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TRAFFIC CRASH REPORT CRASH SEVERITY CRASH REPORT # 12CR 3 221 PRIVATE PROPERTY 1 FATAL ERROR 3 PDO 2 INJURY 4 UNKNOWN N.C.I.C. # TIME OF CRASH MEDINA TWP. POLICE 14:49 TUE MEDINA (TOWNSHIP OF) 1 0071

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Note: The actual purpose or context of the "Wade Jack T" form is not specified in the question, so the examples provided are general and may not directly apply to a specific form with that name.

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