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Cornwell � FiEC��'�� . � MAR 1 3 2013 NOTICE OF CLAIM FORM to the City ��'�1'�ul, Minnesota Minnesota State Statute 466.05 states tl+at"...every person...who daims damages from cmy municipality...shall cause to be presented to the governing body of the municipality within 180 days after the aUeged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weelts or longer depending on the nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name�r}� �' �ea n h � Middle Initial�Last Name �.v� r� �,.� � �� Company or Business Name. Are You an Insurance Company? Yes� If Yes,Claim Number? Street Address �� -1 O<<.-� �' �1 l� V �_ City S �t I�U u� �C.1��Z State � ►ti� Zip Code �.5 G 7 I Daytime Phone(� - Cell Phone(�S 1 �s3-��'Evening Telephone(_� - Date of Accidend Injury or Date Discovered 'a- � a�3 ��t>13 Time ��:�.s�am/� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or res nsible for your damages. `� ,-c,.�, ��,-� � , � . . .�. , _ , - � L t -,r�;, n . � ' - - cxc,i�. Please check the box(es)that most closely represent thel reason for completing this form: ❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow ❑My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow L�My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property ❑Other type of property damage—please specify ❑Other type of injury—please specify ' In order to process your claim vou need;to include conies of all apnlicable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs •Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other pmperty damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs aze always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—ulease comulete this section Were there witnesses to the incident? Yes �'� Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes � Unknown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. � t"' �: �� e,zc:c°y-t.._t"'� Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. ..�u ' ` Vehicle Claims—nlease complete tI�is section O check box if this section does not apply Your Vehicle: Year�uc�� Make S Model �m�t_�� -,:�, Y,c�� r�,.k�� License Plate Number l�{V �-I 9� State �;�1 Color_ l� 1 � c Registered Owner��c:r,�-c� C-c,: n.�.;�� ( Driver of Vehicle a � t I�� C.o ; r, .�; l 1 Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—alease comnlete this section �check box if this section does not annlv How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone L�Check here if you are attaching more pages�o this claim form. Number of additional pages By signing this form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed Submitting a false claim can result in prosecution. Date form was completed .��1+� i �, �C"_�i:� Print the Name of the Person who Completed this Form: V t' � e c��n y�� CC'�� Signature of Person Ma'g the Claim: �,�-��:�'��`'��-��-`-'�- Revised February 2011 _ t �� .�,�,�,� �� ,�� - � � � �� u �. j< �_ - � . �:.� �.�, �� Y ? k': � _ �_� �� F� '., . � �.'i_ �- 'n"'`v "�"'v' �`'}�_ ��` �'�,,"�K�r Z �- � �-��-�- ? �� ,.�`�'$��-�;'�r��*� _ � ��, a„_:,s'�i.�,� � a'' . . , ,a.s „._ � �,�.� � , � _ ,_. _ —�—�--�—'�� 8$8 ��4� � c� .� " � � �t; PAUL �, � ��: _ �� , y �� . " . r=-_. ,,� - � ` ��DF IfAAINNESOTA; .. ; ��iinaersisned,bei� �, � * �� .`6 �4 9 8. 3 * �� - � { �` �- ��,� �^► �x� � � �>. C� ,x�, `�, _ � Date of Offeose � �- � �- ;�' � �� I�'� �;olor��— `�; � F - (�ake ` F �; � ��- Veh.License No. ,�, �a � ,� -- � � � _ ��' - �, c �, ',z� �, . �'..� � : - ;;� : ��,LocaGor►�of Offense: ��-�� , -� , � � � � �"� � �°�, ia� � � =��r x � f'_ � �st.�� ;� E $5�:�". �� _. -, ' . :x�-�1� ,� . �1 �., ,�� _- `arges of S13 0�� rA � . , .. h� �- . t. . � , � �� _,; � �� _ . � ;�; CN � ��,��♦�� : �: � � �� '� �� ` � ��9 r� � ?��x��. � Citing ��rt Ot�is'��. � �� , t. ' Officer� -�.w=Nu�ii��ier ; � . � `'- ❑Drove Off �� $e�o�'e Pbw ❑P� �ndrow) k� �tfit Plow � � ��: � � f { � ,�,- �.� �=�,� _ _ . . x � . _ . - -,-, � �,� , � -� ;� < < ��a �� . I �� „- ��- - � w+u. nwt�o wr J� _ � , ; , �,% , '�',, . " �; .��` �.�� lANfiE LHAl�EL pp � �� : � PAI�,�IN. 55i6T-2966 � � - ;,.••. �� - 551-266-5642 �_ � " �` _ �,_ ° - �` Md�t 49 � :x , _. . ❑NO PLATE 1er.ID: � ` `�' � �� read the bscK � � � x��;. Sate � ci :� �►�a _ = �� o�a�zzz �� +' ��; � Ilet�od: S�ived _ � � �o#a�. ' _ �"±, � ;. : �l1�3 14:19:21 ��:� �aar Code: 696�8C _ {�` I�Iline c�c�'cw� .:-- nw�c mu! _ Calvin Kenneth Cornwell Bom in Hannibai,WI on Feb.24,1926 Departed on Feb.23,2fl13 and resided in S#.Paul Park,MN. Visitation:Wednesday,Feb.27,2013 - 4:00 pm-8:�pm � � �,-u r � Service: Thursday,Feb.28,2013 � :f� 10:30 am � ". g`_ Cemetery:Fort SneNing Nationai Cemetery , �";� Calvin Comwell,age 86.Of St.Paul Park died Saturday moming February 23,2013 at Southview Acres Health Care Cerrter. Calvin was bom February 24, 19�6 in Hannibai,Wisconsin the son of Eart&Meta(Dutrle)Comweil. He was raised in Wisconsin. On July 1, 1947 he was united in marriage witF�Dolores Ki�haber in C.?reernYaod,V�nsin•Calvin wa sa p�aad member of the United States Marine Corps in WWII,and served in the Pacific Theater.Fie was a member of the American Legion and VFW in St. Paul Park. Calvin enjoyed fishing. He is the bebved husband of Dolores;loving fathe�of l.arry(Gayle),Tim�(Sue),Andy(Lynn),Gordy;Kathy(Timothy)Gorr,Virgie; 10 grandchildren;6 great-grandchildren;brother of Vemon(Avis), Leland(Ruth),Herbert(Debbie),Amelia Forster,Vera(Wallace)Kuehl, Gladys(Don)Mabie,Meta(Wayne)Murphy, Lois(Maynard)Hartschom,Phyllis Mabie. Calvin was preceded in death by his parents;2 brothers;son William;2 sisters. Visitation 48 PM Wednesday at KOK FUNERAL HOME, 1201 Portland Ave.St.Paul Park and 9:30-10:30 Thursday at church.Mass of Christian Burial 10:30 Thursday at ST.THOMAS AQUINAS CATHOLIC CHURCH,920 Holley,St.Paul Park.lnterment Ft Snelling National Cemetery. -- _ __ _ __._ _. _ This Memorial Obituary provided by Kok Funeral Home-Cottage Grove I Ii ; � (��II�II1�'��`��`�� INCIDENT INFORMATION REPORT 3/7/2013f 1 STATE OF AAINNESOTA COUNTY OF RAMSEY - � DISTRICT COURT INCIDENT AND CITATION INFORMATION INCIDENT ID PAYMENT PLAN CITATION NUMBER 2535219 888764983 DEFENDANT NAME VIRJEANNE MARY CORNWELL ADDRESS 839 LAURELAVE ST PAUL PARK MN 55071 DEFENDANT INFORMATION DATE OF BIRTH 2/1/1951 GENDER HEIGHT _ EYE��F� —_— WEIGHT DL NUMBER Q007174128407 DL STATE MN RACE HISPANIC(Y/N) OFFENSE INFORMATION DATE/TIME 02/23/2013 15:55 DIVISION RAMSEY COUNTY LOCATION IFO 1451 ENGLEWOOD COMMUNITY ST PAUL AGENCY PUBLIC WORKS METER ISSUING METHOD LEFTAT SCENE OFFICER 1 828 CN 13036203 OFFICER 2 NBRHOOD VEHICLE INFORMATION PLAT� NV498 _ _ _ - MAKE _ JEEP ST�TE _ MN _ _ _ . _ MODEL 4 DR _ I PLATE YEAR 2013 COLOR BLACK VEH TYPE PASSENGER VEHICLE VIN 1J4GW58N8YC154891 VEH YEAR RESPONSIBLE PARTY �METHOD NONE OTHER SYSTEM IDENTIFIERS CN NUMBER CHARGE INFORANATION STATUTE/ ! STATUS REASON JURISDfCTION ORDtNANCE � DESCRIPTION CLOSE FNSUS STPAUL 161.03 Snow emergency parking restrictions ORIGINAL FEE INFORMATtON AMOUNT DUE $40 FINE 40.00 $40 FtNE .00 Srchrg-2nd District 1.00 Srchrg-Znd District .00 Srchrg-Parking 2009 12.00 Srchrg-Parking 2009 .00 GRAND TOTAL 53.00 GRAND TOTAL ,00 OFFICERS COMMENTS DAY PLOW; PLOWED IN (WINDROWj