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OCR Page 1 of 2Form 3865-N. J.
STATE OF NEW JERSEY, ACCIDENT BLANK.
Report Every Accident Immediately.
of Industrial This report
of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau
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.
RAVIULI GULITNOUS HATERIAL COSP
Number
of
Reymond Bichola
Month
366
Employer)
Employee)
23
Day of
313
Month
019
Rest Now Jersey
(Street Address)
Year
Chenion] P1 (City/or Town)
(City or Town)
A. M.
Chomist
Amériean
P. M.
(Business)
Hour
3. (Occupation)
4. (Nationality)
Date report received
Leave this line blank
nale
23
1. accident occurred
5. Sex
6. Age
7. Married yes
out by broiten gitos
8. Give name of machine or appliance involved
9. Indicate kind of work done on this machine
2. Exact part of person injured, with nature and extent of injury
10. Name distinct part of machine causing injury
3 Tingoro nona
11. Was any guard protecting this portion of the machine?
12. Exact location of the wages
fixed
by
the
output
?
no
street and number
17. If the wages were fixed by the hour, state RATE per hour
13. Was medical attention necessary ? yea
hrs
18. Give number of HOURS in ordinary day
14. Name and address of attending physician
6
15. If sent to hospital, state name and location
19. Give number of DAYS in ordinary working week
40.00
20. State the amount of weekly WAGES
2/25/29
Date of preparing this blank
19
Made out by Victor noth
Fill in names and date on FORM "D" before detaching.
If employee has resumed work at time of reporting, do not detach.
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