Accident report, August 15, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Radium Luminous Material Corproation. Full Address #166 Alden Street Street Orange City New Jersey. State 1. Full name of injured employe Ben jamine Rorke 2. Address #3 Watson Avenue, West Orange, New Jersey. 3. Age 47 4. Married Yes 5. Number of Children? 1 6. Weekly wages 7. In whose employ at time of accident Company's 8. Date and time of accident 15 day of August 19.18 at 2 P. M. M. 9. Place of accident Company's Plant, assembling machine parts 10. Cause of accident Caught between a hanger and shafting 11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured) 2 nd finger on right hand (bad bruise) 12. Has the injured employe returned to work kept working if so, when ? 13. Did the injury require medical aid? Yes 14. If so, where rendered and by whom Dr. Dowling 15. By whom was the physician called? Employee If so, when ? August 17th -- 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? Boiler August 23rd, 1918. 20. Date of this notice August 23rd, 1918. 21. Date of notice of accident by employe to employer All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice. RADIUM LUMINOUS MATERIAL CORP Signature of Assured. Superintendent, Please use the other side of this sheet for any additional information. Form 1743 B