Accident report, December 5, 1918

Form 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. RLA Number 11 Month of Herbert Marsh Beliedu (Name of Employer) PC of 45 New Street (Name of Injured Employee) 27 Day Month (Street Address) avuy 1918 ear arany (Street B D Address) or Plant P. M. A. M. fallow (City 10 or Town) american of (Business) Hour 3. (Occupation) 4. (Nationality) Date report received Leave this line blank 1. State fully how accident occurred 5. Sex male 6. Age 75 7. Married yes Citing Planks , blank 8. Give name of machine or appliance involved sliffed Injured 9. Indicate kind of work done on this machine Minshed z fungr pilmy planks 2. Exact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury middle famous mygets hand 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 ? m street and tankhouse number Hel 17. If the wages were fixed by the hour, state RATE per hour 13. yes Was medical attention necessary ? 40c 14. Name and address of attending physician Arlowly 18. Give number of HOURS in ordinary day 11h. 6 15. If sent to hospital, state name and location 19. Give number of DAYS in ordinary working week 20. State the amount of weekly WAGES 26,40 Date of preparing this blank. 1235 18 19 Made out by # Fill in names and date on FORM "D" before detaching. If employee has resumed work at time of reporting, do not detach.