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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
Rad Lum mat Corp
Date of Accident.
12 Month of
Number James (Namp Rooney Injured Employee)
# 166 alden street
(Name of Employer)
15 Day
(Street Address)
Orange (City new or Town) Jersey
18
Year Month of That 125 Watchung Orange (Street (City Address) Town) n.J ane
chemical Plant
or
3:30 Hour P. M. M. Carpenter
american
(Business)
3. (Occupation)
4. (Nationality)
Date report received
Leave this line blank
1. State fully how accident occurred
Working
5. Sex
6.
Age
35
7. Married yes.
on tank of pure of 20rd
8. Give name of machine or appliance involved
feel on foot
20 machinery
9. Indicate kind of work done on this machine
x
2. Exact part of person injured, with nature and extent of injury
10. Name distinct part of machine causing injury
Smached the toes of
left foot
11. Was any guard protecting this portion of the machine?
no
12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output?
street and number
company's plant
17. If the wages were fixed by the hour, state RATE per hour
13. Was medical attention necessary?
yes
50 cents
18.
Give
number
of
HOURS
in
ordinary
day.
11 tomples
14. Orange Name and address of attending physician.
X
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
32.00
Date of preparing this blank.
12/17/18
1918 Made out by
no
Fill in names and date on FORM "D" before detaching.
If employee has resumed work at time of reporting, do not detach.
OK
nr
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Document data
- ID
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- Core
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- Type
- document
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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.\"\nFirst notice of Accident. For use by insuring employers\nRad Lum mat Corp\nDate of Accident.\n12 Month of\nNumber James (Namp Rooney Injured Employee)\n# 166 alden street\n(Name of Employer)\n15 Day\n(Street Address)\nOrange (City new or Town) Jersey\n18\nYear Month of That 125 Watchung Orange (Street (City Address) Town) n.J ane\nchemical Plant\nor\n3:30 Hour P. M. M. Carpenter\namerican\n(Business)\n3. (Occupation)\n4. (Nationality)\nDate report received\nLeave this line blank\n1. State fully how accident occurred\nWorking\n5. Sex\n6.\nAge\n35\n7. Married yes.\non tank of pure of 20rd\n8. Give name of machine or appliance involved\nfeel on foot\n20 machinery\n9. Indicate kind of work done on this machine\nx\n2. Exact part of person injured, with nature and extent of injury\n10. Name distinct part of machine causing injury\nSmached the toes of\nleft foot\n11. Was any guard protecting this portion of the machine?\nno\n12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output?\nstreet and number\ncompany's plant\n17. If the wages were fixed by the hour, state RATE per hour\n13. Was medical attention necessary?\nyes\n50 cents\n18.\nGive\nnumber\nof\nHOURS\nin\nordinary\nday.\n11 tomples\n14. Orange Name and address of attending physician.\nX\n19. Give number of DAYS in ordinary working week 6\n15. If sent to hospital, state name and location\n20. State the amount of weekly WAGES\n32.00\nDate of preparing this blank.\n12/17/18\n1918 Made out by\nno\nFill in names and date on FORM \"D\" before detaching.\nIf employee has resumed work at time of reporting, do not detach.\nOK\nnr"
}