Accident report, November 11, 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 Casnalty Company A 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 Materna/ // of Number Martin Month (Name of Employer) (Name of Injured Employee) 166 Alden Street 11 Day of Month 16 blewelyn (Street Address) (Street Address) Orance N.J. 1918 Year West Orange (City or Town) 10 A. M. Fineman or Town Chemical Plant P.M. Russian (Business) Hour 3. (Occupation) 4. (Nationality) Date report received Leave this line blank 1. State fully how accident occurred 5. Sex male 6. Age 45 7. Married yes 8. Give name of machine or appliance involved Bruised left hand 9. Indicate kind of work done on this machine working in Boilerhouse 2. Exact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury left hand, slightly bruised 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. Boilerhouse 17. If the wages were fixed by the hour, state RATE per hour 13. Was medical attention necessary ? yes 49% & perh. 18. Give number of HOURS in ordinary day 14 hours 14. Name and address of attending physician Dr. Dowling 19. Give number of DAYS in ordinary working week 6 15. If sent to hospital, state name and location 20. State the amount of weekly WAGES $ 4100 Date of preparing this blank Nor 11- 1919 Made out by Fill in names and date on FORM "D" before detaching. thils Pott If employee has resumed work at time of reporting, do not detach.