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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.
Radrim Luminous material 60
Number
10
of
166 alden Threet
(Street Address)
of Date of Accident.
Month
(Name of Employer)
George (Name me of Injured baffrey Employee)
20 Day Month of
30 Valley Road
(Street deress)
Orange (City or Town) n.g
A18 Year
west Orange
445 M. Carpenter M
(City or Town)
american
(Business)
3. (Occupation)
4. (Nationality)
Date report received
10-21-18
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
woodsplint 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
right hand, firstfuige
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 number Tamphonse
17. If the wages were fixed by the hour, state RATE per hour
13. Was medical attention necessary? yes
yes
-36 - 36
%
14. Name and address of attending physiciar E. Semzried 8. Give number of HOURS in ordinary day
13½
momor. 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
1918
Made out by N retor Rater
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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"ocrText": "Form 3865-N. J.\nSTATE OF NEW JERSEY, ACCIDENT BLANK.\nReport Every Accident Immediately.\nThis report of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau\nof Industrial Statistics, State House, Trenton, N. J. Carbon copy will not serve. The other copy is to be sent to\nNew Amsterdam Casualty Company\n59 JOHN STREET\nEXECUTIVE\n7 ST. PAUL ST,\nNEW YORK, N.Y.\nOFFICES\nBALTIMORE MD.\nFORM \"C.\" First notice of Accident. For use by insuring employers.\nRadrim Luminous material 60\nNumber\n10\nof\n166 alden Threet\n(Street Address)\nof Date of Accident.\nMonth\n(Name of Employer)\nGeorge (Name me of Injured baffrey Employee)\n20 Day Month of\n30 Valley Road\n(Street deress)\nOrange (City or Town) n.g\nA18 Year\nwest Orange\n445 M. Carpenter M\n(City or Town)\namerican\n(Business)\n3. (Occupation)\n4. (Nationality)\nDate report received\n10-21-18\nLeave this line blank\n1. State fully how accident occurred\n5. Sex male 6. Age 44\n7. Married. yes\n8. Give name of machine or appliance involved\nwoodsplint under nail\n9. Indicate kind of work done on this machine\n2. Exact part of person injured, with nature and extent of injury\n10. Name distinct part of machine causing injury\nright hand, firstfuige\n11. Was any guard protecting this portion of the machine?\n12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output? no\nstreet and number Tamphonse\n17. If the wages were fixed by the hour, state RATE per hour\n13. Was medical attention necessary? yes\nyes\n-36 - 36\n%\n14. Name and address of attending physiciar E. Semzried 8. Give number of HOURS in ordinary day\n13½\nmomor. Hospital\n15. If sent to hospital, state name and location\n19. Give number of DAYS in ordinary working week 6\n20. State the amount of weekly WAGES\n2800\nDate of preparing this blank 10-20\n1918\nMade out by N retor Rater\nFill in names and date on FORM \"D\" before detaching.\nIf employee has resumed work at time of reporting, do not detach."
}