Form Mv-104d - Police Report For Fatal Motor Vehicle Accidents
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1POLICE REPORT FOR FATAL MOTOR VEHICLE ACCIDENTS
MV-104D (3/16)
Mail to: NYS Dept. of Motor Vehicles, Crash Records Center,
PO Box 2084, Albany NY 12220-0084
Page
of
Pages
Local Code
Accident Date
Military Time
County
City/Town/Village
No. Killed
No. of Vehicles
Work Related
Month Day
Yr.
o
o
Yes
No
Name and Address of Deceased
ACCIDENT DATA
Speed Limit (MPH
Location (Route Number or Street Name)
)
Estimated Speed:
o
o
o
Vehicle 1
______ MPH
Unknown
Vehicle 2
______ MPH
Unknown
Vehicle 3
_______ MPH
Unknown
Vehicle Model (for example, Mustang or Corvette):
Vehicle 1
_______________________________
Vehicle 2
_______________________________
Vehicle 3
_________________________
Roadway Surface:
o
o
o
o
o
o
o
o
Concrete
Blacktop
Brick or Block
Dirt
Slag
Gravel
Stone
Other
o
o
o
No. of Lanes
Roadway Flow:
One-way Traffic
Divided highway, median strip
Divided highway, guard rail
o
o
Divided highway, other barrier or barrier type unknown
Not divided
*
EMERGENCY MEDICAL SERVICES
HOSPITAL INFORMATION
Time (Military):
If the victim was taken to a hospital outside of NYS, give the name, county and state of that hospital:
Notified ................................ ____________
Arrived at Scene .................. ____________
If the victim was transferred to another hospital (after initial transportation), give the name, county and state of
that hospital:
Arrived at Hospital .............. ____________
OCCUPANT
Air Bags
Type of
Initial Point of
Deceased
Extrication
Deployed
Not in
Time of
Extricated
Impact to Vehicle***
Yes/No
Equip. Used
Yes/No
Vehicle
Death
Yes/No**
Name
V
Driver
E
H
I
Passenger
C
L
E
Passenger
1
V
Driver
E
H
I
Passenger
C
L
E
Passenger
2
V
Driver
E
H
I
Passenger
C
L
E
Passenger
3
* This includes any type of EMS service (for example, fire, police, private). If you are unable to furnish the EMS data, please give the name, address and plate
number of the ambulances so we can contact them:
____________________________________________________________________________________________________________________________
** To be “extricated”, the victim must be pried from the wreckage. Unfastening the seat belt is not considered “extricated”.
*** Indicate the first area of the vehicle that was impacted (for example, right front, undercarriage).
Additional Information
Officer’s Rank
Badge/ID No.
NCIC No.
Precinct/Post
Station/Beat/
Reviewing
Date/Time Reviewed
SIGN
and Signature
Troop/Zone
Sector
Officer
HERE
Print Name
in Full
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