Accident report, December 15, 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 Rad. been mat Corp 12 Month of Number James (Namp Iniured Employee) Roosey # 16balden street (Name of Employer), 15 Day Month of 125 (Street Address) aug. orange new Tovn) Jevery (Street Address) 18 Year West n.f. Watching orange chemical or Plant (City or Town) 3:30 P. M. Carpenter american (Business) Hour 3. (Occupation) 4. (Nationality) Date report received Leave this line blank 1. State fully how accident occurred throking 5. Sex 6. Age 35 7. Married yes ow tank & free of and 8. Give name of machine or appliance involved feel on foot all mentioning 9. Indicate kind of work done on this machine X 2. Exact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury Smarked the toes of left fort 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 number company's plant 17. If the wages were fixed by the hour, state RATE per hour 13. Was medical attention necessary ? was socents 18. Give number of HOURS in ordinary day 11 14. Name and address of attendir; Legan 15. If sent to hospital, state name and location X 19. week Give number of DAYS in ordinary working 6 20. State the amount of weekly WAGES 32.00 Date of preparing this blank 12/19/18 19 18 Made out by no Fill in names and date on FORM "D" before detaching. If employee has resumed work at time of reporting, do not detach. OK NV