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Page 1 of 3 Pages New York State Department of Motor Vehicles
Local Codes
POLICE ACCIDENT REPORT 19
MV-104A (6/04) 40464132 7
R5EA01JFT5WF AMENDED REPORT DMV COPY
1
20
Accident Date
Month Day Year
Day of Week Military Time No. of
Vehicles
No. Injured No. Killed Not Investigated at Scene
Left Scene Police Photos
- 4
09 03 2024 TUESDAY 1708 2 0 0 Accident Reconstructed Yes No x
VEHICLE 1 VEHICLE 2 BICYCLIST
X PEDESTRIAN OTHER PEDESTRIAN
VEHICLE 1 - Driver State of Lic. VEHICLE 2 - Driver State of Lic.
2 License ID Number 981170510 NY License ID Number 889474542 NY 21
- Driver Name -exactly Driver Name - exactly
as printed on license DIANE H MONDE as printed on license LAURA L PISKOROWSKI -
Address (Include Number & Street) Apt. No. Address (Include Number & Street) Apt. No.
9 DEERPATH DR 151 BROOKLEA AVE
City or Town State Zip Code City or Town State Zip Code 22
LANCASTER NY 14086 EAST AURORA NY 14052 -
3 Date of Birth Sex Unlicensed No. of Public Date of Birth Sex Unlicensed No. of Public
Month Day Year Occupants Property Month Day Year Occupants Property
3 07 24 1946 2 1 Damaged 09 30 1982 2 3 Damaged
Name–exactly as printed on registration Sex Date of Birth Name–exactly as printed on registration Sex Date of Birth 23
Month Day Year Month Day Year
DIANE H MONDE F 07 24 1946 LAURA L PISKOROWSKI F 09 30 1982 3
Address (Include Number & Street) Apt. No. Haz. Released Address (Include Number & Street) Apt. No. Haz. Released
4 9 DEERPATH DR Mat
.Code - 151 BROOKLEA AVE Mat.
Code
-
1 City or Town State Zip Code City or Town State Zip Code 24
LANCASTER NY 14086 EAST AURORA NY 14052 1
Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code
PRPLDRGN NY 2017 JEEP SUBN ATP2488 NY 2013 ACUR SUBN
5
Ticket/Arrest Ticket/Arrest
1 Number(s) EA24JFT3WQ Number(s)
Violation Violation
Section(s) 1143 Section(s)
25
Check if involved vehicle is: Check if involved vehicle is: Circle the diagram below that describes the accident, or draw your own
6 more than 95 inches wide; more than 95 inches wide; diagram in space #9. Number the vehicles.
3
V more than 34 feet long; V more than 34 feet long; Rear End Left Turn Right Angle Right Turn Head On
1 E operated with an overweight permit;
H operated with an overdimension permit.
I VEHICLE 1 DAMAGE CODES
E
H
I
operated with an overweight permit;
operated with an overdimension permit.
VEHICLE 2 DAMAGE CODES
1. O
Sideswipe
(same direction)
3.
Left Turn
5.
Right Turn
7.
Sideswipe
(opposite direction)
26
C Box 1 - Point of Impact 1 2 C Box 1 - Point of Impact 1 2 3
7 1 9 9
L Box 2 - Most Damage 1 L Box 2 - Most Damage 2. 0. 4. 6. 8.
1 E Enter up to three 3 4 5 E Enter up to three 3 4 5 ACCIDENT DIAGRAM
more Damage Codes more Damage Codes
1 2
Vehicle By Vehicle By
27
Towed: Towed: 1
To To
DIAGRAM IS PRINTED ON LAST PAGE
VEHICLE DAMAGE CODING:
1-13. SEE DIAGRAM ON RIGHT.
14. UNDERCARRIAGE 17. DEMOLISHED 9.
15. TRAILER 18. NO DAMAGE 28
16. OVERTURNED 19. OTHER Cost of repairs to any one vehicle will be more than $1000. 1
Unknown/Unable to Determine x Yes No
Reference Marker Coordinates (if available) Place Where Accident Occurred:
ERIE EAST AURORA, VILLAGE OF
Latitude/Northing: County _____________________ City
x Village Town of _______________________________________.
PINE ST
Road on which accident occurred ________________________________________________________________________ 29
_____________________
(Route Number or Street Name) -
PINE ST / GIRARD AVE
at 1) intersecting street_________________________________________________________________________________
Longitude/Easting: (Route Number or Street Name)
N S
or 2) ______ ______ E W of _________________________________________________________________
_______________________ Feet Miles (Milepost, Nearest intersecting Route Number or Street Name)
Accident Description/Officer’s Notes 30
Officer notes are too long to fit this space. They are printed in whole on a separate page. -
USE
COVER
SHEET
8 9 10 11 12 13 14 15 16 17 BY TO 18 Names of all involved Date of Death Only
N
A 01 1 4 1 78 2 - - - DIANE H MONDE
L A
L B 02 1 1 41 2 - - -
4 LAURA L PISKOROWSKI
I 4 6
N C 02 5 1 2 - - - ARYA P PISKOROWSKI
V 02 6 5 1 2 - -
O D 3 - MAKAYLA S PISKOROWSKI
L
V E
E
D F
Officer’s Rank Badge/ID No. NCIC No. Precinct/Post Station/Beat/ Reviewing Date/Time Reviewed
and Signature ± PATROL Troop/Zone Sector Officer
Print Name
in Full C DENZ 0060 01422 NENE NE CARTWRIGHT, S 2024/09/07 07:44