Document DdaDR7L6a1qwbJBnX3K0DQVn

~v Iib Jmninmitoallij tif Departnieat -ofIndustrial Accidents ^5DD Washirmtcn .Stxest 3DSrm,. MA . J22111 AGREEMENT FOR REDEEMINGLIABILITY13YXUMP SUM UNDER GLL- CH-152. SEC 48' RD HUMBER. 08481087 Alice L. Warren EEcC%R. S'EJ_Fo-EsepETL' eTarryavAeslesrisstaInnsturMaanncaegeErMPLOYER. Monsanto F?--.--S--A--D--D-R--E--S-S____ _________, oatontqMA5 NTOFUJMPSUM _________Wfjii -T0TALn*niJCT70*is S 3,5,3-84. QQ KETTO CLAIMANT <156.916.00 $192,500.00 tlm?PtSnSnd Travelers a 15 192CBAN33829T INSURER'S CLAIM* - One Hundred Ninety-two a- nd ...F,ive H"uulnlU-dr ria.eco.dtuun sea. -n,, o ... -> - - ,, ,,cesa (15 9--2 ,. 50. 0. ..0) 0ra.xing wtci weexiy payment! ilrerny received by ne, ,* One Hundred' Ninety-two Thousand Five Hundred no ,^^92". 500..00 er s waiver or its right under G.L. CH.152^l5to,anvx.ecQ.v.erjy.agains.t any. ---t/are received in redemption oftoe liability for ul weekly payment! now or in Ac future duewojAr-li Wo^j^Srt^iE^SfiSiXst. for all ;ky my husband John Warren . . Monsanto 1948 to 1975 inclusive onorxoout mbjca to approval cf-the-OcpBanignt ofindu-rtred Acddsna. -SZ5 /PA&s J* //Ar**Ssx) VnwiiUdw 'Bfi D* * Ap 40 Midway <ft7`4fncTian Orchard, Ma Oil 51 -,.r r 383.57 and. STRIKE OUT IF NOT APPLICABLE . serand that from Be LUMP SUM unaunr itated above, Ac antouma luted below will be deducted and paid to the foilswin; pirtiei: 84.00 James H. Tourtelotte . - . 1500 Main Street Springfield, M m Nw AcU.-- Oil 15 ^^SbSwToFWPUTE K30UfflONf llhh^y i OBt sou | V^-vitv. r "MmwKtfa<wre uAvw. 4tuj* *w i4w_r.w_b!t,g.i,.^nit:h 152 3 STRIKE OUT IF fiOT APPLICABLE ies^f5!W^ JRXbe iMWRSiJWWIWWKtt Sf35JtftKMtJer <X jek-IOK1fg{<^(lkpt'icdt KdSdnauSejividGilflSHiS&iuTeelei .'* !!**-* V--, >e 1 -yVry;4^;,. 1-* . . *4;t - -**> * * *tsf all ofAcaboveCetmetiora. including inwren1 fesa.tndother litm.l will meirgdiriittimiiiwtnf^ 15.0 , jA^l/ijjrAerunaMtanil eie and Seal settlement ct my claim and that I wiil not be able to reopen my claim or jeeic further benefit! became of this injury, 1 am rnlly ^ M' -. r./'/hu.-J ` ' EREST; o vinyl ch-lc: the.manufact er. 1974 or re to cause gioaarcoroa ymptoms whic attached. .s was denied >1 years old. receive over juage.of 48 part left jnder. 34B. 2 Worker's of'adjustment of injury t.1987, c. 573)4 " W CUilMII * jiffWflifl Alice L. Warren (O-.r) -/jHeanjiss.'!;' UCC 085816