Accident report, February 18, 1919

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. Number RADIUMOLUMINOUS MATERIAL CORP 2 of John Prunier Month (Name of Employer) 166 Alden Street, 18 Day of 48 Month (Street Address) Orange, New Jersey 1919 West Orangerect New Jersey Year Chemical Pi&nt Town) 3 XXX (City or Town) Helper American P. M. (Business) Hour 3. (Occupation) 4. (Nationality) Date report received Leave this line blank male 48 Yes 1. State fully how accident occurred 5. Sex 6. Age 7. Married lifting terra cotta tanks - - and 8. Give name of machine or appliance involved tank slipped and bruised hand 9. Indicate kind of work done on this machine 2. Exact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury right hand second finger 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 yard street and number yes 17. If the wages were fixed by the hour, state RATE per hour 13. Was medical attention necessary ? 55 per hour 11 Dr Dowling 18. Give number of HOURS in ordinary day 14. Name and address of attending physician 19. Give number of DAYS in ordinary working week 6 15. If sent to hospital, state name and location Orange, New Jersey 36.30 20. State the amount of weekly WAGES 2/21/19 Victor Roth Date of preparing this blank 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.