STATE OF MAINE CRASH REPORT
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FIRST PAGE
Report Number
At Scene Date
Reporting Agency
Crash Date
At Scene Time
Crash Time
ME0161800
15-173-AC
11/5/2015
01:38
11/5/2015
01:47
City or Town
Street or Highway
Nearest Intersecting Street
Off Road
Buxton
TURKEY LN
Int of HENRY HILL RD, TURKEY LN
Direction FROM Nearest Intersection to Crash Site
Distance From Nearest Inter. Latitude
Longitude
-70.546610
At Intersection
North
South
East
West 355
Feet
Miles 43.676610
Measurement Node
Distance to Scene Posted Speed Limit
Node 1
Node 2
Unknown
Not Posted 25
52979
53785
52979
N/A
Not Posted 45
0
.06
Miles
Tenths
Miles Per Hour
(F1) Type of Crash
(F2) Type of Location
1 - Straight Road
12 - Rollover
(F3) Weather Condition
(F4) Light Condition
1 - Clear
5 - Dark - Not Lighted
(F5) Road Grade
(F6) Road Surface Condition
2 - On Grade
1 - Dry
(F7) Traffic Control Device
Traffic Control Device Operational (pre-crash)?
Yes
No
Unk
13 - None
(F8) Location of First Harmful Event
Total Damage over Threshold?
Yes
No
1 - On Roadway
(F9) Contributing Circumstances - Environment 1
1 - None
(F10) Contributing Circumstances - Road 1
1 - None
In or Near a Construction, Maintenance, or Utility Work Zone?
Yes
No
(F9) Contributing Circumstances - Environment 2
(F10) Contributing Circumstances -Road 2
Work Zone Workers Present?
Unk
(F11) Location of the Crash related to Work Zone
Yes
No
Unk
(F12) Type of Work Zone
Law Enforcement Present at Work Zone?
Officer Present
Law Enforcement Vehicle Only
No
School Bus Related?
Yes, Directly Involved
Yes, Indirectly Involved
No
NARRATIVE
VEHICLE 1 WAS TRAVELING EAST ON TURKEY LANE AT A HIGH
RATE OF SPEED. AT SOME POINT WENT AIRBORNE AND THE
OPERATOR LOST CONTROL OF THE VEHICLE AND WENT OFF
THE ROAD HITTING CMP POLE 44-S, A TREE, AND ROLLING
OVER SEVERAL TIMES. AT SOME POINT THE REAR DRIVERS
SIDE PASSENGER WAS EJECTED FROM THE VEHICLE AND THE
VEHICLE CAME TO REST ON ITS ROOF FACING WEST ON THE
OTHER SIDE OF THE ROAD.
CRASH DIAGRAM
Witness Last Name
First
MI
Address
City
State
Zip
Witness Last Name
First
MI
Address
City
State
Zip
Non Vehicle Property Damage Description
State
Property Owner Name
Address
Non Vehicle Property Damage Description
City
State
Property Owner Name
Reporting Officer
PO Francis Pulsoni
Maine Department of Public Safety
City or Town
Address
Badge#
3
Report Date
11/6/2015
Page 1
State
City or Town
City
Utilities
Utilities
State
Private
Zip
Private
Zip
Approved By
Approved Date
CHIEF Michael S Grovo
11/9/2015
Form 13:20A Revised January 2010
Last Modified: 11/9/2015 13:46
N
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Report Number
15-173-AC
Unit ID
Hit Run?
1
No Insurance
STATE OF MAINE CRASH REPORT
VIN
1B3CB4HA1AD607029
NAIC
Insurance Company Name
METROPOLITAN
(U2) Vehicle Make
15 - DODGE
(U4)Vehicle Configuration
Vehicle Has 9 or More Seats ?
Yes
Vehicle Year
2010
GVWR or GCWR
< 10,000 lbs.
No
I
V
E
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Minor Damage
Functional Damage
OWNER Last Name (skip if same as Driver) First Name
ESTEY, DAWN M
(D1) Driver Distracted By
1 - Not Distracted
(D3) Driver Actions at Time of Crash 1
8 - Exceeded Posted Speed Limit
MI DRIVER Address
City
10 NATURES WAY, STEEP FALLS ME 04085
Violation 1
Violation 2
MI
C
C
U
P
A
N
T
State
Zip
OWNER Address
City
State
Zip
10 NATURES WAY, STEEP FALLS ME 04085
(D2) Condition at Time of Crash
1 - Apparently Normal
(D3)
Actions
at Time
of Crash
2
16 - Driver
Operated
Motor
Vehicle
in Erratic,
Reckless, Careless,
Negligent or Aggressive Manner
Alcohol BAC Result
Blood
Alcohol Test Result Pending
Test Not Given
Test Refused
Urine
Other Chemical Test (Not Field Sobriety or PBT)
Blood Drug Test Result
Test Not Given
Test Refused
Urine
Other
(D4) Non Motorist Location at Time of Crash
Towed Due to Disabling Damage
(U7) Most Harmful Event
1 - Overturn / Rollover
(U9) Contributing Circumstances - Vehicle
1 - None
(U10) Sequence of Events 2
40 - Utility Pole/Light Support
(U10) Sequence of Events 4
1 - Overturn / Rollover
License Class Endorsements Restrictions
No License
Permit State
C
0
0
Suspended ME
Active
License Number
Driver Bicycle
Pedestrian
0933347
Last Known Operator
DRIVER Last Name
First Name
ESTEY, EDWARD D
Citation Number Pending
Alcohol Test
Breath
Drug Test
> than 26,000 lbs.
10,001 - 26,000 lbs.
Vehicle Travel Direction
Northbound
Southbound
No
Eastbound
Westbound
Not on Roadway
Unknown
Emergency
Vehicle
Responding
to
Scene
?
Exempt Vehicle
Yes
No
(U6) Most Damaged Area
13 - Top/Roof
(U8) Pre Crash Actions
1 - Following roadway
(U10) Sequence of Events 1
8 - Went Off Roadway Right
(U10) Sequence of Events 3
39 - Tree (standing)
Insurance Policy Number
A6461732560`
(U3) Vehicle Color
14 - White
HAZMAT Placarded ?
Yes
(U5) Special Function Vehicle
1 - No Special Function
Extent of Damage
No Damage Observed
UNIT PAGE
State (U1) Unit Type
ME 1 - Passenger Car
License Plate
4149UH
Negative
Positive
Pending
(D5) Non Motorist Action Prior to Crash
(D6) Non Motorist Action at Time of Crash 1
(D6) Non Motorist Action at Time of Crash 2
(D7) Pedestrian Maneuvers
(D8) Bicyclist Maneuvers
PERSON TYPE 1-Driver, 2-Passenger, 3-Pedestrian, 6-Driver/Owner, 7-Bicycle, 8-Passenger/Owner, 24-Last Known Operator 25-Last Known Operator/Owner
SEAT ROW
1-Front Row
2-Second Row
3-Third Row
4-Fourth Row
5-Other Row
6-Unknown
AIRBAG DEPLOYED
SEAT POSITION OTHER
1-Sleeper Section of Cab (truck)1-Not Applicable
2-Other Enclosed Cargo Area 2-Not Deployed
3-Deployed - Front
3- Unenclosed Cargo Area
4-Deployed - Side
4-Trailing Unit
5-Riding on Motor Vehicle Ext 5-Deployed - Other
(knee, air belt,...)
(non-trailing unit)
6-Deployed 6- Unknown
Combination
HELMET USE
7-Deployment - Curtain
1-DOT-Compliant Motorcycle Helmet
2-Other Helmet
3-No Helmet
SEAT POSITION
1-Left (driver)
2-Middle
3-Right
4-Other
5-Unknown
EJECTED
1-Not Ejected
2-Ejected Partially
3-Ejected Totally
INJURY TYPE
RESTRAINT SYSTEM
1-Amputation
1-Not Applicable
2-None Used - Motor Vehicle Occupant 2-Bleeding
3-Broken Bones
3-Shoulder and Lap Belt Used
4-Burns
4-Shoulder Belt Only Used
5-Concussion
5-Lap Belt Only Used
6-Shock
6-Restraint Used - Other
7-Dizziness
7-Child Restraint - Forward Facing
8-Abrasion/Bruises
8-Child Restraint - Rear Facing
9-Complaint of Pain
9-Child Restraint - Used Incorrectly
10-Other
10-Booster Seat
11-Child Restraint - Other
INJURY AREA
1-Face
2-Head
3-Neck
4-Back
5-Arm(s)
6-Leg(s)
7-Chest Stomach
8-Internal
9-Entire Body
10-Other
INJURY DEGREE
1-Fatal
2-Incapacitating
3-NonIncapacitating
4-Possible Injury
5-No Injury
INJURY INFO SOURCE
1-Officer Observation
2-Individual Statement
3-Medical, Paramedical
Observation
AMB CODES - see code sheet
Person Include Driver, Passengers, Bicyclist, and Pedestrians
Type
Last Name, First Name, Mi
Sex
(M,F,U)
DOB
Seat
Pos
Row
Seat
Pos
Seat Air Bag
Restraint Helmet Injury
Pos Deployed Ejected System Use Degree
Other
Injury
Type
Injury
Area
Inj Info
Source
Amb
Code
ESTEY, EDWARD D
10/19/98
300
POTTER, AUTUMN P
08/28/99
60
PACILLO, ZAKARY S
03/19/96
60
GREENE, ANGEL
06/26/99
10
10
Maine Department of Public Safety
Page 2
Form 13:20A Revised January 2010
STATE OF MAINE CRASH REPORT
Report Number
15-173-AC
Maine Department of Public Safety
Narrative / Diagram Supplemental
Page 3
Form 13:20A Revised January 2010
