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<br />FIRE LOSS HEr JRT
<br />STATE FIRE HARSHAL
<br />FI RE PREVENT ION ,SECT IOU
<br />
<br />,,I
<br />
<br />.IE .OF
<br />~.;:(i'\ 8:13pm 'DATE
<br />
<br />, "
<br />
<br />11/22/89
<br />
<br />CITY, OR COUNTY La. POJt;te
<br />
<br />19 .
<br />
<br />, TEXAS
<br />
<br />:ATIOi/_
<br />
<br />11914 NOJt;th Avenue L
<br />
<br />La. PoJt;te
<br />
<br />. TEXAS'
<br />
<br />:U P p.;:cr
<br />
<br />Re.o-i.denc.e
<br />
<br />COtISTRUCTION Woad aJta.me.
<br />
<br />:U?AtlT
<br />
<br />Va.nny R. Wh-i.;te
<br />
<br />NUHI3ER OF PERSONS HADE HONELESS
<br />ADDRESS MLe.lwa.uk'ee, W-i.~ c.o n.o-i.n
<br />
<br />4
<br />
<br />':ER
<br />
<br />Fl~et~MoJt;tga.ge CoJtp
<br />
<br />'.
<br />
<br />, ' .
<br />, ,
<br />, :
<br />
<br />!-'.
<br />'". .."
<br />
<br />::~E DID THE FIRE ORIGIHATE? (bedroom, bath, gar~,ge, yard, etc.) Wa.;teJt hea.;tvt c.lo.oe;t "
<br />~T STARTED THIS FiRE? (cigarette, tool; applia,ce, match, etc.) Unde;teJtm-i.ned
<br />
<br />,'.l
<br />
<br />.'-
<br />
<br />, .' I.'
<br />
<br />~ T TY?E pF HATER 1 AL 1 GN lTED? (pil pe r, ga s', ga 5 0 'Ii ne, fa bri c, e tc. ) M-i..o c. ella.ne a U.o Ma.:teJtia:l;-:;-'"
<br />
<br />, .
<br />H AIDED III THE fIRE SPREAD? (curtain, mattress;. I'tall covering, etc.) Wen:t Unno;t-i.c.ea.
<br />
<br />t, . .
<br />.. .,. .:.
<br />
<br />. :.'
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<br />. I ,
<br />
<br />FIRE LOSS INFORMATION
<br />
<br />. ..
<br />
<br />VALUE
<br />
<br />INSURANCE
<br />COVERAGE
<br />
<br />LOSS'
<br />. SUSTA WED
<br />
<br />: L 0 II/G. .. . . . . , . . S
<br />
<br />$
<br />$
<br />$
<br />
<br />$ 33,000
<br />$ 22,000
<br />
<br />1-"'/-5 $
<br />I I C.! I ,.......,.
<br />
<br />'r"R' $
<br />:~ .............
<br />
<br />...
<br />~
<br />,
<br />
<br />'J ':,
<br />
<br />'ALS. . , . . , . . . . , . s
<br />
<br />$ 55,000
<br />
<br />$
<br />
<br />, .
<br />'E: IF LOSS EXCEEDS $250,000, OR IN'IOLVEO HOR: TIIMI 10 13UILOIlIGS, OR KILLED 3 OR ~IOP.E
<br />PERSOilS, PLEASE IIKLUDE ^ SEPJ'R.I\TE, OET/\ r Lr:O REPOI\T.
<br />
<br />::~EI:TS: Th-i..6 6-i.Jte -i..6 .6:t-i.ll undVt -i.-nve.6:t-i.ga.:t-i.on a.:t :the :t-i.me 0 a .th-i..6 JtepoJt:t,
<br />
<br />Pa.ul R. H-i.c.kenbo:t:tom-F-i.Jte Ma.Jt.oha.l
<br />;'/}~~~illl) r' .101-l)
<br />
<br />L HIS REPORT TO:
<br />~T"'l'~ FHl.E. HAf\SHAL
<br />STJ\TE GOARD OF H~S~R..'\i:CE
<br />1110 SAil J/\C I ilTO
<br />. AUST W) TEXAS 713736
<br />
<br />
<br />C-i.:tif o^ LQ POJt:te, Texa.~
<br />( l. i t I i: }
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