeputy Ropr IL Laytoa. OR 0 Dr.
CAUSE OF DEATH (As appears on D.C.): D Pending OR ~pIe bIwrt force InjOOes OR ~~~..n"--"{ ~ f
OF DEATH (As appears on D.C.): ACCIDENT
DETAILS SURROUNDING DEATH (Desatle beloW. It applicable, pleaIo Include pat medical hiItofy,l.e. heart
disease. hypertenlllon. dlabetu. alcohol abl.lM; 88lzurn. etc..nd oumIf1tlMdk:atlona.): D REPORT ATTACHED
Received . ~ 6'om Oallatin County Sheritrs Dispatch to nlIpOIId to ~ above wtKn . JUUII& n1aIo - dcIoeated. lbo ftlIIIlt
ofanMVA.
Amved OIl _ @ appt'Ox. 1820 hm. Multiple Bomman PO, Bcwman Firo. OaI\atiIl.Comty Sheriff's Deputiea _ MHP Oftlocq
~ on..:ene. Deputy Chief Mark Lachapelle. 132, advilcd dallbo crab involvod. two vWDoloI. 1\e vcbioIo occupied by the
decedeDt was traveling IlOrthbotmd when it au.... IIIe modi... bland at . blah lip-'. _Itnd:... CDlOmia& wIdcIe. Thln_
two oocupana of the northbound vehicle md OOCI oa:upmt orllle toUlhbomd YdaIoIa.. TbCI..-cer In the ~I vcbilllllWII
tmuported to 8oJ:emaD [)eaooneQ with severe lqjuries. Jbo opentor ofebe IOOCbbouod vdiieio '0\'11 abet b.64tpOdIlld to 8<nmnaa
De.loDCII with appateDt minor- injuries.
lobI<<vCld . )'OUIII male lyiDa flee down in the raJIIhq ofthc vdaicIe. Hill lop W~ still in lbe clrtWl["I ~ \lDdcmlIIdl the
IlCrJClrinI wheIl. 1bml WlIll obvioul RVere trauma to bls oppel" bocIJ: 'Ibml wat ex.poIlld bctuIa of the 11Ift ann_ band. ~
_ . manivo defect to the upper left ~ quadraat ofbis skull Tho body __ wanu to the tooda with 110 evicleoce of riaor- or
dqJeodeot lividity pl'ClClDl He _ dmo5Cd in . toil ahirt. jeans, aocb md lIboeI.
Wich the uslItmce of Bor.cman PIre the body -.va remowd tbr" er.aport by Coroncfll van to PUDCAI and Crcmatioo 0aUcry at lho
nqueat oCtile family.
Upon arrival at the tuner.l boDUlldditional pbotograpbll were bbu aDd fluids ~ col~ for IIilllliaion to tile CriGas Lab i.a.
MilIIoula fOl'toxiooloey analysis.
The flunlly _ oonW:md by friends of the decedent
Additiooal details of the aecldcnt Ir'C included In the Bozmnan PO RIpOff. A copy Is included in tho file.
l'ORII DF82 (CompuIw Format 05101)
. CORONER
DI81'RIW11ON: c- I saw Medk:III eu...IrW I County AUonMy
Signature:
"--L,~..u"~"'!I~'
.(~-
\' STATE OF MONTANA < ;
DIVISrON O!!2~~~~f SCIE~NCECONFIDENTIAL
MIuouIa,MonbI="9~8trMt (4CNI)728-4I70 THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.
AUTHORIZED USE IS
PROHIBITED.
,-r-:-..,
CORONER'S
REPORT FORM
SUBMITTING AGENCY: Gallatin Co Coroner COUNTY CORONER'S OFFICE
County: Gallatin CoronerlDeputy: Layton
DECEDENT (Full Given Name): Kayle Iqram
Address:
D.O.B.: Gender: Mal. Raclt: WhIte
Occupation: StudeDt .
DATE & TIME LAST SEEN ALIVE 0; OR IF KNOWN DATE & TIME OF DEATH [gI: 10--18-05 1039 hra.
DATE & TIME FOUND IF TIME OF DEATH UNKNOWN:
PLACE OF DEATH: We Fllcht heUcopter @ approximately BI& TImber Mt.
IF DEATH IN HOSPITAL, DATE & TIME ADMITTED: Dr.'a Name:
AUTOPSY? NO IF YES, BY DR.
TOXICOLOGY SPECIMENS TAKEN7 NO IF YES, CHECK WHICH: 0 Blood 0 VItreous 0 Urtne
FINGERPRINTS TAKEN? NO PHOTOGRAPHS TAKEN? NO IF YES: 0 Scene 0 Autopsy
DEATH CERTIFICATE (D.C.) CERTIFIED BY: [gI CoronerlDeputy Roaer H. Laytoll OR 0 Dr.
I CAUSE OF DEATH (As appears on D.C.): 0 Pending OR Multiple blunt force Injuries OR ~~~.../" .-{ DMadl1
OF DEATH (As appeenl on D.C.): ACCIDENT
DETAILS SURROUNDING DEATH (Descrlbe boIow. If applicable. plaase Include past medlcaI history; I.e. heart
disease. hypertenllion. diabetes, alc0hoi abuse: .lzure., etc. and current lTl8ClIcllIdona.): 0 REPORT ATTACHED
Received a mJ.ueIt from Gallatln County Sheriff'. DlipItch to oontaet Deputy Steve c-. CoroJMi". otBoe. Yello'oVlttnMl County.
He advised tIW the pasengec from the MV A earlier in the eveom., hid died In fliabt to BilIiD.p.. tMUll ofhijurilll auataioed in the
aooidmt. The decedtot had been cmatcd at the lICCIDe. tnD8pOrkd to Bozeman DeaooDCIII and aubIeqacntly lJ1b-FUaht trusport to
BillliD8I.
See dcWilI in C8ICl O~ 1018. CbCIlTy. Oeofti'ey David.
Following diecuasion with Deputy Conlon and staff at S~\rincmtl Hoapi:tal, the body wu reIcucd to Frlmzal Cavil Funeral HOlM In
Uvin&Jton, Mt.
I"OItM OF8a (Compuw Pormat 0Ml1)
. CORONER
DI8TRJaUT1ON: Coranw I ,.... MedIcal bwnIner I County Attorney
./
Signature:
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Incident Repo
2005~01686 -000
Alarm Date and Time
Arrival Time
Controlled Date and Time
Last Unit Cleared Date and Time
Response Time
Priority Response
Fire Department Station
Incident Type
Initial Dispatch Code
Aid Given or Received
Alarms
Action Taken 1
Casualties
EMS Provided
Apparatus. Suppression
Personnel - Suppression Personnel
Fire Service Injwies
Property Use
Location Type
Address
City, State Zip
Latitude
Longitude
BozomanIC~IDENTIAL
THIS INFORMATION IS FOR lAW
ENFORCEMENT PURPOSES ONLY.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED,
Batie
17:33:45 Tuesday, Octobor 18,2005
17:42:09
23:10:59 Tuesday, Octobor 18,2005
0:08:24
Yes
1
312 - Vehicle accident with injwies
MVA
N - None
1
32 ~ Provide basic life support (BLS)
Yes
Yes
2
7
1
963 - Street or road in commercial area
Intersection
On N 19m AVE at BURKE ST
BOZEMAN, Mf 59715
49.490048
506.184816
EMS Patient
Last Name
First Name
Street Address
).. Person Involved - Cherry, Geoffrey
Yes ./
Cherry
Geoffi'ey
259 Evening Star
EMS Patient
Last Name
First Name
Street Address
"P.O. Box
City, State Zip
Person Iawlved - IllIram, Kayle
Yes
Ingram
Kayle
310
Livingston
Location Type
Service Type
AreaTypo
Mass Casualty Incident
ID of First Unit on Scene
Number ofPationts This Incident
Response Mode to Scene
EMS Scene
Street or Highway
Unknown
Urban
Multiple Patient Incident
BOZE2
2
Emergency
Page: 1
Printed: 1012012005 12:37:44
'I
Incident Repo{
2005-0001886 .000
First Name
Last Name
Street Address
Gender
Pate of Birth
Age
Race
Ethnicity
Provider Impression / Assessment
Cause of Illness/Iqjury
Injury Intent
Severity of Injury
Transporting Unit
Chief Complaint Code
Code ofVchicle Patient Involved In
Code of Vehicle Patient Involved With
Location of Patient RE: Vehicle
Restraint Used
Path ofEjcction
Condition of Steering Wheel
Condition of Windshield
Driver Name
Driver Address
Bozeman I Department
'. CONfiDENTIAL
THIS INFORMATION IS FOR LA~
ENFORCEMENT PURPOSES ON~ .
R\ZED USE IS
STRICTLY PROHI!3\TE .
EMS Patient - Cherry, Geotrrey
Geoffrey
Cherry
259 Evening Star
1 - Male
November 21, 1987
17
1 - White
o - Non Hispanic or Latino
28 - Obvious death
29 - Motor vehicle accident
Unknown
Full Arrest
R99
Motor Vehicle
Car
Truck/Bus
DriVel;
Unknown
Other
Compressed
Other
Cheny, Geoffrey
259 Evening Star
Assessment - Obviou:l Death
Assessment - Bleeding
EMS Patient - Cherry, Geofli'ey Assessment
Traum.~ Brain
Severe
Symptom 1
Symptom 2
EMS Patient - Cherry, Geoffrey Symptoms
UnrcsponsivrlUnconscious
Traumatic Injury
Triage Criteria 1
EMS Patient - Cherry, Geofli'ey Triage Criteria
Death same MV
Injured Body Site 1
Injury Type 1
17:45:00 - Assessment Only
Provider
Success
Charge
EMS Patient - CIIerry, (Jeoff'ffy 1..,."-
Head/Scalp. Medial
FX/Open, Incapaciting; 3rd Degree or Higher fur Burns
EMS Patient - Cherry, Geoft'rey Flow Chart
Attempts "" 1; Quantity -; Size -; Checked pulse of MV A victim
126 - FISCHER, JEB S
Yes
$0.00
Narrative Name
Narrative Type
EMS Patient - Cherry, Geoft'rey Narrative
Cherry MV A
EMS
Page: 2
Printed: 10/2012005 12:37:44
...
Incident Repo(
2005-0001686 -000
Bozeman I 'neeeNFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.:
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED,
Narrative Date
Author
Author Rank
Author Assignment
Namtive Text
EMS Patient ~ Cherry, Geoffrey Narradve
06:33:31 Wednesday, October 19,2005
120 - CRINER, MARK A
AC
1
Report of an MY A with injmics. One victim was pronOlmced OOA. Firefighters
assisted ambulance personnel with the other victim in loading and transport to the
hospital.
>-
./
Page: 3
Printed: 10/2012005 12:37:44
,
~,--:--' T-
Incident Repot
2005-0001686 ..000
First Name
Last Name
Street Address
P.O. Box
City, State Zip
Gender
Race
Ethnicity
Provider Impression I Assessment
Cause of mneullnjury
Il\iury Intent
Severity ofInjury
Transporting Unit
Chief Complaint Code
Time to Extract
Code ofVchicle Patient Involved In
Code ofVchicle Patient Involved With
Location of Patient RE: Vehicle
Restraint Used
Patient Was Ejected From Vehicle
Path ofEjcction
Condition of Steering Whccl
Condition of Windshield
Driver Name
Driver Address
Assessment - Bleeding
Bozeman I
EMS Padent . lnanm, Kayle
Kayle
Ingram
310
Livingston
I - Male
I - White
o - Non Hispanic or Latino
38 - Trawna
29 - Motor vehicle accident
Unknown
Urgent
AMRl
Motor Vehicle
10
Car
Truck/Bus
Front
Unknown
Yes
Other
Compressed
Other
Cherry, Geoffrey
"
259 Evening Star
EMSP;'dent - (Biram, Kayle Aaessmeat
Severe
-'~ent '
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.
ANY UNAUTHORIZED USE I
, EO,
Symptom 1
EMS Padent - Ingram, Kayle Symptoms
Traumatic Injury
Triage Criteria 1
Injured Body Site 1
Injury Type 1
Injured Body Site 2
Injury Type 2
17:43:00 - Assessment Only
Provider
Charge
EMS Patient - Ingram, Kayle Trial" Criteria
MV Speed 40+ MPH
EMS 'a.ot - {ncn.... ~yIt Injllri.
Head/Scalp, Medial
Penetrating, Jocapacitins; 3rd.Degree or Higher tOr aurns
Fore Ann, Right
Amputation, Non-Incapacitating; 2nd Degree for Burns
EMS Patleat - (BIram, Kayle F1ow. Cbart
Attempts '"" 1; Quantity ""; Size -; Provided assistance to ambulance crew
126 - FISCHER, JEB S
$0.00
Narrative Name
EMS Padent .. (agnm, Kayle Narrative
Ingram MV A
Page: 4
Printed: 10120/2005 12:37:44
'\.
Incident Repo(
2005..0001686 -000
.,....
Bozeman 1 ~Department
Narrative Type
Narrative Date
Author
Author Rank
Author Assignment
Narrative Text
EMS Padent - Ingram, Kayle Narrative
EMS
06:55:00 Wednesday, October 19,2005
120 - CRINER. MARK A
AC
1
Report of an MV A with injuries. One victim was pronounced DCA. Firefighters
assisted ambulance personnel with patient care, loading and transport to the hospital.
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONL'f.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
>"
./
Page: 5
Printed: 10/20/2005 12:37:44
~
Incident Repo,
2005..0001686 ..000
Apparatus ID
Response Time
Apparatus Dispatch Date and Time
En route to scene date and time
Apparatus Arrival Date and Time
Apparatus Clear Date and Time
Apparatus priority response
Number of People
Apparatus Use
Apparatus Type
Personnel 1
Personnel 2
Personnel 3
Personnel 4
Bozeman 1 Department
Apparatus - BOZE2
BOZE2
0:04:17
17:37:51
17:37:52
17:42:09
23:10:59
Yes
4
1
11 - Engine
115 - BUSHNELL, KURTIS E
Position: CAPT
126 - FISCHER. JEB S
Position: FF
0529 - KOLMAN, JASON
Position: FF
2942 - DUBAY, CHRIS
Position: FF
Tuesday, October 18,2005
Tuesday, October 18,2005
Tuesday, October 18,2005
Tuesday, October 18,2005
Apparatus ID
Response Time
Apparatus Dispatch Date and Time
En route to scene date and time
Apparatus Arrival Date and Time
Apparatua Clear Date and Time
Apparatus priority response
Nwnber of People
Apparatus Use
Apparatus Type
Personnel 1
Personnel 2
Personnel 3
Apparatus - DOZEI
BOZE 1
0:36:30
17:37:52
18:19:05
'>
11:42:35
18:39~J..
Yes
3
1
11 - Engine
117 - JOHNSON, GRAVER
Position: AC
136 - BARTON, TRAVIS W
Position: FF
5537 - MUMMEY, CODY
PCliSition: FF
Tuesday, October 18,2005
Tuesday,Octo~18,2oo5
Tuesday, October 18, 2005
Tu<<$day, 0ct0tJer 18,2i05
Reported By
Officer In Charge
Reviewer
Authority
115 - BUSHNELL, KURTIS E
06:56:34 Wednesday, October 19,2005
115 - BUSHNELL. KURTIS E
06:56:38 Wednesday, October 19,2005
103 - WINN, CHUCK C
12:22:23 Thursday, October 20, 2005
Narratives
Narrative Name
Narrative Typo
Cherry MV A
Incident
Page: 6
Printed: 10/2012005 12:37:44
. .
Narrative Date
Author
Author Rank
Author Assignment
Narrative Text
Narrative Name
Narrative Type
Narrative Date
Author
Author Rank
Author Assignment
Narrative Text
,;fr-_"
Incident Repo~
2005-0001688 -000
Bozeman If ):>cpartmcnt
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.
S IS
Narratives
06:44:06 Wednesday, October 19,2005
120 - CRINER, MARK A
AC
1
Report of an MV A with injwics. One victim was pronOWlced OOA. Firefighters
assisted ambulance personnel with patient care, loading and transport to the hospital.
New Narrative
Incident
12:35:09 Thursday, Ootobcr 20,2005
103 - WINN, CHUCK C
CHIEF
7
At 1733 hours on Tuesday October 18, 2005 we were dispatched to a vehicle accident
with itijuries. Two units were assisned to this incident. Seven personnel responded. We
arrived on scene at 1742 hours and cleared at 2310 hours. The incident occurred at On N
19TH AVE at BURKE ST, BOZEMAN. The local station is 1. The general description
of this property is street or road in commercial area. The primary task(s) performed at the
scene by responding personnel was to provide basic life support (BLS). No
mutual/automatic aid was given or received.
A special resource was called to staff Bozeman Engine 3. Engine 2 and Engine 3
remained on scene to provide lighting and scene control during MHP's accident
reconstruction and investigation
iwo patients were involved with this incident. One fire service casualty was associated
with ~!J..incident.
Alarm nwnber 0001686 has been assigned to this incident.
End ofRcport
Page: 7
Printed: 10/20/2005 12:37:44
!trY! rz 1. 'CRt:i ro () <Sh tAr+:e-
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CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONLY.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED
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MONTANA AUTOMOBILE INSURANCE IDENTIFICATION CARD
(STATEI "
COMPANY N"~.R"R COMPANY
PROP & CASUALTY INS CO OF HTFD.
POLICY NUMBER EffECTIVE DATE EXPIRATION DATE
55 PHJ514375-264401 04-28-05 04-28-06
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER
1984 TOYOT CELICA GT JT2RA64C5E6229220
INSURED
rCHERRy,GEOFFREY CHERRY
259 EVENING STAR LN
LBOZEMAN
& JA
MT 59715
SEE IMPORTANT NOTICE ON REVERSE SIDE
. ( 5~~i3~
~fX)$ ~t( ~
o/fJ~ / tJS' '1 ?
f)IIRE
TO RESIST DRUGs"
AND VIOLENCE.
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CONFIDE.\JTiAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONL'{.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
PLATE 6 p,9 162 1 Ot\ TE OS 162005 F617 !:.~S,8
1"'10"ITAt'.I~\ VEHICLE REGI:3TRATION AND PAYMENT RECEIPT
TAXES PAID THROUGH 04302006 VALID THROUGH 05312006
T'.....F' \IF' tVlAI/E 1-.100L ST{L COLon VII\I
PC '19F::4 TUfT (";:)1' 2Cl Ml:..F<: .J1'2Rl~64C5E6229220
1'TL 0/-\86 18 1 S:LDT 03192005 TI'-.'TRC G(::t,1J /tvlGVW 000000
PL T 1 G A9 16:: 1 Tyr' PC B(~l< NOOO SJ:.)E:C TAB 06X04597 1
F'UEL TYPE 1 EOUIP NO UNLADEN WG1' 0:';000 TON 000
CI-iERFN ~ GETJFFRE....t . DI~VID
CHEF-<:RV . .jAr'IIE:::. . EDWARD
259 EVENING :3T ";~R LANE
J;:,02EMAN MT !-:;.97''15
\.
~'FEE INFORMATION: .-------'-----------------'-~--------------'--
32 TTLS~TT 5.00 94 TTLTEC' 5.00 2,1-\ Lr\/I"\TT 2.00
12 VETFEE 0.50 13 TRNFEE 0.25 61 REGRAT 6.00
14 COOPT ;2 . \3(') 70 NE\lvI'3:::: 5.00 84 L TI-1\1PI< 4.00
87 HVYREG 2~~ .00
....COUNTV INFOF:\Y1A TION : ,__.__.h.__~_.__________r_-------_:--..,.-----------
T(.l,)(W:..L 500.00 (:0 06 SCH 7R--03 0$8 PROF';T, 00 FEE hl
\lEHVAL 8799..00 -IY1ILL 00000 pee Tr;;:EAS DEP 10
CALC\I.o,L t~SSo DATE 05162005 ASSD [-;,\'
UI'.!L,t~WF:-I.JL TO uf:'t:~:F<_,'J1 TE Vl:::,H Vv lOUT VALID ""i[] -t LTf"E:.IL.ITV INSURANCE
.l ~ c:ER...rIFI'~/~j.TE ()F: r::t:L.F-r ~~.Ir\.l::;:1.Jr~~l~tr~I~.l: t!I CJf\' P()~3T[::[) .II'..jCIEJv'jr"~
(
BONO 1 PIS REQUIRED BY 61 ~-6-'30 1, UNLESS EXEMPT e,\( 61-6-'303.
/(~
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1-
'.. - '.::.'_.cONFIDENTIAL
FORENSIC SCIENCE DIVI~INFORMATION IS FOR LAW
DEPARTMENT OF JUSTICE ENFORCEMENT PURPOSES ONLY.
STATE OF MONTANA ANY UNAUTHORIZED USE IS
2679 PALMER STRlPTt;LfRO. HIBITED.
MISSOULA, MT 59808 "' i'(---1) 8'; '\\0'-'
(406) 728-4970 ,"'- I)::'=- ' '1/
.,_m__...
~~...'''::''i:
,".' \,;t~
".'1'lt,i. I
/J..,.. ',.' ..~
I... .,.......
:J '~:. 7-~...:.t~~~~w-
~. ;~ ~;",:,A'.::' ,gi, '." ~
'\i ". ::"n~. :-..s:~t.it ;,.,
,..~~~~~
ROGER LAYTON
GALLATIN COUNTY CORONER
615 SOUTH 16TH AVE
BOZEMAN, MT 59716
Lab Case #: FSO..Q5..o04697
Agency Case #: 051018
SUBJECT: CHERRY, GEOFFREY DAVID
SUBJECT: INGRAM, KAYLE L.
SUBJECT: ABBOTT, DANIEL B.
cc:
EVIDENCE:
The laboratory received the following evidence tor analysis:
One kit reported to contain biological spec/mens
DRUG CONFIRMATION RESULTS:
SUBJECT: CHERRY. GEOFFREY DAVID
CAFFEINE
DETECTED IN BLOOD AND URINE
THC..cOOH, 5.3 NGIML
./
QUANTITATED IN THE BLOOD AT THIS
CONCENTRATION
(THC-COOH IS AN INACTIVE METABOLITE OF THe)
QUANTITATED IN THE URINE AT THIS
CONCENTRATION
(THC-COOH IS AN INACTIVE METABOLITE Of THC)
"
slfll/lf
Forensic Toxicologist
THC-COOH, 47 NG/ML
)..
~4d-h;4
J~. u n,Jr.
Fo nslc Toxlcoloalstl Supervisor -
Date of Report: 11/23/2005
PLEASE NOTE: All bioloiica1 specimens or other items that were submitted In this CllSCl will be retained at this Laboratory for a period
of two years at which time they will be dcstroyeq unless or until werccclve a letter from your office stating what other action you may
require.
CERTIFICATION: The undersigned, as Custodian of Rocords for the Department of Justice, Division of Forensic Sciences, hereby
certifies that this document, when signed and dated, is a true and correct copy of the original of said documC(l1t on file In the offices of the
Division, of FQlP!tSic Sciences....., ~ /
Dated thIS ~ day of ---.n~ . ~
Ic Sciences
- PrlntS(fOn: 11/23/2005
PaQe 1 of 1
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<.;i CONFIOENTIAL
FORENSIC SCIENCE DIVISI~IS INF.ORMATION IS FOR LAW
DEPARTMENT OF JUSTICE ENFORCEMENT PURPOSES ONLY.
STATE OF MONTANA ANV..llN.A(e)Q81?EO USE IS .
2679 PALMER STHf~ ~ HreI)flto7
MISSOULA,MT 59808 .~j7 ~I /1-- ,
(406) 728-4970
;.
ROGER LAYTON
GALLATIN COUNlY CORONER
615 SOUTH 16TH AVE
BOZEMAN, MT 59716
Lab Case #: FSO..oS..o04697
Agency Case #: 051018
SUBJECT: CHERRY, GEOFFREY DAVID
SUBJECT: INGRAM, KAYLE L.
SUBJECT: ABBOTT, DANIEL B.
cc:
EVIDENCE:
The laboratory received the following evidence for analysis:
TOX KIT
,t.,'; '.
ALCOHOL RESULTS:
Subject CHERRY, GEOFFREY DAVID:'
Date of Report 10/27/2005
>.
BLOOD - NONE DETECTED - "T:.o1"
BLOOD - 0.01 GM/100 ML - "T -02"
URINE - 0.02 GM/75.3 ML
./
PLEASE NOTE: All biologiCal speclmCIU or other Items that were submitted In this C8SC will be rctai
of two years at which time they will be dcstroyect unless or until we rcocive a letter from your office
require.
CERTIFICATION: The undcr3lgncd, as Custodian of Records for tho Department of JUltloc, Division of Forensic Sciences.. hereby
~ clJac rJW ~ Wll~ ::I1~1gu. 6hd ulbo, IS a uud' ana comet copy CU Ml!I OheiiiACOflaid dOCUrrieDtoil'tIfe fn the oftlccs oftlic
g=::fFO~:~~ ~. a~ ..
J l.~
Custodian ofRecol,'ds, Division Forensic Sciences
\~
Printed On: 1'1/23/2005
.,. . " ,
Page 10f 1
DEC. C.~. 200, (THO) 11: 58 FORB:1fBIC BCIB:NC!!: DIV
1-' -,
406S~~1067
PAGE. 2
FORENSIC SCIENCE DIVISIOrtON~-;:U:H.;.\jTiAL
DEPARTMENT OF JUSTICE THIS INFOFlMAT10N 1$ FOR LAW
STATE OF MONTANA ENFOAC!MENT PURPOSES ONL'f.
2679PALMER ANY UNAUiHORIZED USE IS
MISSOULA, MT 59808 STRICtLV ~~R()HlaITEO.
(406) 72fJ..4970
JI
CORONEH LT. WILLIAM JONES
YELLO~ TONE COUNTY CORONER
PO BOX 35020
BILLINGS, MT 89107
Lab Cue f;: FSD..o&..Q046Q7
Agency Calle #; 051018
SUBJl!CT: CHERRY, GEOFFREY DAVID
SUBJECT: INGRAM, KAYlE L.
SUBJECT: ABeOTT, DANIEL B.
cc:
EVIDENCE:
The laboratory received the following evk:lance for analysis:
One kit reported to contain biological specjmena
DRUG CO" FIRMATION RSSUI. r8:
SUBJECT: INGRAM, KAYLE 1.,.
NICOllNE
DETECTED IN BLOOD
OETECTED IN BLOOD AND URINE
CAFFEINE:
FENTANY_
./
DETECTED IN URINE
QUANTITATED IN THE BLOOD AT THIS
CONCENTRAnON
(TliC-COOH IS AN INACTlVE METABOUTE OF lHC)
QUANTITATED IN 11iE URINE AT THIS
CONCENTRATION
(THC-COOH IS AN INACTIVE METABOLITE OF THe)
DETECTED IN URINE
THC-cOO -I, 9.4 NGIML
::..
THc..cOOI-l, 71 NG/ML
ALPHA..H'V DROXYMlOAZOlAM
J a_~~~
e! eoloB~ SUpervialOT
( sm~?~ ~~ ---~
ForensIc TOX:~
I
I\:
f<'oJ'CDlllc ToxfaolOlillt
Date of RelJOrt: 11/2312005
PLEASE NUTE: All bfologlcalllpeClmcns or other items lhal were $Uhm1tt8d In thll cue will bo r<<aiu<<J at tbb Laboratory for IS pOIiod
of two years It which timo trnty will bedntroycq una or unlil wotOOetve alett<< ft'om your oftloo Jtatll\gwhar. other action youmly
requbu.
Prlnted On: 11/2312005
Page 1 of2
DEC. (4. 2003 (THO) 11: 58
FORENSIC 8CIENC~ DIV 4065491067
" - - ltInuadon of Report for Lab # FS0-06-004' -. .
PAGB:. S
CERTIFt(:A.TION: The undcralplcd. u CUltDdlan of ReoordIlbr tho Dcpwtmcut of JUIdca, O'vllton of PORlDllio ScIences. hereby
certJfica tht t \his document, wbcn signed and dIred, ls a It\tC and 00I1'0Clt copy at thc: orfsJaal of.tald document 01'1 roo in the otftocs of the
Division of fJOI'tlJ1Ifc ScleftCCIS.
Dated thls_ ~ oC_
Printed On 11/2312005, "
CUslodiln oCRoDordI. Dlvllioo ofForcnalc 8clencet
CONFiDEi\JTIAL
THIS INrzORMA TIQN IS FOR LAW
ENFOACf!M!Ni PURPOSES ONL'i.
ANY IJNAufHORIZED USE IS
STRICTLY PROHIBITED.
),
.......
Page 2 of 2
DEC. O~. 2005 (THU) 11:56 'OREN8IC SCIENCE DIV
40654.91067
PAGE. 4
; j
, ,
FORENSIC SCIENCE DIVISlCiNcoNFIDENllAl
DEPARTMENT OF JUSTICE ~Ff18 INf!ORMA TIQN IS FOR LAW
STATE OF MONTANA ~NP:OACIM!NT PURPOSES ONL'f.
1679 PALMER ANV UNAUlHORIZED USE IS '
MISSOULA, MT 59808 sf~lejL'~' PROHfSrrED
(406) 728-4910 '
r-.
KAYCEE J~OERSON
BOZEMAN POLICE DEPARTMENT
61 ri S 16TH AVE
BOZEMAN, MT 59715
Lab elM .; F8D.o!l-004897
Agenoy Case #: 051018
SUBJECT: CHERRY, GEOFFREY DAVID
SUaJECT: INGRAM, KAYLE L
SUBJECT: ABBO"., DANIEL B.
cc:
eviDeNce:
The laboratory received tho tollowfng evidence for ana1y81s
DUI KIT -INGRAM
ALCOHOL ReSUL TI:
Subject: lto. GRAM, KAYlE L.
Date <tf Report 1OJ2~
./
BLOOD - 0.04 GM/100 ML
VlTREOUB - NONE SUBMITTED
URINE - (1.03 GMI75.3 ML
URINE SAMPLE SUBMITTED BY YELLOWSTONE CO CORON
).
PLEASE NOD.. All b1nlOSlcalllp8CUncna or other items thal W1lf'O aublnllled In thIt cae will be
of two YCUlllt which timo they wal be desaroyc4 unk:a or until wo rMVO alo<<ar troa'l your oft!
tcquirc.
CERTJFICJ.nON: Tho undcnJ8oed, u CustodJan of Record. fur 1110 ~t of Jl1Idcc, JJlvtslOll 0 0. Sclencea, ha"cby
cortI1JM that thla dOCW1lCllt" when lIicno.1 and dated, II A b'UO end comet copy of Ch~ OtlafnaJ of IIAId doc:umcnt on illo in (h~ QtliceA of the
Division ocf onwlo SclonceJ.
Dared thl.!l__day of __
-cu.odllD of Rooorck. Dlvl,Jnn of forcn;[c ScIClllOCl
Printed On 11/2312006
Page 1 of 1
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FORENSIC SCIENCE DIVISIONCONFIOEi\JTiAl
DEPARTMENT OF .ruSTICE THIS INFORMATION IS FOR LAW
STATE OF MONTANA ENFORCEMENT PURPOSES ONL'f.
2679 PALMER ANY UNAUTHORIZED USE IS
:MISSOULA, MT 59808 STRICiLY NiOHI8ITEO,
(406) 728-4970
i:,
C. ANDERSON
BOZEMAN POLICE DEPARTMENT
615 S 16TH AVE
BOZEMAN, MT 59715
Lab Case #: FSO.QS..()Q4697
Agency Case #:051018
SUBJECT: CHERRY, GEOFFREY DAVID
SUBJECT: INGRAM, KAYLE L.
SUBJECT: ABBOTT. DANIEL B.
cc:
EVIDENCE:
The laboratory received the following evidence for analysis:
DUI KIT - ABBOTT
DRUG CONFIRMA nON RESULTS:
SUBJECT: ABBOTT, DANIEL B.
LIDOCAINE
Ao,.,. I" 'Hilla> & '( l}.OH-
DETECTED IN BLOOD
(tit l-1-€t..4 UJ~
. HutchisOn. Jr.
Ic Toxicologist! Supervisor
../
Date of Report: 11/23/2005
PLEASE NOTE: All biological specimens or other items that were submitted in this case will be retained at this Laboratory for a period
of two yCllI5 at which time they will be destroyeq unless or until we receive a letter from your office stating what other action you may
require.
CERTIFICATION: The undersigned, lIS Custodian of Records for the Department of Justice, Division of Forensic Sciences, hereby
certifies that this document, when signed and dated, is a true and comet copy of the original of said document on file in the offices of the
Division of Forensic Sciences. ~
-'10. ~ - / . -:l~__- l
Dated this ex \dayof , \...l"'TV . ~ ." ~ _"- ~ ~
Custodian of Reoords; Division ~iC Sciences
Page 1 of 1
Printed On: 11/23/2005
. .{
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,
FORENSIC SCIENCE DIVISI(j~ONF1DENT'AL.
DEPARTMENT OF JUSTICE ON IS FOR LAW
STATE OF MONTANA THIS INFO:~:;lpURPOSES ONL'l
2679 PALMER ENFORC;UTHORIZEO USE IS
MISSOULA, MT 59808 ANY CU~y PROHIBITED.
(406) 728-4970 sTA1
.'
KAYCEE ANDERSON
BOZEMAN POLICE DEPARTMENT
615 S 16TH AVE
BOZEMAN, MT 59715
Lab Case #: FSO..oS..o04697
Agency Case #: 051018
SUBJECT: CHERRY, GEOFFREY DAVID
SUBJECT: INGRAM, KAYLE L.
SUBJECT: ABBOll, DANIEL B.
cc:
EVIDENCE:
The laboratory received the following evidence for analysis:
OUI KIT - ABBOTT
ALCOHOL RESULTS:
Subject ABBOTT, DANIEL B.
.. NONE DETECTED
Date of Report: 10/27/2005
>.
CERTIFICA nON: The undersigned, as Custodian of Records for the Department of Justice.. retlslc Sciences, hereby
certifies that this document, when signed and dated, Is a tnle lUld correct copy of the orl&lnal of said document on filo in the offices of the
Division ofF2f..OI1sic Sciences.'-"1 A ...._J
Doted this ~ Cf day of v v!2:!.... ,~
L
Custodian ofRccords, Divis! 0 orenslc Sciences
Printed On: 11/23/2005 Page 1 of 1
CONfH)ENl'HAL
THIS INFORMATION IS fOR LAW
ENf:OACEMENT PURPOSES ONLY.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED.
!IUim
~t ' <
t '
Ii
'Z
n
m
>.
./
CONFIDEJ\lT~Al
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONL'f.
ANY UNAUTHORIZED USE IS
STRICTLY PROHIBITED,
~ J l 0 l l I !l '1 f !l t <
i r r' I . ! I .f · I
'. - l/ ic ~.D
I p'i f f m
! ~."~.f~"~ fZ
~ ~ ~ ~ (l) sa,
i' . .~I ~
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"
EVIDENCE I PROPERTY IN-PUT
2. PR NUMBER/OTHER NUMBER
OS) 60 I
5. BADGE ~
\ t.;.)
1. DATE IN
9. Q.EfENSE
l-q ta. J
=-..1. } t'~ 0J~vJ I /G.y/p Tt'()r,,~
~ol ~,ooLf)r~t..J
, [
SAFE KEEPING
WHiTE COPY - TO E'/IDENCE
YELLOW COPY - TO EVIDENCE
PfNK COPY - TO CASE ALE
GOLD COPY - ATfACH TO CITATION OR REQUEST FOR PRQSECUnON
"-
'J
3. AGENCY
o VAULT
STORAGE
OTHER
15. OUT-PUT
~ DATE OUT
SECT10N
# OF ITEMS RELEASED
SHELF
o TO BE RE11JRNED
o NOT TO BE RETURNED
o DESTROYED
o CONVERTED
..-:.
17. DlSPOSmON
. 0 GUILTY
~ 0 DISMISSED/AQU!TfED
-.~ 0 APPEALED TO DISTRICT COURT
18. RELEASE
DEFENDANT
o V1CTIM
o STATE
o DESTROY
o OTI-lER
JUDGES SIGNATURE
DATE
.
CONFIDENTIAL
THIS INFORMATION IS FOR LAW
ENFORCEMENT PURPOSES ONL'f.
~t\Y UNAUTHORIZED USE IS
E10,OD TEST REQUEST E'O~-RICT'LY PROHIBITED. -
Pursuant to the provisions of MeA Section 61-8-405,
I, ~I ,JlcJU-;'9-
(Officer' name -- please print)
request that a
blood sample be withdrawn by IHt-GBo1YJI'1/ST
(Physician, R.N., etc, please print)
ror the purpose of determining the alcohol co~centration therein
from the follqwinq individual: -
'~lf Namf'
1()Ob III
Ad.ctre~5
Gn(~~(iY"lI Aft sq'7rS
~~ (2t~
17K Ate f7~o
J
K. 4t~/~~^~
ot!icerl~ s gna ure
r) r,n...t"A\^Aid-. A if)
Agen'ey
Ie II '?' /~
Date of R'eque5t
CHECKLIST FOR MEDICAL STAFF
/verifY that gray top "Vacutainer" tube supplied with our
---- Kit does contain crystals (powder) in the tuba and
integriby of the vaccum has been maintained. Important
use a gray top tube or one that contains a perservative.
/ .~
~ A non-alcoholic or non-phenolic swab was used to prepare
the site for blood draw. Povidina-Iodine swab supplied
in kit or an appropiate substitute, betadine solution,
may be used.
(Requesting officer should witness the blood collection
so that he/She may attest to the authenticity of the
sample.) .
~ The tube is labeled with the, subject's name, date, and
time of the blood collection.
~ ~ The tube is seij.led with .nclpseGi paper seal and given
to the requesting officer.
AzP-'
iT (Signature, Medical staff)
Refer to Administrative Rules of Montana
of blood samples for alcohol analysis.
'Hl.G SOTU Yt-\l .s 1
(Title)
23.4.220 -- "Collection
THIS FORM TO BE RETAINED BY REQUESTING O~FICER -- PHOTOCOPY ~S
NEEDED FOR MEDICAL STAFF. ."
. .
2S~~ l22~ 5000 09~t hOOL
IIIII~IIIII" III
2S~~ t22h 5000 09~t hODL
SCIENCE DIVIS~1
I'MENT OF JUSTICE EN
E OF MONTANA ~
9 PALMER ST. ~~
OULA, MT 59808 STR1"
406) 728-4970
.~tJft:O~~rlAl.
~ ~ ~fl@fl t.8 FOR tAW
" MT_ ~ld~POSES ONlY:
-..
REQUEST FOR ALCOHOL
AND DRUG ANALYSIS
Submitting Officer. -t<. Andt~~
~E PRINT)
==: 't1?""'S i~u-t.
~ l,.c..4'\^ tJ~ M I Zip
(NpOrt will be rttumed ~
to tNe addrwu)
Phone No.: ~ $b.J~ dO})
I RELA: ED
(check d that apply)
o OUI 0 DRIVER
$ACCIOENT J'.8-. PASSENGER
J8lFATAl 0 Other
BREAlH ANALYSIS PERFORMED?
Agency Case No.:
(is/oJ ~()() f3
\Yl7/S
SubJectName~jrlll'^- I .~C--
l.Mt RlIt
O.O.B. . Sex IlA Race \tJ
Date CoUected: 0 llme Collected: ~
Sample Drawn By: ..
L,
M.
(PhytikWI. NurM, MIld. Tech)
Court Date:
E LA: D
(dleetI: alIlhat apply)
o SUSPECT
o VICTIM
o Other
o HOMICIDE
o UNATTENDED DEATH
o Other
PBT? Y N
INTOXlLY"ZER Y _ N /" RESULTS: O.---PflJ/210L
>. .
Please list all drugs, medications, prescriptions, etc.
,/
SpIdty doJge{a). It knoWn.)
EVIDENCE RECEIVED FROM
CHAIN OF CUSTODY
EVIDENCE DELIVERED TO DATE
COMMENTS
PlEASE LABEL, DATE., SIGN AND SEAL AU. SPECIMENS
LABORATORY USE ONLY
Speelmen Submitted: 0 BLOOD OVITREOUS 0 OTHER Seal: label:
Seal: Intaat 0 Broken 0
ANALYSIS RESULTS
ETHANOL: gml100 mI Blood Other
Other Volatiles Detected:
Date Analyzed: Analyst:
unTC. at C ^ cc <<11 (QUIT anTU ,..nDtI:a ne TU(~ en.::",.
Lh6~ L22h 5000 09tt hOQ~
I111II II I'
Lh6~ L22h 5000 D9tt hOOL
. Submitting Officer
~~ ~.fO
G'/.S- -5 Jb~ ~
City ~'2..~ ST~Zip~
(t"IpOrl win he ~ to Ihb adtinzs)
Agency Phone No. (LJOIo s-8;J- ;;).~
Address
Subject Name
La.d, FinJ M.
D.O.B___ S~x /Ill Racey
Date Collected ...J 0 /,3 los- TIme Collected ;)0 ~
, ,
Samplo DtawnBy -.ewe..b~ sf"
(Phy.Jtck1n, Nur.rfl, Md 7lteh)
Agency
Court Date
Q DUI
;3...ACCIDENT
~FATAL
'IAFfIC .IUTED
(chock all that apply)
)1i.. DRIVER
o PASSENGER
o OTIffiR
.....TIIFfle BELATED
. (check all that apply)
Q HOMICIDE 0 SUSPECT
o UNATIENDED DBAlH 0 VICTIM
Q OlHER 0 OTHER
BREAn.fANALYSIS PERFORMED? PBT? Y N ~
>.INtOXlLY'ZER Y N ~ RESULTS: O.
Please list all drugs.. lIledications, proscriptions, *' (SpecifY dNglI ifknown)
gm/21OL
CIIII Of CaSTODY
EVIDENCE RECEIVED FROM EVIDENCE DELIVERED TO - DATE
0:
COMMENTS
Ponn FS03 (Rev. 3AJS)
PLEISE UBEl, DITE. SIGI... SEll AU SPECIMENS
NOTE: PLEASE SUBMIT BOTH COPIES OF TIllS FORM
MONTANA DEPARTMENT OF JUST
Non..cMV IMPLIED CONSENT ADVIS...... \ Y
, '(Operation of non-commerdal motor vehicles. only) .:-. J, \ \
A You are under arrest for. (check aooroorlateoffenslif) eQ~!R~ iF.
o Driving (or being In actual physlcal control of) a motor vehlde while unde~ifl '
o Being under twenty-one (21) yean> of age and driving (or being In actual alcohol concentration
of ,02 or more. t4j.tf.t ~ '
- OR - .~'l<Ic'l. ?B9 \ .'
B. I have probable cause to believe that you were drMng or In actual physical conuqli1r1N6~e, 'snd: cnecf appropriate circumstance)
o Were under the Influence of alcohol (and/or drugs) In violation ot 61-8-401 and the vehicle you were driving was Involved in a motor
vehicle accident resulting in property damage.
~ Were Involved In a motor vehlde accldent rosultlng In serious bodily Injury or death.
Under Montana law, a person In your situation Is deemed to have given his or her ImpUed consent to testing for alcohol and possIbly testing for
drugs. .
As the requesting officer, I have the right to select the type of test or tests you will be asked to take. I am going to ask you to take a breath (or
blood) test (lat8r J may ask you to take a'blood test.)
(1) You must decide to take or refuse this test without talking to an attorney. Your right to an attorney under Miranda does not apply.
(2) W DRlVEA HOLDS A BASE DRIVER'S UCENSE (ONLY NON..cOMMERCIAL MOTOR VEHICLE DRIVING"'PRIVILEGES):
It you refuse this test, your driver's ficense will be seized and suspended forslx (6) months;
It you have refused similar testing within the ps'st t1ve years and you refuse again today, your driver's liCense will be seized and your
prtvRege to drive will be suspended tor one year.
IF DRIVER HOLDS A COMMERCIAL DRIVER'S UCENSE: In addition to any actions taken against your non-commerclal driving
prlvfieges. as the holder of a com,mercial driver's license:
(3)
(4)
(5)
(6)
(7)
(8)
,
If you refuse this test, your commercial driver's license \!fill be seized and suspended for one (1) year.
~ r ~ 4 ~_ ~ 1
If you have refused similar testing In the pas,t of,tiav& a prior major offense on your driving record and you refuse testing today, your
commercial driver's license will be seli~ 8J1d sus~nded for life.
. .... ,~ 'l.
. .
If you have a driver's license issued ~ another Jurisdiction and you refuse to tal;te this test, your non-resldent driving privileges In
Montana wiU be suspended for a minimum of six months to a maximum ot lite, depending on the class of license that you are holding
(noo.commercial or commercial driver's liceru:-e) and your current drlvlnlfrecOrd. plus your Ucense will be seized and returned to the
licensing aqency at your home jurisdiction eTong with a repan of your testing refusal.
You will not be eligible for a probationary driver's license during the suspension.
It you refuse testing, you may contest the action taken against your "cense by tiling a petltlon In a Montana District Court. The action wi!
not be overturned unless you prove that your arrest or the Investigatory stop was unlawful or that you did not refuse testing. You may as
the court to restore your driving privileges \Jl)~1 the court rules on your petition.
Your test results or testing refusal may bEl' used as evidence agaln,st you In a criminal trial. Additionally. if you refuse testing today. the
Jury (or judge In a non-jury trial) may Inter trom your refusal that you were under the Innuance ot alcohol and/or drugs. The Inference Is
reputable.
After the requested testing Is completed or refused. you may have 8 dodoror nurse administer an Independent test for alcohol or drugs
your expense. If you refuse testing now, taking an Independent test will not change the action taken on your drlver'sllcense.
A-brenth t~1,6quire$ ) Ol::l tQ. blew a-pfe(ilQr i:iml"lo of air into thJs In.:str\Jm9Rt. It win analyze your breath sample tor alcohol concentration. WIll
you take a tJreettt test? /'
tfcsrrv\ Yas . V . No
This advisory was read on
Name -'-oq."i "'_\
Date of Birth
to:
'1 1
(S~f \ J
'-/ Ir-r AI
, '
A-J.:.t~ t-/-
J~ /t,rf,./J )/,/':i/\r__
Advising Officer's Signature
Commercial Driver's Ucense: 0 Yes
Commercial Motor Vehicle: 0 Yes
Witness SIQnature - Optional
TO BE REf AINED BY OFFICER FOR FUTURE REFERENCE
No
No
Driver's Ucense Number
3S-0300 10103
: QtJS:P""'ENTlAL
CN;~~'xl~" ~W
~~tk~neuRf.P$fjA~
t;n~~mf&d$S!l ~L'l
BOZEMAN DEACONESS HOSPIT~2irUTROR'\nBl1lQJSE IS
915 HIGHLAND BOULEVARD etIl\h.v.V" ..
BOZEMAN, MONTANA 59715 STRICTLY ~Rt~HIBlTE[,
PHONE - 585-5000 .
.Abb.:J:+
DATE OF BIRTH:
MED REC #:
DATES OF SERVICE:
~ 8 /0.<:-
~
RELEASE TOWHOM:
()'"
l:.1.J' '',,If_
p~:r.,. r~F"
The undersigned hereby authorizes and consents to the
disclosure by the above named hospital to the above named company
or persons, or their representatives or the bearer of this
instrument, of medical records and consen~s to the inspection and
copying of sarne by said company, persons or bearer and to the
furnishing to them of photostatic or other copes of same.
In furtherance of this authorization, I do hereby waive all
provisions of law and privilege-related to the disclosure hereby
authorized. ~
DATE: --1Q(m/bS
I
........
~~j)~
PA lENT'S SlGNAT- E OR
NEAREST RELATIVE
RELATIONSHIP
RELEASED BY:
~
COMMENTS:
1
BOZEMAN DEACONESS HOSPITAL
Admission/Registration Record
915 Highland Blvd. ~i""" ;\';' '.
(406) 585.5000 H 1.'1i ,,'
Admit Date/Time: 1
Discharge Date/Time:
Service/Location: E "
Account No: V00009093576
ROOOI/Bed :
Patient Type: REF
PATIENT
ABBOTT. DAN
1627 W MAIN NO 106
BOZEMAN. MT 59715
(406)539-6931
Emp 1 oyer:
SSN:'"
[X)B:
Marital Status: M
Sex: H Age: 44
Phone:
GUARANTOR
ABBOTT. DAN
1627 W MAIN NO 106
BOZEMAN. HT 59715
Home: (406)539-6931
Work:
PERSON TO NOTIFY
NEXT OF KIN
ABBOTT. AL YSSA
1627 W MAIN NO 106
BOZ~N.MT 59715
Home: (406)539-6931
Work:
Relationship: SP
Horne:
Work:
Relationship:
INSURANCE POlICY
l)PATIENT WILL SUBMIT 010010001
Reason for Visit: LEGAL SA
Accident Oeser:
Admit Physician:
Attend Physician: NONSTAFF MD
ER Physician:
Last Visit Date: 10/18/95 Registrar:
SUBSCRIBER
ABBOTT. DAN
QUICH
ICD-9 CGOES
../ PROCEDURt CODES
CPT-4 CODES
EDITING CHECK LIST
Edi ted by:
Clear for disch? Yes / No
Consent Signed. If not signed. why?
Fin/Agreement signed by patient
Indicate if you saw patient: Yes / NO
Medicare appeals letter 5lgned
Card/s scanned!
Check payors: Med MA BC
Infonmat1on verifie~
Other notes:
wny!
questlonna1re comptetea.
we Other camm.
-----
11I..DlII..BIIIII.11
Printed on: 10/18/0S at 2046 by QUreH
, ,
,. ,
,^"
CONFiDENT~f4.L
THIS INFORMATION IS FOR LAW
BLOODTESTREQ~STFO~~O~~;~~~:~:6~~~~N~
STRICTLY PROHIBITED,
Pursuant to the provisions ofMCA Section 61-8405,
I. (ornccr1;;mc -1~:::;~ req~est that a blood sample
be withdrawn by pt1t-e~f)rf)#1 (.s~ for the purpose of
(phYSician. R.N.. etc. - P 91. print)
.
d<:termining the alcohol concentration therein from the following individual:
_Oa~;~ 13tp H~bb+4-
ubJcct name leu. p nt)
t.~
ce 8 'I;naturc
\ 3~ GdJer rOt\Y^~ ~
J;o7qv.a", All r6'17JS-
J '
~7~ fo
Aaency
)oIJ~/o&
' atCI of cst
CHECKLIST FOR MEDICAL STAFF
J Verify that gray top "Vacutainer" tube supplied with DUl kit does contain crystals
(powder) in the tube and integrity of the vacuum bas been maintained. Important:
use a gray top tube'>or one that contains a preservative.
/'
../
A non-alcoholic or non-phenolic swab was used to prepare the site for blood
draw. Povidine-Iodine swab supplied in kit or an appropriate substitute, betadine
solution, may be used. (Requesting officer should witness the blood collection so
that he/she may attest to the authenticity of the sample.)
~
The tube is labeled with the subject's name, date and time of the blood collection.
~ The tube is sealed with enclosed paper seal and given to the requesting officer.
!'";;..f6L-'--
(H-Le&r0Il115 T
(Title)
Refer to Administrative Rules of Montana 23.4.220 - "Collection of blood samples for
alcohol analysis."
THIS FORM TO BE RETAINED BY REQUESTING OFFICER. PHOTOCOPY
AS NEEDED FOR MEDICAL STAFF.
]:crmlshareJblood telt request
"-~
Bozeman Deaconess"~.J~FIDENTIAl
Consent for Treatm8'~IS INFORMATION IS FOR LAW
~t\l1= PURPOSES ONL'Y.
1. Medical Consent: I hereby consent to the provisions of health care Serv1CUS. ~rf.:1' such as
X-rays, exams, administration of drugs, lab tests, and other hospital (Bot4)I~ IYPhysiclan.
I understand that the patient care Is under the control of an Independent$'fii".'l'alibYa I liable
for any act of omission provided the hospital has followed the Instructions of said physlclan(s). Services provided
by all physicians are Independent of SOH.
r--
(
2. Release of Infonnatlon: I will refer to the BOHS Notice of Privacy Practlces regarding the release of my health
Information.
3. Assignments of Seneflts: I hereby authorize payment directly to the hospital for the hospital benefits herein specified
and otherwise payable to me. I also authorize payments directly to the physlclan(s) providing services to me from the
benefits otherwise payable to me.
4. Insurance Disclosure: I understand that it Is my responsibility to notify my Insurance company directly within the
time limits of my polley, if I am admitted to SOH or for pre-authorization of special procedures and/or tests.
5. Financial Agreement I hereby assume full responsibility for charges I incur for services from SOH and agree to
pay said charges In full. I have given my Insurance InfonnatJon, If any, to BOH. It Is my understanding that I
will be responsible for any balance not paid by this Insurance. If I. or my guarantor, choose to bill my Insurance, my
account will be considered as self-pay. If I am unable to pay In full, I will contact the Credit Dept. at 585-1015
to discuss options, with a minimum-monthly payment of $100. It Is further understood that the entire balance. pursuant
to this agreement, will be due and payable one year from the date of admission/service. (Guarantor Initials)
6. Personal Valuables: I understand that SOH shall not be liable for persona/Items. If admitted, I have been advised
to send all valuable personal property home.
7. Nursing Care: SOH provides general duty nursing care. If a patient needs continuous or special duty nursing
care, the patient, legal representative. or the physician must arrange such care. SOH shall /n no way be
responsible for failure to provide the same and 18 hereby released from any and all liability.
8. Grievance Procedure: All patients have the right to submit a complaInt regarding care and services rendered without
fear of retribution. As a patient, I may communicate my concerns regarding care, services rendered or billing to the
BOH Quality Improvement Oept>at 585-5045 or send It In writing to 915 Highland Blvd., Bozeman, MT 69715-6999.
9.lntormstion Practices: I acknowledg&r8c81pt of the abHS Notice of Privacy Practices.
10. Patient's Rights & Responsibilities: I understand my patient rights as desctibed In the Patlenfs Rights and
Responsibilities brochure. (Pattent/Responslble Party Initials)
11. Facility Directory: If I am admitted, SOH maintains a facUlty directory that lists my name, room number, and If I
wish, my religious affiliation. This Infonnatlon (excluding religious affiliation) will be disclosed to anyone who
requests It by asking for me by name.
I DO NOT want this information listed In the facility dIrectory.
I DO NOT want religious affiliation shared with the clergy.
I certify that I have read the above Infonnatlon and as the patient, or one who Is duly authorized to act in a representative
capacity for the patient, that the Information has been fully explained, that I unaerstand Its content, that It may not
be modified and that I may withdraw my consent for services at any time.
PatlenUGuarantor Signature:
Relationship to Patient:
Reason Patient Unable to Slgn:~ ~f\
I acknowledge receipt of an Importa~'
Message from Trlcare
Date:
Witness:
Date:
1 acknowledge receipt of an Important
Message from MedIcare
Signature:
Signature:
Date:
Date:
Acct#: V00009093394 Name: ABBOTT,DAN
MR#: M01148341 SvclLoc: ER 10/18/05
NEURO ~
lOG: AlERT lETHARGIC UNRESP
PUPILS: EQUAl NON-EQUAl
REACTIVE NON-REACTlVE
HEADACHE.: YES NO
ONSET
GCS:
EYES
MOTOR
VERBAl
TOTAl
CARDIAC NA--
CHEST PAIN: YES NO
SEVERITY (HOL
RADIATION: YES NO
ONSET: DATE
TIME
MONITOR RHYTHM
RElPUWORY NA_
BREAlli SOUNDS: ClEAR
. PRESENT ABSENT DIMINISHED
WHEEZE CRACKlES
COUGH: YES NO
CP WIINSP: YES NO
SPUTUM
Oz: NONE NC FM
PKFlOW: PRE _ POST_
OIl8U N~
PAIN: ABO PELV FLANK
SHARP CRAMPING ACHING
BURNING CONSTANT
INTERMITTENT RADIATING
ASSOC. SYMPTOMS: NAUSEA
VOMITlNG DIARRHEA
BlEEDING DYSURIA
~URIA URGENCY
FREQUENCY
LASTMEAL
MUSCUlOSKElETAL AA-
EXTREMITY:
TENDERNESS SWElliNG
ECCHYMOSIS DEFORMITY
SENSATION: NORMAL
NUMljNESS TINGLING
ROM: NORMAl lIMITED
PULSE: YES
NO
ImOOMENTARY ""--
LACERATION: LENGTH
LOCATION
M1RASION: YES NO
LOCATION
RASH: YES NO
:..OCATlON
3URN: PARTIAl RJLl
_OCATlON
EENT NL-
nsUAl ACUITY OS
00
OU
rHROAT:
PAIN SWELUNG
REDNESS DYSPHAGIA
)
)
J
TIME ARRMD:
HOW ARRIVED: AMBUlANCE WAlK W!C
BROUGHT BY: SELF RELATIVE ffilEND 0
NURSING HISTORY:
CHIEf COMPLAINT:
NURSE SIGNAtuRE:
PRIMARY PHY11CAN: 0 YES
DNa
EA PHYSICIAN
TO SEE 0
TETANUS:
o CURRENT
o UNKNOWN
o OUT-OF-DATE
WEIGHT
LMP
Al.LERGIES: .).
MEDICATIONS:
TIME T P R BP
P
BP
TIME
FSBS
IV THERAPY
TIME CATH SITE flUID RATE
TOTAL INIllAl
,
,.-UIl
T/O_ OEKGl/o_
CHEM T/. _ 0 TROP 1/._
o AMYl f/, _ OCI(MB 1/._
QPTT/o OA8GTfo_
o PIT '10 _ 0 RAPID SlR T/._
OHCGf/o_ OUATfo_
o 0
o 0
o 0
PHYSICIAN ORDERS - RADIOLOGY
X-RAY
o
o
o
o
TIME TO
CT
o
o
TIME TO
us
o
llMETO
T/.
T/.
fl.
'I.
FROM~
'f.
II.
. FROM_
IlUCMED
o
FROM_
PHYSICIANS ORDERS - MEDICATION
PHYSICIANS ORDfR8 - PROCEOURU
o roLEY
oOSU
o VNJ EXAM
ONG
o QRlllO VS
o OLD CHART
O.
o
OClfAN WOUNDS
o DRESS WOUNDS
o KNEE IMM
o AIR 8l1RRUP
o SUNG
o WRIST SPl
o
o
PHYSICIANS ORDERS - PREPACIS
PHYSICIANS ORDERS. PRESCRIPTIONS
MEDICATIONS (ADOmONAl SPACE ON BAa) OISPOSmoH
NO PAAT HOME NAA POlICe DEe
R8. lIB.. R8. NA ADMIT: ROOM
NO PAAT PHVS:
RB.. llEl RB.. NA
NO PART
R8. RB. RB.. NA DISCHARGE INSTRUCTIONS:
1<<) IWIT WRITfEN VERBAL \HIT:
RB. llEl R8. NA
:mc:~m q;.
DIAGNOSIS:
PHYSICIAN SIGNATURE
"'........
BOZEMAN DEACONESS HOSPITAL
Account No: V00009093394
Room/Bed:
Pa~1ent Type: ER
PATIENT
ABBOTT. DAN
1627 W MAIN NO 106
BOZEMAN.MT 59715
Employer:
GUARANTOR
ABBOTT. DAN
1627 W MAIN NO 106
BOlEMAN.MT 59715
Home: .
Work:
INSURANCE
l)PATIENT WILL SUBMIT .
SSN:
OOB:
Marital Status: U
Sex: M Age: 44
Phone:
PERSON TO NOTIFY
NEXT OF KIN
Home:
Work:
Relationship:
Home:
Work:
Relationship:
POLICY
010010001
SUBSCRIBER
ABBOn. DAN
Reason for Visit: MVC
Accident Oeser: 10/18/05
Admit Physician:
Attend Physician:
ER Physician: MAJXNER MO.R JAMES
last Visit Date: .>. Registrar: CARJ
1CD-9 CODES .'/ PROCEDURE CODES CPT -4 CODES
EDITING CHECK LIST Edited by:
Consent Signed. If not signed. Why?
Fin/Agreement signed by. patient
Indicate if you saw patient: VfiS I ria
Medi ca re, appea 1 s 1 etter signed
Card/ s scanned.t
Check payors: Hed MA Be
Information verifiedt
Other notes:
1118111111I11111.11111
Clear for disch? Yes I No
WhY't
questlonnalre completed.
we Other comm.
Printed on: 10/18/05 at 1829 by CARJ
CY PHYSICIAN RECORD
MY A (S
NInIRI~ IWMwed RrM....-d 0
PHYSICAL EXAM
~ Appearance 7c-c~/1n ED)
...:..~CIStreSS ~ ~I seveR dls
'ilert - anxIo~ I ~ .r..
~ ~:'~JtI ~01t1J-€
.::::::tlO evidence of Satde.s tip I Raccoon Eya
tn&Jma
DATE:_ TIM .
HISTORIAN: padent spouse
_HX I _EXAM lJt1ITED BY:
HPI
occurred:
QlA
It-
=OfDaI~~U
In"",": - <: S l ')~ -
had face moUth C ~
neck chest abdomen
back upper mid- Iaw<er
~ to (RIIJ thIfh tier
sev.ritv of pain:
mild l c '5 J..o
elt. of imD8ct: reStfalntl:~
"p" .. primary "S" <= secondary none shoulder
doesn't realI
~
or seat
(oM low mod~
PAST HX Cnepdv)
~mnm_
KD I see nurses note
~
-EOH
mkllne
_He cJb&nm
_~ polnt-tMdemesI
_muscle spam I decreased ROM
--Plin on movement of neck
~l
~
nmI exwnaf
/ lnIpecdon
_no dentallnjwy
RESP I CV8
~non-tMder
sounds nmI
_heart sounds nml
~EH
~
- orpnomepIy
" Nt-
NEJJ.RO I PSYCH
~t.d x3
~n)POd & aBect nml
~s nml
~
_sensation &
motor nml
\ I
_unequal pupils A- _/111II L-_rrvn
EOM entnpment I palsy
-subconJuncdvll hemorrha&e-
_hemocympanum
_1M obscured by WlUC
dotted nasal blood
dentallnfurY I maIocdusiof'
_Jell cUavam (on reverse)
decreased breath sounds
wheezlnll raJa
_spIInq I paradoxkal movementS
_confusion I dIsorienbdon
_EOM palsy I anIsocorb.
_&cb1 asymmetry
_unsteady I awdc pit
_sensory I motOl" deficit
+
It
ll.n.IC..
')\0/1'''-'-'
T......
...,....
~1-*
~
~ ....n
~.-M
_Irrr ~...
~
1lno - T____
,."... (NNH,I
,""'" ,
CONFtDEi~T~Al ~~
THIS INFORMATION IS FOR ~LY.
ORCEMENT PURPOSES' .
~~~ IINAUTHORIZEO U .. _ ~ _ ,
5'tRICTLY ~'ROHI8ITE
~
_ I diaphoresis
~
_wann,dry
BA':K
~no CIA
~
tenderness
~ES ~tMdemess
~ Stable ~ I unable to bear W81aftt.
3fB' non-tender -f'U~.tIcIt
..... .- ..... ~ \ ~ j/Yrs\
~I ROM _~~ ~ ~l c\.u. L ().JJ I I
_" R III~ IIXIty I Join .tfi.JIIon
1Lu\_
I a.. ~ . "'\
<...
_see dJacnm
_vembnlpol~
_ OIA t:endemus
_muscM spasm I limited ROM
~r7
L R
PROGRESS:
TIme
undw1pd
Improved
r&4Xamlned
-s- O'V\ to.. c..
6(o~
~LJ,
/lr~.~~J!:Jts~
contualon
IMad wrist R/L
cae. hand R/L
chat hlp R/L
abdomen chi. R/L
bad< knee R/L w/o LOC
~ Ie& I\/L
arm anIcIe k/L
elbow foot R/L
foNlnrl
(.
-
horM D~ D~
D. unchanIId 9inproved stabI-
CXR _rib fractunl
_nmll NAD _Inflltrata I ,teIectuIs
_no infiltrates
nml heart size
- nml mediastinum
OTHER OSee separate
~~ ~
V -" MDIDO
o D\ctlI.tedAddendum . ) 0 Template Complete
MVA.17
j
J
,
~~~~~D~ac ER C~~fro\g~~~j.
~93394 M01l4~~OZEMAN DEACONESS HO ~:un~ II F . :-ry;t;J1 tt \ )1 .c NF.2-
MD, R JA DO~ EMERGENCY OEPARTME It-\ "1 .J.ii rrr. '.' 10/00
irlilii......... NURSING FLOW SHEE' ~N'~ I ~I \ t ~ ' \~E \5
~ NEURO' ~ TIMEARRIVE~: ,0 ~T~~! I"' -\ V'pl- \P"PHYSlC1ANORDERS'lAIl
=k. UAl~&:~- I-oow NlRMiQ~ WN.I4--WIC( ~_.~ -..-.- .--
. REACTIVE NON-REACTIVE OROOOHT BY' fiVE ffilENO OTHER PHONE NUMBER: 0 cec f/~ - 0 EKG '/~-
iEAOACHE' YES NO I QCHEM 1.- OTROP 1.-
)NSET . NURSING HISTORY: hiliA- R ~ J.-! A - Lt JAM ~iA. tfi J At nt1 . 0 AMYL rfo - 0 CKMB f/._
ICS: /Y! AI;ih~ / /Yf-l"Jl' tJf1~ /1 *r" i j) P ~ I') I X1.!..P..tl ~~/:, ~::I~.~
EYES J A () !J A ( f- I # I '" I'oll;. - '-' f ,un 0_
MOTOR 191LA' /lA iLIA 'J-C.I"7Y 'ff-JA f -lJ7- -1 dA1IP 1!1 QHCG 10- QUA 1.-
~~ 0 0
TOTAl I111l1tJA) If ~ ~
CARDIAC ~ MURSIMG AS.SE88MEIIT:
:tfEST PAIN: YES NO
EVEAfTY (1-10)
.ADIATION: YES NO
NSET: 'OATE
TIME
IONITOR RHYTHM
REATH SO=~ NA_
RESENT ~MINlSHEO
WHEEZE CRACKlES
DUGH: YES NO
P WIlNSP: YES NO
F'UTUM
,: NONE NC fM
(~:PRE _ POST_
~rO ) QIIOU IIA_
. 0 PElV flAHK
P CRAMPING ACHING ALl..fRGIES:
BURNING CONSTNlT
INTERMIITENT RADIATING
:SOC. SYMPTOMS: NAUSEA
VOMITING DIARRHEA
BLEEDING DYSURIA
HEMATURIA URGENCY
ffiEOUENCY TIME T P R
ST MEAl rrK?o ~'11 fn1 10
M~AL, NA........:....
TREMl1Y'
TENDER - SWELUNG
ECCHYMOSIS DEfORMITY
NSATION: NORMAl
NUMBNESS TINGlING
1M: NORMAL UMfTED
LSE:YES
NO
ENTAfty
GERATlO~GTH
liImUNiQ.
RASION: 1tS' NO
CATION
SH: YES NO
::ATION
RN: PARTIAl FULL
::ATION
HA_
EENT
UAl ACUiTY OS
00
OU
NA 7-
lOAT:
PAIN SWElliNG
~EONESS DYSPHAGIA
PHYSICIAN ORDERS - RADIOl..OOY
;i~.1t't1~~
- " 0 ~ -' Tfo ~ \. ....._~
IYMAI/J run \:xl II """-f"'AA/"-I~'"
~., """\...)11'1 ~ ~ AM... A ~ . . /"\~.
nMErO FROM ' ,r 1C
CT IV ad>:,o l"f~:(
~ f/o
n . .0 TlMHO.o FROM
us 'NUCMED
C 0
T1METO
. \ 1_____
I,~ \ 1'1\ Kt\fl.AJ.\- (j./( I A ~./1A^
. J _ ( I
1(.1f J t/11 /Yl tIJ/lP / J D IIJ1tV\1
~I 7
CH~COMPlAIHT:'7(f rnJIl/ (j)n-~/~ PCtR ~
-A
MUIUIE SIGNATURE: .'~
PRIMARY PHYSICAN: 0 YES-V
~O
ER PHYSICIAN
roSEE
TETANUS:
o CURRENT
o UNKNOWN
o OUH1F-OATE
WEIGHT
LMP
)..
MEDICATIONS:
n
~X
- ;L./
TIME
CATH
UP i~
~ 'J:!.~ P
~ OP
~ TIME
.~ FSB$,
IV THERAPY '-ro>
FLUID
TOTAl
0--
ll..
SITE
RATE
FROM
PHYSICIANS ORDERS - MEDICATION
o ~ 0.\ f\^.L 1M...
1
PHYSICIANS ORDERS. PROCEDURES
o FOlfY 0 ClEAN WOUNDS
IJ DSU 0 DRESS wotR<<lS
o VPl!. EXAM 0 KNEE IMM
o NG 0 AIR 6TIRRUP
o DRTHO VS 0 SUNG
o OLD CHART 0 WRIST SPl
o 0
o 0
PHYSICIANS ORDERS - PREPACKS
-
U VW ~ -- t!!-Gf-
INITI~ viOl .:f?on A<<: a~ A if
r,-.. PHY8lCIAH1i ORDER
\V t.-tCoaA'Y\ S7~1JJ
(f}) (/n1i?: (~t. ~1J6/l~~~
t '-'U '(L U
___ DISPOSlnuN
I VWMt:' /1NA. POLICE DEe
NA. '--""
ADMIT: ROOM
NA PHYS:
MEDICATIONS (ADDmOIW. SPACE ON 1IACl)
TIME MEDICATION AUT ROIITF ~In: NIT m:~
I'l'}] ~5-T__ Ohll,'fl J 1 Ifl~:'/ l:r
ror_ u.o. ~VN:;"
l.IS O<M Ue...277 RI..., I / l.Jicf I'IUIT
1Md1ty.__m_' IlK RB. lIB.
_"" 18l1O IJSI\
<:pre C<Jdo: lIlI7l1 ..3J HI) . PART
I , " I I Ra I\B. . AEl NA. ~~.INSmUCTlONS:
I I I IRa:' :r NA. ~ VERBAl INtT:
DIAGNOSIS: r)\ r:tf. l~ eCAJI I J N llli , .-' 0 C- _
rt1" J . .aill 1..I1J C I {l r <: rJII\ (LJ 1 ya.+... AJ,.-, j Itli' c..rr-.. "'rl.."r~ n
-\::7 'v . . '1/1 {./\ -/1.,1 /1~.,. ..., G..Ld; ;J.
PHYSICIAN SIGNATURE r J.AJ I A Jfi, ./ r V v V r -V
Bozeman Deaconess Hospital
Trauma Rowsheet
G-SpIne Immobilized: ~
Removed by
TIme:
~Of ArrtvaI:
_ Ambulance
_ Helicopter
_ Private Auto
_ Ambulatory
_ Other
Safety Equlpment:
_ Helmet
_ Soatbelts}J 0
_ Ch8d Seat
_ Protective Clothing
_ None
TIme of 1r1ury: A/ 1'7
T1me of EO AnfvaI: I f 170
TT AotivalIon: Yea No ER EMS
5 N AN
Na e
aed
Armed
Radlology;
Portable:
C.Splne
Chest
Pelvis
IV '1
12
13
Departmental:
Chest Pelvis
C-Splne
T -spine
LS-Sploe
NGlOGT
Foley
Chest Tube
DPlAJS
FIuicl Wanner
Blood Adm
Product
, of UnIt8
TIme to: _ TIme From: _
CT:
Head Abdomen
Chest Pelvis
Total IV Intake
Total Output
TIme to:_TIme From:_
Temp
Weight
LMP
Tetanus::~M-
Outdated _
GIven:
SIte:
lot;
:=~'f~~~/~
)..
Glasgow Coma Scale
~
Spontal'l8OU5 4
To Voice 3
To Pain 2
None 1
NF-31
3/03
_ Deceased
Transfer
Facility
NoUfled
Arrtve
Depart
Phy8Iclan
_ Helicopter
_ FIxed Wing
_Ground
IV Tne!1!PY:
TIme Ruld
Amt
lnlt
Y.IxtHlI;
Oriented 5
Confused 4
Inappropriate 3
lneomprehenslble 2
~e 1
6
5
4
3
2
1
RevIsed Trauma, Score: RR:+SBP+QCS
RR: SBP: GCS:
1()"29 - 4 >89mmHg "" 4 12-15 '" 4
>29 - 3 >76mmHg - 3 9.12.. 3
5-9 - 2 >5OmmHg - 2 e..s '" 2
1-$ '" 1 >1mmHg '" 1 4-5 _ 1
No pulse - 0 <4 - 0
.-" Mt:Ilac
Obeys Command
Purpoaetul/Paln
WIlhdnlwsIPaln
FfexIon
Extension
None
::tupll Slle:
.....e..
123.5. 1 .
Pupil Reaction: S'.. sluggfsh B _ brlsk N EO non-reactlve
NWlI89 Notoo
71 1.-1) q7
: ~ :S'
I
1
I
,
MedIcation
Bozeman Deac ER
ABBOT'!' , DAN
V00009093394 MOl14~
MAJXNER MD,R JA DO~
tfBl1io.DDill Diii.....1D
Name: ABBOTT, DAN
Phys: MAJXNER MD, R JAMES
tJOZEMAN DEACONESS HOSPIT '~t..;.:J ',",' '1:' u Age: 44 Sex: M
115 HIGHLAND BL VD ' 'N l~ e:: 093394 Loe: ER
106-585-1035 THIS INF -~ ' " :
ENFORC ~'Ei5ru" ,tl.J:J1C ...,MOl148341
ANY UN I '-rEo'\-! Xt-E[
STRICTC I .
REG ER
IR AI1JEl<?Wl, SPEAKIN:; 'IO FAST, PIEASE FIIL IN BLANK
CERVICAL SPINE SERIES
RFAS:N FtR EXAM: M:JICR VEIUOE ACf'llltNI', INJURY '10 'mE NEO<., NEX:K
PAIN, EVAlIlA1E FCR FAACIURE.
Carpariscn - none.
FINDIN3S :
AP and lateral radicgraphs of the cervical spine were cbtained as
well as lateral an:l <:pen m:uth odontoid view
radicgraphs of the cervical spine. These radi~a{i:ls dem::nstrate
m:derate1y severe l3fXJlrlylosiB an:l degenerative disc disease seen at
the (5-6 leveL 'lbere is no evidence of acute fracture or
subluxaticn.
:>.
a::NCU1SIrn :
1. M:x:lerately severe degenerat!'Ve chan3e at the CS-6 level wt no
evidence of acute fracture. If patient has clinical synptars of
radiculcpathy or myelcpathy than MRI of the cervical spine nay l:e
helpful in further evaluatiCll.
lEFT FOREARM SERIES:
RJW:OIl R:R EXAM: MJICR VEHIOE ACOI>>n'. INJURY 'IO 'mE FtRE:ARM.
EVAI.llA1E
llQR FRAC1tJRE.
O:trpariscn - none.
FlNDlN3S :
AP and lateral radicgraphs of the left foreann are dJtai.ned
denonstrate what appears to be radiopaque debris seen overlyi.n;J the
tredi.al aspect of the left wrist. 'Itere is no evidence of acute
fracture or dislocaticn alCX1lJ the forearm.
PAGE 1.
Draft Report Printed From PCl
( CONTINUED)
BOZEMAN DEACONESS HOSPITAL
915 HIGHLAND BLVD
80ZEMAN, MT 59715
406-585-1035
Name: ABBOTT t DAN
Phys: MAJXNER MD, R JAMES
DOB: Age: 44 Sex: M
Acct: V00009093394 Loc: ER. .
Exam Date: 10/18/2005 Status: REG ER
Radiology No:
Unit No: M01148341
'T&
~11~&jj.i{ -."~i~~es%@ti~Y.
. )~_nt. OJ~~gS
aHllEICN, ~ J:\' iCTL'l~R:c;,..'i~EO
L PrdJable debris overlyi.nJ the rredi.al aspect of ~ Wrist rot no
evidence of acute fractUre.
.
IEFr HlMEro\L SERIES:
RE1\.9:N FOR EXAM: K1IOR VFHIa..E ~. INJURY 'ID '!HE ARM.
EVAIJJATE Frn.
FRACIURE.
CCrrpariaan - none.
FINDlN3S :
AP anci lateral radiographs of the left burrerus ~ cbtained
dem:nstrate no evidence of acute fracture or dislocation.
a:N:LlJSICN: .).
1. Onrem3J:kable left hurreral series.
.......
cr SCAN OF TIlE BRAIN WI'IlOJI' o:::t'lIRASI':
~ KR EXAM: rvroR. VEHIOE ACCII'ENl'. HFAD INJURY. AI1ImED
lEVEL OF
CXNSCIaBIESS. EVAIllA'IE F(R INIRACRANIAL
INJURY .
O:rr{:arlsan - nc:ne.
~: Patient was eK2IIrIined m a .Philips Brilliance 1.6 slice
nultidetector cr scanner. M..tltiple 4.5 mn. thick helical cr i.rrages
were obtained t.hra1gh the brain witJ:xnt the use of IV cx::ntrast.
FINOI:N3S :
'Ihese irrages dem::nstrate 00 evidence of acute cortical infarct or
acute intracranial hem::1.rrbage. '!be ventricles appear within xx:mnal
limits for size.
PAGE 2
Draft Report Printed From PCl
( CONTINUED)
BOZEMAN DEACONESS HOSPITAL
915 HIGHLAND BLVD
BOZEMAN, MT 59715
406-585-1035
Name: ABBOTT, DAN
Phys: MAJXNER MD, R JAMES
DOB: Age: 44 Sex: M
Acct: V00009093394 Loc: ER
Exam Date: 10/18/2005 Status: REG'ER
Radiology No:
Unit No: MOl148341
I I \ .1.,_
erijf@>rR~M~.*1l0~PISSE:G,q)~
,ijW~f'i{1a~liItmRPOseslt>NL '
cncr..usICN: ~,(r.blNAUTH(l).I~Z8fr USE IS
1. Ulren'arkable non ccntrast cr scan of the brain. STRICTLV FRCH-<181TED
1U.J;D/ at
d:. 10/18/2005 20:34
t: 10/19/2005 09:38
-----------------~------------
RepJrt.ed By: AI.DERMAN, DANIEL M.D.
).
,-
cc: R JAMES MAJXNER, M.D.;
Technologist: ANDERSON, KIM
Transcribed Date/Time: 10/20/2005 (1516)
Transcriptionist: TANS
Printed Date/Time: 10/20/2005 (1516)
PAGE 3
Draft Report Printed From PCI
BOzeman Deac ER r r'"'.' I--' .., . --IAL
~=O~~9~ ~~1~~~"" Bozeman Deaconess HOS~MSt:~~~rJ;,;;~;~;~<~'~s4/F.()p I
f.g~ IWiRlll1 AFTERCARE INSTRUCT~AC2~~f;,ri::t t l'j~!f~~1.Aw..
..ai..1 (406) 585.1000 EI>RN.'lrUJllA\l~~ "jj'>i;iQSES.{)P!lV.
NOTE: THE EXAMINATION AND TREATMENT YOU HAVE RECEIVED IN THE EMERGENCY DE~e~€tklij Af&MERGENCY
BASIS ONLY AND IS NOT INTENDED TO BE A SUBSTI ruTE FOR OR AN EFFORT TO PRCMOE ~l1::lE MEDICI';L ClRij:'IT:IS IMPORTANT THAT YOU
LET 'rtlUR DOClDR CHECK 'iOU AGAIN AND THAT YOU REPORT 10 HIM ANY NEW OR REMAINuiiG PR6BLEMS AT THAT TiMe, BECAUSE IT IS IMPOSSIBLE
--JO R~nr.NI7F ANn TRI=.u:ALLFI FUI=NTC:: nFIN.llIRV nR III NF<::<:: IN 4 C::IN~I F FUEjDns::W"'V n!;D4RnAliNl IJ.ISQ:, l~ 'YOU hlAD-X-RA\C$TAKIiit>'. THERE
MAY HAVE BEEN ONLY A PRELIMINARY READING OF YOUR X-RAYS, IN WHICH CASE. FiNAl REVIEW BY THE "'IADlOLOGIST WILL BE MADE WITHIN
2-4 HOURS. MEANWHILE. FOllOW THE DIRECTIONS BELOW AS INDICATED FOR YOu.
H 0 INJURY INSTRUCTIONS
REPcl=rr 10 YOUR DOCTOR IMMEDIATELY IF ANYTHING LISTED
OCC~S (EVEN W~IN SEVERAL MONTHS).
AWAK N PATIENT TIMES THE FIRST NIGHT TO CHECK
,f ~:~I ENT VOMITING, STIFF NECK,. FEVER OR HEADACHE.
I ~ UNE AL EYE PUPILS (ONE LA~GE. ONE SMALL).
O:::::~Y ANGES IN VISION.
~CON SION OR UNUSUAL DROWSINESS.
.L"boN LSIONS OR UNCONSCIOUSNESS.
ZoWFI ULTY IN SPEECH OR INABILITY 10 SPEAK.
~U BlING. WEAKNESS OR OTHER PROBLEMS WITH NORMAL
USE ARMS OR LEGS; OR AREAS ON SKIN NUMBNESS.
~D NAGE OF BLOOD OR FLUID FROM EARS OR NOSE.
LAN TYPE OF UNUSUAL BEHAVIOR.
A AlCOHOL. SLEEPING PILLS. TRANQUILIZERS. SEDATIVES. OR
aTles FOR 2-4 HOURS.
ING STRONGER THAN ASPIRIN OR TYLENOL UNLESS
RESCRIBED BY DOCTOR AWARE OF THIS TRAUMA.
BACK AND NECK INJURY rNSTRUCTION~
~ USE HEATICOLD ON INJURED AREA. Co\. )C't... a...t.r S I fA-uJ
~REST AS MUCH AS POSS.lBLE UNTIL YOU ARE IMPROVED. 11..{ U:r
....,('"AVOID POSITIONS AND MOVEMENTS THAT MAKE THE PAIN
jVORSE. ".
LRELAX, EMQTIONAUY. IF YOU ARE TENSE, THE PROBLEM MAY
,-
...- SEE A PHYSICIAN OR RETURN IF YOU DEVELOP:
~ TINGLING, NUMBNESS, WEAKNESS. OR LOSS OF USE qF ARMS
9R LEGS.
LLoss OF CONTROL OF BOWEL OR BLADDER.
NARCOTIC MEDICATIONS t.l\..Co~ $/ <;~
TAKE THIS MEDICINE ONLY AS DIRECTED BY YOUR MEDICAL
DOCroR. 00 no( lake more of II and do not lake II more ohen or for a
longer period of lime lhan ordered.
NF.l
6/l
o SPRAIN, FRACTURES, SEVERE BRUISES
_ ELEVATE THE INJURED PART TO LESSEN SWELLING.
_ USE ICE PACKS TO HELP PREVENT SWELLING THE FIRST 48
HOURS.
_ IF YOU HAVE AN ElASTIC BANDAGE ON, REWRAP IT IF IT IS TOO
TIGHT OR TOO LOOSE.
_ IF YOU HAVE A CAST. KEEP IT PERFECTLY DRY AT ALL TIMES.
ALLOW CAST TO HARDEN 48 HOURS BEFORE PUTTING
PRESSURE OR WEIGHT ON ANY PART OF IT.
_ WIGGLE TOES OR FINGERS TO HELP PREVENT SWELLING IN
THE CAST. DO THIS OFTEN IF IT IS NOT PAINFUL 10 DO SO.
_ IF THE PART SWELLS ANYWAY OR GETS COLO. BLUE. NUMB, OR
IF PAIN INCREASES MARKEDLY, HAVE IT CHECKED PROMPTLY.
_ REMOVE ACElSPLlNT/SUNG.
I. ; WHEN COMFORTABLE WITHOUT rr. IN DAYS.
: ~ ONLY WHEN FOLLOW-UP DOCTOR INSTRUCTS YOU.
_ SlOP USING CRUTCHES:
C: WHEN ABLE 10 WALK WITHOUT PAIN IN DAYS.
L: WHEN FOLLOW-UP DOCTOR INSTRUCTS YOU.
~OUND CARE (CUTS, BURNS, ABRASIONS)
~'5EEP THE DRESSINGS CLEAN AND DRY.
./'f:LE"'~TE THE WOUND TO HELP RELIEVE SORENESS AND SPEED
HEALING.
~ DESPITE THE GREATEST CARE. ANY WOUND CAN BECOME
INFECTED. IF YOUR WOUND BECOMES RED. SWOLLEN. SHOWS
PUS OR Reo $TRflAKS, OR FE!:LS MORE SORE INSTEAD OF
v!:ESS AS DAYS GO BY. REPORT TO YOUR DOCTOR IMMEDIATELY.
~F RESSINGS NEED 10 BE CHANGED, YOU SHOULD:
CHANGE'THEM 0 CALL YOU?V'
........ HAVE SUTURES REMOVED IN -- ~ YS.
This medicine wi" add 10 I e effects of alc0hoi and or r CNS
depreasants. CHECK WITH YOUR DOCTOR BEFORE TAKING ANY
SUCH DEPRESSANTS WHILE YOU ARE USING THIS MEDICATION.
CHECK THE LABELS OF ALL NONPRESCRIPTION AND Thi. ~clolt mJY.~ IIOmopeoptlll to become cll'l'JWsy, dizzy or
PRESCRIPTION MEDICINES YOU NOW TAKE. If any conlaln lightheaded, or 10 feel 8 false sense of 'MIIJ.being. MAKE SURE YOU
acetaminophen or III narcotic, be especially CIlIf9ful. since laking them KNOW HOW YOU REACT 10 THIS MEDICATION BEFORE YOU DANE.
white.. 13k1ng IhllI medicine may lead 10 overdose. USE JAAC;tflNES ,OR DO QTHER JOBS THAT REQUIRE YOU 10 BE
'1"- 0 ffWk ~ {C L.J.{ lrwr . ALERT AND CLEARHEADED.
KEEP THIS AND ALL OTHER MEDICINES OUT OF THE REACH OF CHILDREN AND NEVER SHARE YOUR MEDICINES WITH OTHERS.
~~~~~;;~:S:~ri~iiS~~'l5
~~I ~11'I\(~a.bO/t..).,IA'llri~~ COWVIl'l5/d7
E THAT ALL PHYSICIAN CARE HAS BEEN PROVIDED BY I EPENDENT MEDiCAl PRACTITIONERS. I ACKOWlEDGE RECEIPT
o THE RUCTIONS INDICATED ABOVE. I UNDERSTAND THAT I HAV AD EMERGENCY TREATMENT ONLY. AN THAT I MAY BE RELEASED
E AC MY IPS ARE KNCMlN OR T "D. "'ij'firE fUR FOLLCMI.UP RE INSTRUCTED ABOVE.
BOZEMAN DEACONESS HOSPITAL
Admission/Registration' . lt~"'.tp1AL
Tt'Jt~st~NFB~' ~~
915 Highland Blvd. EE!Nt::(:H~t;e' 't: - y
(406) 585-5000 A ,,~,' 1- _ ,_ ,H Il'Y
Admit Date/Time: 10/~64 PRH~ 48341
Discharge Date/Time:
Service/Location: ER F/e: CO
Account No: V00009094780
Room/Bed:
Patient Type: ER
PATIENT
ABBOTT. DAN
1627 W MAIN NO 106
BOZEMAN.MT 59715
(406)539-6931
Employer:
SSN:_
DOS: ......
Marital tatus: M
Sex: M Age: 44
Phone:
GUARANTOR
ABBOTT. DAN
1627 W MAIN NO 106
BOZEMAN.MT 59715
Home: (406)539-6931
Work:
PERSON TO NOTIFY
NEXT OF KIN
ABBOTT.ALYSSA
1627 W MAIN NO 106
BOZEMAN.MT 59715
Home: (406)539-6931
Work:
Relationship: SP
Home:
Work:
Relationship:
INSURANCE POLICY
l)PATIENT WILL SUBMIT. 010010001
Reason for Visit: RE CHECK ARM
Accident Oeser:
Admit PhYSician:
Attend Physician:
ER Physician: ELSON MD.DOUGLAS R
Last Visit Date: 10/18/OS Registrar:
SUBSCRIBER
ABBOTT. DAN
10/18/05
BURK
ICD-9 CODES
./ PROCEDURE CODES
CPT -4 CODES
EDITING CHECK LIST
Edited by:
Clear for disch? Yes / No
Consent Signed. If not signed. why?
Fin/Agreement signed by patient
Indicate if you saw patient: Yes I No
Medicare appeals letter signed
Card/s scanned'!
Check payors: Med MA Be
Information verifiear---
Other notes:
Why ! -, qaest, onn'a 1 re camp 'I e~ea.
we Other comm.
11.1111111111111.011
Printed on: 10/19/05 at 1004 by BURK
Bozeman D8aconesS_h~O~!FIDEi\JT~i~L
Consent for Treat.'~~~~MATION IS FOR IJ\W
ENFORCEMENT PURPOSES ONLY.
1. Medical Consent: I hereby consent to the provisions of health care sf,lOfJ~/rJt:Il~Jall6lDdlttllBnJ81ts, such as
X-rays. exams, administration of drugs, lab tests, and other hospital @~I:1~~rAAl't~y my physician.
I understand that the patient care Is under the control of an Independenl physician aria 'Bt:5l4'lsn6t liable
for any act of omission provided the hospital has followed the Instructions of said physlclan(s). Secvlces provided
by all physicians are independent of BOH.
(
2. Release of Infannatlon: I will refer to the BOHS Notice of Privacy Practices regarding the release of my health
information.
3. Assignments of Benefits: I hereby authorize payment directly to the hospital for the hospital benefits herein specified
and otherwise payable to me. I also authorize payments directly to the physlcian(s) providing services to me from the
benefits othelWise payable to me.
4. Insurance Disclosure: I understand that It is my responsibility to notify my Insurance company directly within the
time limits of my policy, If ~ am admitted to BoH or for pre-authortzatlon of special procedures anellor tests.
6. Financial Agreement: I hereby assume full responsibility for charges I Incur for services from SOH and agree to
pay said charges In full. I have given my Insurance Information, If any, to SOH. It Is my understanding that I
will be responsible for any balance not paid by this Insurance. If I, or my guarantor, choose to bill my Insurance, my
account will be considered as self~pay. If I am unable to pay In full, I will contact the Credit Dept. at 585-1015
to discuss options, with a minimum monthly payment of $100. It Is further understood ~ entire balance, pursuant
to this agreement, will be due and payable one year from the date of admission/service. ~ (Guarantor Initials)
6. Personal Valuables: I understand that BOH shall not be liable for personal Items. If admitted, I hava been advised
to sand all valuable personal property home.
7. NursIng Care: SOH provides general duty nursing care. If a patient ne&cls continuous or special duty nursing
care, the patient. legal representative, or the physician must arrange such care. SOH shall In no way be
responsible for faUure to prOVide the same and Is hereby released from any and all liability.
8. Grievance Procedure: All patients have the right to submit a complaint regarding care and services rendered without
fear of retribution. As a patlen~, I may communicate my concerns regarding care, services rendered or billing to the
BOH Quality Improvement Oepl: at 585-5046 or send It In wrttlng to 915 Highland Blvd., Bozeman, MT 59715-6999.
9. Infonnatlon Practices: I acknowled~recelpt of the BOHS Notice of PrivacY Practices.
10. Patient's Rights & Resp~lItl~S: I understand my patient lights as descr1bed In the Patient's Rights and
Reaponslbilltl86 brochure. ~ 8< (Patlent/Respenslble Party fnlttals)
11. Facility Directory: If I am admitted, BOH maintains a faclllty directory that lists my name, room number, and If I
wish, my religious affiliation. this Information (excludIng religious affiliation) will be disclosed to anyone who
requests It by asking for me by name.
I DO NOT want this Information listed in the facility directory.
I DO NOT want religious affiliation shared with the clergy.
I certify that I have read the above infonnatlon and as the patient, or one who Is duly author1zed to act In a representative
capacity for the patient, that the InfO(Tnatlon has b,en fully explained, that I under(ttand its content, that it may not
be modllled and that I may n con.ant ~ sarvIcas at any tlma.
Patlant/Guarantor Signature: P 'Ij ~ Date: V
Relationship to Patient:
Witness:
Data: 1'Jf~5
Reason Patient Unable to Sign:
I acknowledge receipt of an Important
Message from Trlcare
I acknowledge receipt of an Important
Message from Medicare
Signature:
Date:
Signature:
Date:
Acct#: V00009094780 Name: ABBOTI,OAN
MR#: M01148341 SvclLoc: ER 10/19/05
Bozeman Deac tER _ " :...1 . C. J ~-', (:Cd:.NffJ:OcNTiaL _.
- ~:gO~BO MOlUB34l 44/M; 80zeMAN DEACONESS HOSPMt:tNf',QffiiM. l\.1'~ NF
ELSON MD,OOUGLA DO EMERGENC n ~j:~1 .T.
W~ .J.RJli....11 Y DEr'AR1ME"rIN'lT~HO~E[DJ 10/(
,.......... ~,~ fjURSlNG FLOW SHeE'JA _'l'IJI-': ?OO$;j~OOED
TlME ARRIVED: {/lfq)- D~ /I)---n
HOW MRlVED: AMBULMCE WALK W/C GURNEY CNlRlED....
BROUGHT BY: S8.f CE:I 'T1UI: FRIfHD OTHER PHONE NUMBER:
11 i" _
NURSING HISTORY: J{ I A~ AI) A I V N V'-1..--ffl
/ I /1
L./ U
~o .~
. GIC UHAESP
PU. NON-EOUAl
REACTM NON-RfACTM
:ACHE: ~
GCS: -
EYES
MOTOR
VERBAl It --
TOTAl I Q.
CARDIAC
CHEST PAIN; YES NO
SEVERRY (HO)
RADlAllOtt YES NO
0NSEr. DATE
TIME
MJNrroR RHYTHM
RElPUWOftY ___
BREATH SOUNDS: ClEAR
PRESENT ABSENT DIMINISHED
WHEEZE CRACKlES
COUGH: YES NO
CP W/INSP: YES NO
SPUTUM
Oa: NONE NC fM
PKR.OW: PRE _ POST_
---
Ol,m ~
PAIN: ABD PELV FlANK
SHARP CRAMPING ACHING
BURNING CONSTANT
INTERMrmNT RADIATING
ASSOC. Sl'MPTOMS: twJSEA
VOMITING DIARRHEA
BlEEDING DYSURIA
HEMATIJRIA URGENCY
fREOUENev
lAST MEAl
: IlUlCULDlmETAL ~
E'xTREMTY:
TENDERNESS SWElUNG
ECCHYIIOSIS DEFORMITY
SENsAmN: NORMAl
NUMBNESS TINGliNG
fl_ NOfUMl UMfTB)
PUlSE: YES
NO
UflEGUIIEHTARY
lACERATION: LENGTH
L~TION
ABRASION: YES NO
lOCATION
RASH: YES NO
LOCATION
BURN: PARTIAl FULL
lOCATION
HA_
EfNT
VISUAl ACUITY OS
00
au
NA .
~
nfROAT:
PAIN SWEWNG
REDNESs DY5PHAGIA
PHY'IICIAN ORDERS - UIl
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o PT'I, 0 AlIIP/. _
OPTTTfI_ ORAPJOSlR'I,
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PIfYBICWI ORDERS .IWJIOLOS
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CHIEf COMPlAINT:
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NURSE SIGNATURE: ~ J /, / VI J.L~
PRIMARY PHYSICM: 0 YES' J!'/1 . (I .
o NO ....h~..ft /"
FROM_
PHYSICWIS ORDERS - MEDICATI(j
AI.l.EROIES:
"1" n;rn ~'.- .
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ER PHYSICIAN
TO SEE
mANUS:
o CURRENT
o UNKNOWN
o OOT-QH)ATE
WEIGHT
lMP
PHYSICIANS ORDElla - PROCEDURI
o FOlEY 0 ClEM WOUHO::
o OSU 0 OREll5 WOUNDl
1:1 V1.b EXAM 0 kNI;E IUM
o NO 0 AIR STIRRUP
o ORllfO lIS 0 SlMG
o OLD CHART 0 WRIST SPl
o 0
o 0
o
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TIME
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%!f~t IRJ ~ ~
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PHYIICWCS ORDERS - PREPACKS
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TIME
TIME
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IV THERAPY
R.UlD
INmAl
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SITE
RATE
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PHY8ICIAIIS OROERS - PftESCRIPTIOIf.
TIW:
MEDICATIONS (ADDI11OIIAL SPACE 011 WK)
AUT ROim SITE WIT ~
DISPOsmON
PART ' " -1iOMi'-.. POlICE DEe
R8. Hi( ADUlT: ROOM
PART _ 1'tUV<\.
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DIAGNOSIS: I'-<,,~
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STICI(EA l. O.
PHYSICIAN SIGNATURE
WUUNU 1iMt:
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CllAIaN8: STERILE WATER f) ".."_ GLENS III I'MT
HYDROGEN PEROXIDE BET ADINE fIB. RI!l. NA
HIBIGLENS CASTILE NO fMT
As.. Aa leA
DfIE88IN8: CONFORM ACE WRAP BETADINE NO PART
AOAPTIG KERLEX SILVADENE Ra fIB. NA
POLYSPORIN NUGAUZE STERI STRIP NO PAIIT
GAUZE 4 X 4'8 (10PK) BACTOBAN BANOAlDE fIB. AS. NA
NO PART
ruBE GAUZE RB. Ra leA
DATE TIME NURSES NOTES:
>-
..-'
NURSES SIGNATURE:
o SEE CODE SlEET CJ SEE TRAUMA SHEET 0 lEE ADDmONAL MURSlNI Mom
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PHYIICIAN 8IBNATURE:
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-~~\'-
CONTINGENT FEE EMPLOYMENT AGREEMENT
WALTERH. MADDEN
KARL KNUCHEL
Attorneys at Law
116 West Callender
P.O. Box 953
Livingston, MT 59047
Gentlemen:
You are hereby employed to represent me, Cole Ingram, individually and as Personal
Representative of the Estate of Kayle Ingram with respect to all claims for damages both incurred
by Kyle Ingram and myself arising out of the following:
Automobile accident of October 18,2005, on North 19th
A venue in Bozeman, Montana in which Kayle Ingram was
a passenger in a vehicle being operated by David Cherry.
For your services you shall receive the following:
Twenty-five percent (25%) of the gross amount recovered by settlement. If the case is
tried. the fee would be forty percent (40%) of the amount recovered from the trial.
You shall be promptly reimbursed for all court costs advanced by you and any other expenses
necessarily incurred in the prosecution of the claim whether said prosecution is successful or not.
You are hereby authorized to take such action on behalf of the undersigned as in your jlldgment
may be necessary or desirable for the proper handling of the above claim.
.
Each of us shall keep the other fully informed at all stages of the proceedings relative to the
prosecution of the above claim and no settlement shall be made unless acceptable to all parties
hereto. !
DATED thi~ day October, 2005.
ividually and as Personal
e Estate of Kayle Ingram
/, . Madden and Karl Knuchel.
~ ~(2)
c~oss SECTIONELEMEt;r8
December 2000
..
In urban/suburban areas. Seqtion 11.2.4 provides Inrormation on design details for 8
TVVL TL.
11.3.2.2 __Ised MedI..
A median Is defined as 8 ra~ median if it contains 8: raised portion within Ita limits.
Raised medians may be used bn urban end IUburban htghway8 and streets to control
ecceas and left turns. The use of raised medians Is not recommended adjacent to high--
speed lanes N > 70 kmJh}. ~ .,~
~
Advantaoes
VVhen compared to flush medl8Jf1s, raised medians offer several advant8ges:
1. MJd..bIock left tLwns are controlled.
2. Left-tum chamellzation 08n be more effectively deJlneated.
3. A dlsthct Ioc8Uon Is available for trsrrJc signs. BignIlIII8 and pedestr1an refuge.
4. Limited physical separation Is available.
5. UnoonttoIled erose-tnmlc movemera ere prevented.
6. RedUC8 the potential for ~ead-on oolli8tor'ts.
Dl8advant8aes
The disadvtlnt8Q88 of raised medians wtwn compared to flush medians ere~
~ 1. Access for emergency W1h1clM (e.g., fire, 8I'11buln:8) may be men dIIicufl
2. Prohibiting mJd--bJock left hnl8 may overload ...t Inter8ectIons and may
Increase the numb<< aflHu'ns. They also may Impact other A Nta In the
corridor.
3. They may need greater roedw8y widths to serve the earns function (e.g., Ieft-tum
lanes at intersections) bec:8use fA the rafMd Island and otfa4tt between c.rb and
travel lane.
~ 4.
--'? 5.
6.
Curbs may result In adver8e vehicular behavior upon Impact.
They ere more exp<<lllve to construct and more dltllcult to maintain.
Prohibiting mid-block Ieft-tums causes drivers to take alternative 8CC88S routes to
and from adjacent propart~s.
"
-
December 2000
c~oss SECTION ElEMEtfTS
11.3@
~
Desion
If a raised median will be used, consider the following In the design c:I the median:
~ 1. ~. Mountable concrete curbs are used for railed medians.
~ 3.
Surf8cina. The raised portiOn of the median wID be psried, typically with
concrete.
7> 4.
~ Wlere raised medlml 8re used, the roedway mLllt be Ught8d and the
medians must be delineated.
Existiog
Evaluate all existing raised mledlans within the project Ilmila for their current
appropriateness. The existing configIntion of the I'llIsed median should be evaluated
with Its consistency to the existing' geometric needs. This includes sight distance for the
:'~
,,'
-
""
48.
49.
so.
51.
52.
53.
54.
~8)
GLOSSARYIINDEX
December 2000
44.
.LmL.I.IIm!a. Level t9l1l'81n is generally COI'lIIdered to be flat, and has minimal
impact on vehicular performance. HJghWay elglht distances are either long or
could be made long without major c:onetnJctlon expense.
.Ls. length of spiral.
Low-Soeed j,frb8n StreIU. 1heIe are all streeta within urbanized and smell
urban areas with a d$S1gh speed 0170 kmlh or lese.
Maximum S~. The overall ~1IW8t1on control used on fa
specific facQity. Ita selection depends on aeversl fllctora Including overall climatic
conditions, terrain cond~, type of facility end type d .... (rural or l.Wban).
~. Channelization which Mp8I'8teS opposing traffic flows, 818m.
the driver to tho cross rosd ahe8d and tegu1ate8 traffic through the 1nt8l"MCtion.
MftdIIn. The portion of 8 divided highway eeparating tho two traveled Wttf8 for
traffic In opposite d~.. The median width incbtes both Inside $houIders.
Median Ooenfng. OpenIngs in the median (raised or depre8sed) on divided
facilities which allow vehldle8 to aoss the facility or to make a u-turn.
Median SIooe. The slope In the ansa section view of a d&pre888d median
beyond the surfacing inelaper &xpressed as a retlo of the cIw1ge In horizontal to
the ch8nge in vertical.
Morne~ ~. A aite where en upgrudG ia preceded by 8 d6Nngrade,
thereby allcrNlng 8 tnJck to increase Its speed on tho upgrade. lhie Incr8a8e In
speed allows the detlgner to use . higher speed ftIClIt.IctIDn in the' critJcIIllength of
grade fbn.
~ Curb. A longitudinal element, typ~ concrete, pIaoed at the
roadway edge for dellneetion, to control drainage. to 'control 8CCeS8, etc.
Mountable oorbs have 8 height of 160 mm or leas wflh 8 face no eteepet tha11
horizontal to 3 vertical. .
45.
46.
47.
.YOtJI1ainous T erraIQ. longitudinal and tr8nIVerI8 changes fn elevatiOn ana
abrupt. Benching and aide, hili 8XCfWatIon are frequently required to provide the
desirable histawaY allgrment. Motnainous lenah eggravatea the performance
of trucks relstlve to passenger cara, resulting In 8Ort1e trucks operating at alIWI
speeds.