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OCR Page 1 of 3Form 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.
Number
Redum pAntorical Commission
11 Month of
Thomas me Hugh
(Name of -Employer)
(Name of Injured Emplayee)
166 Alden Street
21
Day of
Month
47 bortland Place
(Street Address)
1918 Year
mount Clair
(Street Address)
Orange n.J
bhem. Plant
(City or Town)
(City or Town)
7'51 M. themmatter American
(Business)
Hour
3. (Occupation)
4. (Nationality)
Date report received
Leave this line blank
1. State fully how accident occurred
5. Sex male
6. Age 37
7. Married
them hose blow
8. Give name of machine or appliance involved
Steamhose our
ont and the man
agitator
got the steam in both
9. Indicate kind of work done on this machine
Eyes.
sleamfitting
2. Exact part of person injured, with nature and extent of injury
10. Name distinct part of machine causing injury
got steam in both
Eyes
11. Was any guard protecting this portion of the machine?
12. Exact location of accident. If away from plant, give town,
16. Were the wages fixed by the output ?
no
street and numbero
Plant # /
17. If the wages were fixed by the hour, state RATE per hour
13. necessary yes
Was medical attention ?
43cher hour
18. Give of HOURS in ordinary day
66hr 11ho
14 Name and address of atte Ming physician
memoral Hospital Qamp
19. Give number of DAYS in ordinary working week 66 has
15. Lf sent to hospital, state name location
memoral Hospital
20. WAGES 28.38
State the amount of weekly
Date of preparing this blank 19.
Made out by Historicates
Fill in names and date on FORM "D" before detaching.
If employee has resumed work at time of reporting, do not detach.
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