Accident report, October 20, 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 Luminous Material to 10 Month of (Name of Employer) Number George Name, me of Injured Caffrey Employee) 166 alden firset 20 Day of Month (Street Address) 30 Valley Road (Street Address) Orange n.j 918 Year west Orange (City or (fown) (City or Town) 145 M. Carpenter american (Business) 3. (Occupation) 4. (Nationality) Date report received Leave this line blank - 1. State fully how accident occurred 5. Sex male 6. Age 44 7. Married. yes 8. Give name of machine or appliance involved Woodsphints under nail 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 night hand, first furge 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 ? no- street and numbe Tamkhouse 17. If the wages were fixed by the hour, state RATE per hour 13. Was medical attention necessary yes yes - - 36 % 14. Name and address of attending physiciar E. Pempried 8. Give number of HOURS in ordinary day 13% monor. Hospital 15. If sent to hospital, state name and location 19. Give number of DAYS in ordinary working week 6 20. State the amount of weekly WAGES 2800 Date of preparing this blank 10-20 19. 18 Made out by N netar Rater Fill in names and date on FORM "D" before detaching. If employee has resumed work at time of reporting, do not detach.