Accident report, July 18, 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. Railm Limines Math Carp 7 of Number Dominuts Quim Month (Name of Employer) (Name (of Injured Employee) 166 alder St. 16 Day of Month 97 Lehnvell are (Street Address) (Street Address) Orange If 1918 Year (City or Town) range (City or Town) mfor of Radium (Business) 1030 A. M. Laborrer ammian Hour 3. (Occupation) 4. (Nationality) Date report received Leave this line blank 1. State fully how accident occurred 5. Sex male 52 7. Married Under 6. Age cement wall clinel littled cutting lurch 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 cut alay ride lift age 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 ? mo. street and number cempuns plant 17. If the wages were fixed by the hour, state RATE per hour 13. Was medical attention necessary ? Jent ail at plant went to Dr must day 32 & 14. Name and address of attending physician Dr. Parting 18. Give number of HOURS in ordinary day 111/2 Pah are Orange 15. If sent to hospital, state name and location 19. Give number of in ordinary DAYS working week 6 20. State the amount of weekly WAGES. 24.72 Date of preparing this blank. July Fill in names 18 and 19/8 date on FORM Made "D" out by before detaching. upk ABRewland If employee has resumed work at time of reporting, do not detach.