Document 7vMVY74GpGzVKYVxrr9373Y6

h o me o f f ic e Bituminous Casualty Corporation Cleveland Building Rock Island, III. STATE OF ILLINOIS INDUSTRIAL COMMISSION 20S W. WACKER DRIVE, CHICAGO, ILLINOIS Occupational Dimmm# Number Report of Disablement From Occupational Disease FILL OUT COMPLETELY! Occupational disease resulting in death must bo reported immediately. All others should he reported within two weeks. Has this occupational disease resulted in death, (yes or no)?.. Mo l Ins. Co. File Number.. Employer Address Insurance and Business (1) Employer's Name: __ (2) Doing business under name of: ........ ................ ................................... .--........................ (3) Office address* Street and No.: ........ #520.Wsl5thStr*t ______ City: ........... ......................Chicago........... ........................... ............. County: __ (4) Name of compensation insurance carrier:___ B?ti*InptCsfMa ...... (5) If not insured, what arrangements have you made to cover workmen's compensation payments: Place and Time Employee (6) Business (goods produced, kind of work done, kind of trade or transportation): _________ ...__Iesd.m1nuf0ctur.ar..................... ........... JohnE>Uc(LregorLead(7) Name`of plant or place where occupational disease occurred: .. Street and No.: ...MiO...M.*....1.5.l.|l...$.t.r.t.t.......................................... Chicago Cook.............City: ........................ ............................................................. County: (8) Date of disablement:AprJ15,1960..................................................................................... 19........ (9) Date injured ceased work: ......................................................................................................................... 19........ (10) Employee's Name: Ca*.I.wlr^P.ojp? .................................. (II) Sex: ..Jto.j.e. ................. 1719 H* Sayr# Chicago......(,,.1.2,) Address: Street and No.: ............................................. City: (13) Age (as of last birthday): .AS.(14) Birth date (If under 18 yrs. of age):.............................................. (15) Number of employment certificate (if injured is under 16):........................................................................ (16) Date issued____________ (17) Piece issued (18) For what job: ................................................................... Foreman......(19) Occupation: (20) Hours per day:______ per week: ............ day* per week:......... .....lA..y0&r.S(21) How long employed> . -------- (22) Piece or Time Worker:................................... .......... (23) Wages per Hr* 8....................... -...... (24) Day Shift or Night Shift Worker: .................................. -........... (25) Average weekly wages: ........................... (26) If board, lodging, fuel or other advantages were furnished in addition to wages, give estimated value per day, week or month:..................................... Cause of Accident Marr-lsdtt) Mens(27) Single, married, widowed, divorced: How many children under 16 yrs. of age ....Dn...nd...Q.f.ff...hsd..(29) Describe clearly and definitely bow occupational disease occurred: paJa ...In..shoulders...elbows...*^ ............. nautea.t..e..d..l.n..A...M....w!th.jnetan.Lc...t^^ ________ ..yes.(30) (a) Was safety appliance or regulation provided? .....__ (b) Was it in use at time? .........................JfSS Nature and Extent of Disease pain.In._____(31) State exactly the nature of the disablement (silicosis, lead potoning, etc.) eliKtfSAndfthouljders4...iiauseAte.d..ln.jMi___________________ ...lift___(32) Wes there an amputation: Mark exact point of amputation or dismemberment on chart on reverse side of report. (38) Attending doctor or hospital name and address:........ ........... Yes..(33) Has employee returned to work:.. (35) At what occupation:....................................... .(34) When (give date): . .(36) What wage:------------ Occupational Disease Resulting in Death (37) Date of Death: ______....________________ ... (39) Name of nearest Relative of deceased: (40) Address; Street and No.: (41) Date of this report: -J6/JA/60 .(38) Length of disability before death: ........................................................... City: ----(42) Signed: ------------------------------------------- (43) Position: ...PfesJdeat-- Form OD-46