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6 Particulars of the viciims (Attach separate sheet, if requir.ed)
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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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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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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 :
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I.AQimarirrc @:-ur.Irs(ruv' |
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Desisnation: ulUf
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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