Accident report, August 12, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Radium Aminas material Cap Full Address 16 6alder Street. Orage City merfore State 1. Full name of injured employe Daninah gimm 2. Address 97 Labirds are Comenge m.f 3. Age 52 4. Married Uidaur 5. Number of Children? 5 6. Weekly wages Jucurty eight dullars 7. In whose employ at time of accident 8. Date and time of accident 12 day of august 1918 at 10 A. M. 9. Place of accident Campuys Plant 10. got same of the culture in a cut and Cause of accident Perining and cystals from puts cares abreases 11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured) Ondy and middle finger affected 12. Has the injured employe returned to work yes if so, when ? at Jest n three 13. Did the injury require medical aid ? yes 14. If so, where rendered and by whom Dr Darling at his office 15. By whom was the physician called ? Employer If so, when ? any - 25-18 16. Taken home or to hospital 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? Baler 20. Date of this notice ang 26-18 21. Date of notice of accident by employe to employer any 16-18 All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice. Signature of Assured. Please use the other side of this sheet for any additional information. Form 1743 B