Accident report, June 17, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Radim deminars Material Cerpration Full Address 166 alden Street 0 rangleing new Juney State 1. Full name of injured employe sony Defrave 2. Address 39 Cane Street Prange M.J. 3. Age 33 4. Married yes 5. Number of Children? 3 6. Weekly wages 11 2416 7. In whose employ at time of accident Company 8. Date and time of accident 17 day of June 1918 at 10 A. M. 9. Place of accident Company's plant 10. Cause of accident m am vos mlooing 300 et lags F ueda and from truck One bay fill an by and threw him to the grand. 11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured) 2 r states bad grain an left fort. 12. Has the injured employe returned to work no if so, when ? 13. Did the injury require medical aid ? yes. 14. If so, where rendered and by whom an plant by Dr. Smallined of Meminal pital 15. By whom was the physician called ? Superiticatent If so, when ? 11 brafter accident 16. Taken home or to hospital Jo hespital for ray pritine of fort there to have 17. Name of hospital Memorial Address? 0 romge M.f. 18. Have you advised the attending physician or the hospital that your liability for the cost of treatment is defined and limited by the Compensation Act? yes. 19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's Collective Insurance? steam Balir 20. Date of this notice gune me 17-1918. 21. Date of notice of accident by employe to employer Same date All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice. Radim Luminas math Corp Signature of Assured. Please use the other side of this sheet for any additional information. Form 1743 B Suft