Accident report, May 4, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Radim Liminas Material Corporation Full Address 166 alden Street City rangle mg State 1. Full name of injured employe Joseph Andumm. 2. Address Main st. Orange. Hannels Bluch 3. Age 20 4. Married no 5. Number of Children? more. 6. Weekly wages 7. In whose employ at time of accident Company's 8. Date and time of accident 4th day of may 19.8 at 1000 30 A.M. 9. Place of accident Company plant. 10. Cause of accident main fainted at his unh. MAK 11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is CON CASE injured) MAY ENS 61918 (TYON - 12. Mo. mo infury Has the injured employe returned to work if so, wheni 13. Did the injury require medical aid ? yes. 14. If so, where rendered and by whom Company dector and ambulance dato 15. By whom was the physician called ? If so, when ? I humanter attach 16. Taken home or to hospital Idental 17. Name of hospital memmial Address ? 6 Prange 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? 19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's Collective Insurance? Steam Biler 20. Date of this notice may- 4-1918 21. Date of notice of accident by unploye 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 dimineus Matt Corp HRRartane suff. Signature of Assured. Please use the other side of this sheet for any additional information. Form 1743 B