Accident report, June 29, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Radium Luminous Material Corporation Full Address Street City State 166 Alden Street Orange N.J. 1. Full name of injured employe Barney Sharkey 2. Address 17 Bradford Street Orange N.J. 3. Age 24 4. Married no 5. Number of Children? 6. Weekly wages $33.66 7. In whose employ at time of accident Hadium Luminous Mater 1al Corpin 8. Date and time of accident day of 19 at M. 29 June 18 A 9. Place of accident Boiler House 10. Cause of accident wrench slipped and lit the man above the eye 11. Nature and extént of injury (state definitely which fingers, hand, foot or eye is injured) had ent ahove the right eve 12. Has the injured employe returned to work did not stop when? 13. Did the injury require medical aid ? yes 14. If so, where rendered and by whom Dr. Herbert Simmons 15. By whom was the physician called ? Employee If so, when ? 11.30AM 16. Taken home or to hospital no 17. Name of hospital Address? 18. Have you advised the attending physician or the hospital that your liability for the cost of treatment is defined and limited by the Compensation Act? yes 19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's Collective Insurance? Boiler 20. Date of this notice August 15 1918, 21. Date of notice of accident by employe to employer Augus to 15 1018. All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice. Radium Luminous Material Corp!n Signature of Assured. Please use the other side of this sheet for any sulitional Form 1743 B