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Page 1 of 2 Pages New York State Department of Motor Vehicles
Local Codes
POLICE ACCIDENT REPORT 19
MV-104A (6/04) 41101517 66
R5EAW2L5J1PF 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
- -
12 31 2025 WEDNESDAY1342 2 0 0 Accident Reconstructed x No
Yes
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 114910315 NY License ID Number 376021578 NY 21
- Driver Name -exactly Driver Name - exactly
as printed on license JAMES W WHITE as printed on license THOMAS M KEGLER -
Address (Include Number & Street) Apt. No. Address (Include Number & Street) Apt. No.
12067 VALLEY LN 270 PINE ST
City or Town State Zip Code City or Town State Zip Code 22
EAST AURORA NY 140520000 EAST AURORA NY 140520000 -
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 01 10 1974 1 1 Damaged 11 04 1970 1 1 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
JAMES W WHITE M 01 10 1974 THOMAS M KEGLER M 11 04 1970 3
Address (Include Number & Street) Apt. No. Haz. Released Address (Include Number & Street) Apt. No. Haz. Released
4 12067 VALLEY LN Mat
.Code - 270 PINE ST Mat.
Code
-
1 City or Town State Zip Code City or Town State Zip Code 24
EAST AURORA NY 14052 EAST AURORA NY 140520000 5
Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code
BDS3124 NY 2012 NISS PICK LSZ9307 NY 2023 NISS PICK
5
Ticket/Arrest Ticket/Arrest
1 Number(s) Number(s)
Violation Violation
Section(s) 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.
7
V more than 34 feet long; V more than 34 feet long; Rear End Left Turn Right Angle Right Turn Head On
4 E operated with an overweight permit; E operated with an overweight permit;
H operated with an overdimension permit. operated with an overdimension permit.
O
H 1. 3. 5. 7.
I VEHICLE 1 DAMAGE CODES I VEHICLE 2 DAMAGE CODES Sideswipe Left Turn Right Turn Sideswipe 26
C Box 1 - Point of Impact 1 2 C 1 2 (same direction) (opposite direction)
7 Box 1 - Point of Impact
5 5 1
L Box 2 - Most Damage 2 2 L Box 2 - Most Damage 2. 0. 4. 6. 8.
4 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 _______________________________________.
GIRARD AVE @ PINE ST.
Road on which accident occurred ________________________________________________________________________ 29
_____________________
(Route Number or Street Name) -
GIRARD AVE @ PINE ST
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
ON ABOVE DATE AND TIME, VEH 1 WAS TRAVELING EAST BOUND ON GIRARD AVE. AND WAS APPROACHING THE STOP SIGN LOCATED AT -
THE INTERSECTION WITH PINE ST. DUE TO THE ROADWAY CONDITIONS (HEAVY SNOW, SNOW/ICE COVERED ROAD), VEH 1 WAS UNABLE
TO STOP AT SAID INTERSECTION AND DID SLIDE THROUGH THE INTERSECTION WITH PINE ST. THIS RESULTED IN A CRASH WITH VEH 2, USE
COVER
WHICH WAS TRAVELING SOUTH BOUND ON PINE ST. THIS CRASH CAUSED DAMAGE TO THE FRONT END OF VEH. 1 AND THE PASSENGER SHEET
SIDE OF VEH 2. NO INJURIES REPORTED. Both Vehicles drivable. Drivers issued a Driver Information Exchange form.
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 51 1 - - - JAMES W WHITE
L A
L B 02 1 1 55 1 - - -
4 THOMAS M KEGLER
I
N C
V
O D
L
V E
E
D F
Officer’s Rank Badge/ID No. NCIC No. Precinct/Post Station/Beat/ Reviewing Date/Time Reviewed
and Signature ± LIEUTENANT Troop/Zone Sector Officer
Print Name
in Full D WALDRON 0050 01422 NE SPECHT, C 2026/01/03 15:50