Accident report, February 21, 1919

Form 3865-N. J. STATE OF NEW JERSEY, ACCIDENT BLANK. Report Every Accident Immediately. of Industrial This report of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau 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. RAVIULI GULITNOUS HATERIAL COSP Number of Reymond Bichola Month 366 Employer) Employee) 23 Day of 313 Month 019 Rest Now Jersey (Street Address) Year Chenion] P1 (City/or Town) (City or Town) A. M. Chomist Amériean P. M. (Business) Hour 3. (Occupation) 4. (Nationality) Date report received Leave this line blank nale 23 1. accident occurred 5. Sex 6. Age 7. Married yes out by broiten gitos 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 3 Tingoro nona 11. Was any guard protecting this portion of the machine? 12. Exact location of the wages fixed by the output ? no street and number 17. If the wages were fixed by the hour, state RATE per hour 13. Was medical attention necessary ? yea hrs 18. Give number of HOURS in ordinary day 14. Name and address of attending physician 6 15. If sent to hospital, state name and location 19. Give number of DAYS in ordinary working week 40.00 20. State the amount of weekly WAGES 2/25/29 Date of preparing this blank 19 Made out by Victor noth Fill in names and date on FORM "D" before detaching. If employee has resumed work at time of reporting, do not detach.