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CRiME :DETAI,LS-FO;RM

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\\.\" "' vqg" "' ry7'-w" " " w-r*w aTK;4. TYPE OF CRIME (Allincluding M. O. Crime):

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6 Particulars of the viciims (Attach separate sheet, if requir.ed)

6. Motive of Crime:

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Description of physical evidence from the scene of crime for the property recovered/seized for the purpose ofinvestigation :

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.:Description of the place of occurrence :

10. Sketch/Map of the place of occurrence (Attach Sketchimap with legends separately, if needed. lf to scale,

indicate so. May be certified and signed by witnesses, if required :

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Signature of the Investigation Officer with

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bt*P9.cAsuALrYU\

To,

The Police oncall,

GMCH, NagPur.

This isto informYou

details has been

from the casualtY on

2 o{.v1

I'fonnant: CN4O cl^,

tL^cr-r^rt cr-'4 k1 *,I R't-..n u n)"

Kiirdil' clo the needftii.

Name' gW rf *'Yr ga'n-r

Age/Sex: fr SI,J {t4

MRDNo: l lK 19 6 g

MLC No. , \4 941 :

A*-{ rc

fl*.

I.AQimarirrc @:-ur.Irs(ruv' |

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Nu*. , Vl +-"rDvdLY4/nt

Desisnation: ulUf

ooo,--o-,,u'-o*ro*Srtd #-'o-'u-'* Reg (100 Lvs eacn) PA

& Hclsi:'ital, I''l agPu{

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Form Comm. AA( see rules 253(c), 25a(c)(iiD, 254(80255(t)(iv))

REPORT ABOUT THE MOTBR VEHICLES ACCIDENTS;

,lt Name of the Police Station Lakadgani Police Station Nasnur Ci7 cr.no. /Tar.no. /SDE no. cr. No. 157 ll8 I sec.279,,337, 338, 304 A IPC r/w 134

177 Mv act 15 i6il8 03-09 am3 Date, Time, and Place of Accident 16/6/18 22-10 pm OId Bhandara road Sudarshar

Chowk ps lakadgani Nasnur .4 Name of the injured/ Deceased Bhagwan Vensani age 34 add- Shantinagar Nagpur

5 Name of Ilospital to which he /she wasremoved

Mayo Hospital Nagpur

6 No. Of Vehicles and type of the vehicle 2 vehicle , Accused --car no. PB 57 -2653victim - 2 wheeler Mh 49 K1376

7 Name and Address of the driver of thevehicle with particular or driving licenceof the said driver and the address of theissuing authority of the said drivinglicence . The number of badge in case ofpublic service vehicle and the address ofthe issuins authority of the said badpe

Shekhar Omkar Potdar age 33 add. Kalamana

8 Name of the adderess of the owner of thevehicle as it stand on the date ofaccident-

9 Name of the adderess of the insurancecompany with whom vehicle wasinsured and the divisionaloffice of thesaid insurance comDanv.

10 Number ol' lnsurance Certificate andthe Date of validity of the InsurancePolicy / Insurance Certificate

ll Action taken , lf any, and the resultthere of.

on investigation

Inspector of PoliceLakadsani Police Station