Amusement Device Notification Of Accident Report - Nyc Department Of Consumer Affairs Page 2

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Page 2
ACCIDENT INFORMATION (CONT’D)
Continue briefly describing how accident occurred:
WITNESSES (Continued from Page 1)
Name of Witness:
Address of Witness:
Telephone Number:
Name of Witness:
Address of Witness:
Telephone Number:
Name of Witness:
Address of Witness:
Telephone Number:
8/09

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