Accident report, November 27, 1918

Form 3865-N. J. STATE OF NEW JERSEY, ACCIDENT BLANK. Report Every Accident immediately. This report of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau of Industrial Statistics, State House, Trenton, N. J. Carbon copy will not serve. The other copy is to be sent to New Amsterdam Casualty Company 59 JOHN STREET EXECUTIVE 7 ST. PAUL ST. NEW YORK, N. Y. OFFICES BALTIMORE MD. FORM "C." First notice of Accident. For use by insuring employers. Radium Lunisions material Number 11 of arthur a Britton Month 166 alden Street (Name of Employer) (Name of, Injured Employee) 21 Day of Month 253 ave (Street Address) watching (Street Address) Orange n J 1918 Year west Drange (City or Town) (City or Town) Hour 4 A: P. M. M. Pepefille Univian (Business) 3. (Occupation) 4. (Nationality) Date report received Leave this line blank 1. State fully how accident occurred Sex male 26 5. 6. Age 7. Married yes 8. Give name of machine or appliance involved nail infort gota 9. Indicate kind of work done on this tuachine Pejos fitting in Jank house 2. Exact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury left foot instef of 11. Was any guard protecting this portion of the machine? 12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output ? street and number. 17. If the wages were fixed by the hour, state RATE per hour 13. Was medical attention necessary? yes and address of attending physici 18. Give numler of HOURS in ordinary day 14. Name Road W.O. 19. Give number of DAYS in ordinary working week 6 15. If sent to hospital, state name and location 20. WAGES 31.35 State the amount of weekly Date of preparing this blank 19 Made out by Outor Rotte Fill in names and date on FORM "D" before detaching. If employee has resumed work at time of reporting, do not detach.