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4)067 1/ir / MOUNDS VIEW POLICE Case Number 7/0 11/17/9/(,
<br /> Classification OFFENSE REPORT
<br /> Complainant's or victim's Name (Firm name If business) DOB Age Sex Phone:Bus.
<br /> Last First Middle ., 1l-_/3-h,q i .S"7I-3V/ ,'
<br /> f_ (� C j City) (� State ,�j Phone:Res.
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<br /> Complainant's or Vidtims Address Offense or Incident
<br /> 13
<br /> Ra 130,k Rae.1-� Pc �, B ( 7` e
<br /> Place Where Offense Occurred Type of But-Ming, (Residence, store, bank, etc.)
<br /> :5100 5e f1 rayDI- Iv e—
<br /> Reported By I Phone Officer Assigned
<br /> {I /�.ct "Niro 9
<br /> Date and Time of Offense Date and Time of Report
<br /> 01- d q cit / 70o h .- S 09 -ay- 9f a /58- ti.-.1
<br /> Name and Address of Suspect(s): DOB/age/race/sex/description Circle If suspect is:
<br /> employee/relative/acquaintance
<br /> 1.
<br /> 2.
<br /> Witness Name Best Contact Address -Age Best Phone Other Phohe Parent or Guardian
<br /> 1.
<br /> 2.
<br /> Narrative (Write in any available details not,covered above.) .
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<br /> investigator C 1 _ ________
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