Document K6e38akEwpNbvz0o3jkKN4ZK2

HOAGIffND LONGO MORAN. DUNST & DOUKflS, LLP ATTORNEYS at LAW 40 Paterson Street New Brunswick, NJ 08901 Tel: (732) 545-4717 Fax: (732) 545-4579 www.hoaglandlongo.com Nora J. Grimbergen Partner Environmental/Toxic Tort Department ngrimbergen@hoaglandlongo.com March 30, 2015 PLAINTIFF'S EXHIBIT W CD-248 Leah Kagan, Esq. Levy Knigsberg, LLP 800 Third Avenue, 11th Floor New York, NY 10022 Re: Gilvin, Janet vs. Whittaker Clark & Daniels Our File No.: 6120330 -N JG Docket No.: MID-L-6187-14 Dear Ms. Kagan: Pursuant to the Court's order of March 25, 2015, enclosed please find the Workers' Compensation records with the Social Security number only redacted. Very truly yours, /s/N oraJ. Grimbergen NJG:sf Enclosures NORA J. GRIMBERGEN K NJ New York, NY Buffalo, NY - Philadelphia, PA Clinton, NJ Wall, NJ Hammonton, NJ -Ofi- 3B0 DeoanmeM, a f L ab o r swi Indt&wy rVlgJftK OF WRK.BSS' COMPfiNSATION ca m lwswsL rte> jfenw se BMyLOEE'S C U I M PETTnoM .... AMS: ____ ....... ount <r #(.> om xm , 3 2 Uni arc.* JtST>3*y v i e ; . . ils -...... ....... .>> .v, -. ..... ...,..m.....t...m..m...c.../...e..m...n....n..m...m...s..s..k............-- vi \<^M! -MSb&Su, )' '1 'ft lowras! qttsrs, ity floor .TjJ reayifK:!A-.wCf;! {25lj (fciHMOO " vir VT**' h .W P- AME: mas?, B r f w K w a r 1 - j m s p j $ }OKty OF 3DRSS. I'-''-' 1 .il-'V-''"I.. ;..J*\ 4vrt>'' \n,r J,:;-:---- rt/Q3Q..;0i 8 GLOSE :<TDif?*i'V COMPAM ?., a . B t<45 nraarevillB, lsr Jersey 98012 . u<Mwwu~ - { : tOTK ': /' :>.?.f-mi*'!';. ]'4:: 'FFfttiif&cl..''..m'';; -.UlyuvS-v'Sv i t .m H r 1 Mury bj? s *iarMrwKtgm t a i m m tiw *w ^f p#: Wiouw'i* eeraapptoto'pi''..asrr..-'' ;; ;..tvV;..!-it;^v-:>!. ,.'= ...-./Mrj.sr! .'. &*j.t and*&&<*' A`^K?etU!feafiets', $ fls 'uilTCE.^ i" ' ^6 <t|rie/vr,ri Hrsmlitfis ta W; ' ................ ..........JJ$gP Ji . 5JKv;i i j' ..1*. s.? v " : m C K h - S g O v .U ^ X v t e l & H i S J i b s '- a A W C f t - J . .:.> sroft.-. ' - &'*>3wS' 'V-5^i'19i50nfvSrS{aRSTCw S! %r3? ^rt::z\! }*,MPO*A'.Y O i i ^ F ? f Ain jPRM,. - vW &Z&Cm vMp i 0C..V i ,,m ..........r-'-- m * SCaBi* l U>%v Ki fe*a m p m tu to n e? * ifai.- o? a y -f | liber "'=" 3 inc*/<..? 1 * i- r ji,: . a>.:?; i l ....... i t a & i l t o * . . ............,................................. . g I % ioner(P ) 5 1D.D -{5.'*;'j i; is copy of P etto p ' ' '' : ."i.-' 's.-*' 3n-JbPW hattpnw. ^is./i.-!.aattnehe^ bws , Wo cal aid < W iW A S `-i-' l'! -!l";V'd by P<f**teiic': iKirdovcP. 5-: | names and addrwm of j.1' ' '";?* f laaesh M. Kaaia M.w-, iv 5, Mua Avenue* E&st Orange. S, J. 07019 t; fesse 6. Kangone, H.0-, 196 baceraon Avenue, Hast Rutherford# H. J. fl70?3 J ind Company Physician and obhara, yet to bo determined# *H$9t mtnif' Sji* iv- . m<'. mjix T 2syys uS t (OVER) eo ffl AS m o NOIB311BO ZV5S m m i w m 16/ 11/01 **** ***'** Uipartmcm o f U b r m d ladtotty >!VlS-N OF WORKS* 1C0 MFENSATK3W CM 38! Tttfttan* Mtr JelttOK bi'LsEdiurr1WMlWfc WV - 41M</4W IS M P LtY E E c LiiM P ZH T IO N C.P.S mj.,, - M HUDSON' t HAMBt QUWYOf KSS5B2NC& -4aW ODRBSS: 326 RUCtWt Jrs> C?. K*w Jeiv;ay 8750f> 'WQoxy. VE. Y2~,i&f-*tl AgHOSESS' ^mcFk S| Joottlnl Squae, lfch f lo o ._fl23Q& |mwiML(AHC*M fa o i) 65-.840 I i r a i|. .>ft. .m *v.w u ' . ------------- -~ H B lT T A K E B O SR * iM H Ig U S . * , J QLom t oe i m o s Utm OPRSSl&fflQi; ' WS'ddifitWV.. .. JOaSSS; 1000 C ocidg S iz m z 1 !!S ?, 0, Box 1045 h n n f* M , 3* j'sryavr 07Q8~100p * j . Tarnattv lU e , Km J*-- ,... J }'68fSR`<SEI&inSfSERSSr 08012 5 tOTKgomS^SOF'WSCa^OlPlNMTION: f Ptitfone? ,?if.ng iiJtf tb* f& fU .;'i>.lcs3,cdis feaey o.v m dafent iiaingwit ef and in hcourse of ptfttoimr^ | eiBpkysigi.; c i i' "`imteit, am vm atik OderlUUftl*-?1:m.<>fHiipia*st8wdaKmdKWnts, respeettully taise; | WsAcBWh-" "r^'^^^t!8iAttS?8ilES' .. I II I!iTfriii!. "WIH..6"Tiw,ttAitgiifniir.ij.niilnoniygpij^..iihjm,^ , .............. umrmrrirrll pr6vAisa8 lit FrOK :..o pwBsai5:, wr ' ' =! ?s-ffieanta frad c-th&r.- du,& tarifa __ r. ......... ".. " . * ' jftTSCTOmOW?i;" ' ptf?'RtU8HE8'WwiRs -UV.i/.' v'jjU-iU . f f .te's;;- ! r ~ p . .;:? H T 'is n r a r n & t i r U ..1 . ' & _ J & S l ------tsw dqafea . i t e m A sai& iift* f o r f ^ r a t fia*, i n s-SVC-. .''# ,'* 0 3 8 [ W W W ^ MPS??Sst!SS j'rSMWJU.OV taSMBVmr PW C^^^^lW RM ^gNTW SABlttTY PAIO 20,00 ^tL ^Jte am . 1* Siona Jiom , 3GEfJ.il" B ^ .-2 'T i-K D rilAi/j.CTt iP 'Wt&Y; I f thfP8'bas boee np&tkni 0" \m of a s e fa in e s s al my nbor or in?!-!CTA&r. o ftar pNy4;;*J ?(?*). ospiain faHy,^,..>l!ftTMHtl\,.g'M9BiJJ.,,4fl?>j|8.,,K4'fe,.KAt!.(l4 , ........... ...... ...................... ........... U < .M H * rU * * * * * )* , v l 1 :ioaer (K 1BID MOT) s.soJteaipansation ,,t atty Informa! boarinir, ioeosycn , jti! -'..y'? ( M d pfqwteiwrti {attaehed hareM C Yn d s J Ho cal aie1 ,r' . fiOT) faraisbod by Patitloner'a employer, namr ... . sSKSj oi hysktess w 4 Wpita!*; Ramch M* Kanla, KD., 109 S., Mann. Avenue * Sast Otrange* S J* 07015 Jesse 5. Mangoaa, H .',, 196 Datet-aon Avenue, Eaat Kutfaarfoyd lf, 3 , 07073 and Company h y s ic ia n s and othwre, yat to ba dstermined. i **Vh**H**** fs'Sc, <U& t"Ha*l*;:*m*?ax.r; _3>C.`'.iia*>.. 9 . ?','<1T. a3 wvrw m . LAW OFFICES SALVATORE MARABONDO, ESQ. 26 Journal Square Jersey City# New Jersey 07306 (201) 656-8400 Attorney for Petitioner ----- ,-------------------------- : WILLIE J. MALLORY, : : Petitioner : .-vsWHITTAKER, CLARK & DANIELS, Respondent : i f : : NEW JERSEY DEPARTMENT OF LABOR & INDUSTRY DIVISION OF WORKERS* COMPENSATION Hudson County Claim Petition #91-028646, 91-028649, 91-028651, 91-028657, 91-028659, 91-028665, 91-028668 & 91-028675 INTERROGATORIES TOi RICHARD J. SAUERWEIN, ESQ. 325 Columbia Turnpike, Suite 303 P. O, Box 891 Florham Park, New Jersey 07932 Attorney for Continental Ins. co. SIR: PLEASE TAKE NOTICE that the Petitioner demands Answers, under oath, of the Respondent to the following Interrogatories within the time prescribed by the Rules of the Division of Workers* compensation. -1- l. Set forth the date on which the petitioner started working for the respondent and the date on which the petitioner last worked, or indicate if the petitioner is still employed by the respondent. 2. What was the chemical composition of the liquids, powders, gases, fumes, mists, dust and all other substances and materials which the petitioner used or was exposed to in his work or which in the course of his employment were handled by him, or which, were in any way used or processed in the vicinity in which the petitioner worked; list these substances both by common or trade name and by chemical name and composition, for the entire period that the petitioner was employed by the respondent. 3. In the area where the petitioner worked, was there any oven, or machinery which in the operation or use there generated heat? If the answer is affirmative, then specify in particular, the type of oven, machinery, and contrivance used and to what degree of temperature of heat such contrivance generated and the purpose for which they were used and the manner in which, they were used. - 2- a) Were smoke, fumes, dust or any substances emitted from the aforesaid oven, machinery or contrivance while in operation? b> Describe the type of smoke, fumes, dust or any substances emitted. c) During what period of time was the petitioner exposed to such smoke, fumes, dust or substances? 4. Describe the room or rooms in which the petitioner performed his work, during the entire period of the petitioner's employment with you. Also set forth the size of said room or rooms by length, width and height. 5. Did the room or rooms in which the petitioner worked contain any ventilating or blower systems, and if so, describe such systems in detail, indicating the location of the intakes and exhaust of such systems and the details of the capacity of such systems. 6. if natural ventilation was relied on, state the location and size of all openings. -3 - 7. State the name and address of all treating physicians who have examined and/or treated the petitioner on behalf of the respondent prior, during and since the time of his employment, and give the complete medical findings and diagnosis including all laboratory data of each such physician, and describe in detail, the nature of the treatments and dates of the treatment. I 5 8. State the interpretation made of any x-rays taken of the petitioner by any physician on behalf of the respondent, naming the particular physician in each instance, and the date of I each such x-ray and interpretation made of said x-ray. 9. State the company policy of the respondent when a treating physician has a finding and/or diagnosis indicating that there is a manifestation of some health problem. In particular, what is the company policy regarding notification to the employee of said findings? -4 - i 10. Did the respondent prior, during and subsequent to the period of the petitioner's employment cause to be made any air sampling test to determine the presence and nature of any gases, smoke, fumes, mists, elements, substances and dust in the environment in which the petitioner worked? If the answer to the foregoing is in the affirmative, give in detail the results of said tests, setting forth the dates on which they were performed and by whom made. 11. Did the respondent prior, during and subsequent to the period of the petitioner's employment become aware of any technical, scientific or industry literature or warnings regarding the health hazards and the potential health hazards of any of the substances or chemical compositions that the respondent would deal with and that the petitioner did handle or was exposed to in the course of his employment? Set forth in detail what were said warnings or notifications, by whom they were made, and what course of action respondent took regarding each. Annex copies of any such literature, notices or reports hereto. i 12. Set forth the specific work classification assigned to the petitioner during his entire period of employment with the respondent, and include the following information: a) The dates of the period covering the various classifications. b) The exact nature of the work performed in such classification and the methods of operation by which such work was performed.. 13. set forth by trade name- and chemical composition all substances and materials used in composing molds used in metal pouring. 14. Set forth by trade name and give the chemical composition of all oils, greases, parting compounds, lining compounds or dusting compounds used in lining molds and cores. DATED: March 16, 1992. SALVATORE MARABONDO Attorney for Petitioner - 6- STATE OF NEW JERSEY COUNTY OF I, the undersigned, being duly sworn upon ay oath, according to law, depose and says: 1. 1 am the in the within action. 2 . 1 have read the foregoing Interrogatories and answers thereto and they are true to the best of my knowledge. Sworn and subscribed to before me this day of , 1992. LAW OFFICES SALVATORE MARABONDO, ESQ. 26 Journal Square Jersey City, New Jersey 07306 (201) 656-8400 Attorney for Petitioner WILLIE J. MALLORY, Petitioner -vs- WHITTAKER, CLARK & DANIELS, Respondent NEW JERSEY DEPARTMENT OP LABOR & INDUSTRY DIVISION OF WORKERS COMPENSATION Hudson County Claim Petition #91-028646, 91-028649, 91-028651, 91-028657, 91-028659, 91t 028665, 91-028668 & 91-028675 INTERROGATORIES TO: STEVEN A. WEINER, ESQ. 300 Harmon Meadow Boulevard Secaucus, New Jersey 07096 Attorney for Fireman's Fund Ins. Co. ; SIR: PLEASE TAKE NOTICE that the Petitioner demands Answers, under oath, of the Respondent to the following Interrogatories within the time prescribed by the Rules of the Division of Workers' Compensation. -i'4 l; Set forth the date on which the petitioner started working for the respondent and the date on which the petitioner last worked, or indicate if the petitioner is still employed by the respondent- ! j 2. What was the chemical composition of the liquids, [ powders, gases, fumes, mists, dust and all other substances and l materials which the petitioner used or was exposed to in his work or which in the course of his employment were handled by him, or which, were in any way used or processed in the vicinity in which the petitioner worked; list these substances both by common or trade name and by chemical name and composition, for the entire period that the petitioner was employed by the respondent. 3, In the area where the petitioner worked, was there any oven, or machinery which in the operation or use there generated heat? If the answer is affirmative, then specify in particular, the type of oven, machinery, and contrivance used and to what degree of temperature of heat such contrivance generated and the purpose for which they were used and the manner in which they were used. )! -2 a) Were smoke, fumes, dust or any substances emitted from the aforesaid oven, machinery or contrivance while in operation? b) Describe the type of smoke, fumes, dust or any substances emitted. c) During what period of time was the petitioner exposed to such smoke, fumes, dust or substances? 4. Describe the room or rooms in which the petitioner performed his work, during the entire period of the petitioner's employment with you. Also set forth the size of said room or rooms by length, width and height. 5. Did the room or rooms in which the petitioner worked contain any ventilating or blower systems, and if so, describe such systems in detail, indicating the location of the intakes and exhaust of such systems and the details of the capacity of such systems. 6. If natural ventilation was relied on, state the location and size of all openings. 3 7, State the name and address of all treating physicians who have examined and/or treated the petitioner on behalf of the respondent prior, during and since the time of his employment, and give the complete medical findings and diagnosis including all laboratory data of each such physician, and describe in detail, the nature of the treatments and dates of the treatment. 8. State the interpretation made of any x-rays taken of the petitioner by any physician on behalf of the respondent, naming the particular physician in each instance, and the date of each such x-ray and interpretation made of said x-ray. 9. State the company policy of the respondent when a treating physician has a finding and/or diagnosis indicating that there is a manifestation of some health problem. In particular, what is the company policy regarding notification to the employee of said findings? -4 - I 10. Did the respondent prior, during and subsequent to the period of the petitioner's employment cause to be made any air sampling test to determine the presence and nature of any gases, smoke, fumes, mists, elements, substances and dust in the environment in which the petitioner worked? If the answer to the foregoing is in the affirmative, give in detail the results of said tests, setting forth the dates on which they were performed and by whom made. i 11. Did the respondent prior, during and subsequent to the period.of the petitioner's employment become aware of any technical, scientific or industry literature or warnings regarding the health hazards and the potential health hazards of any of the substances or chemical compositions that the respondent would deal with and that the petitioner did handle or was exposed to in the course of his employment? Set forth in detail what were said warnings or notifications, by whom they were made, and what course of action respondent took regarding each. Annex copies of any such literature, notices or reports hereto. 5- ii v 12. Set forth the specific work classification assigned to the petitioner during his entire period of employment with the respondent, and include the following information; a) The dates of the period covering the various classifications. b) The exact nature of the work performed in such classification and the methods of operation by which such work was performed. 13. Set forth by trade name and chemical composition all substances and materials used in composing molds used in metal pouring. 14. Set forth by trade name and give the chemical composition of all oils, greases, parting compounds, lining compounds or dusting compounds used in lining molds and cores. DATED: March 16, 1992. /SALVATORI MARABONDO Attorney for Petitioner 6- STATE OF NEW JE R S E Y : * ss COUNTY OF ESSEX : I, the undersigned, being duly sworn upon my oath, according to law, depose and says: 1. I am the in the within action. 2 . 1 have read the foregoing Interrogatories and answers thereto and they are true to the best of my knowledge. Sworn and subscribed to before me this day of , 1992. -7 - ?V. iila *i8 k ry &:;> tfaktfi Street 4st Or'ftss^m* NJ wT'Vj?) Setkptyfr 2-% Qi'ffi S#*r Mr, ialory: c t f t s e d a k a t e f i e # c o p i e s - $ f t*>* *tiw j r s i - y HaaaritiM. B a t e r f a k Fact St^ets" forj QesHpHw i CfiS S w & e r C s k tiw Bydroxtd* Csletw o xide Clrfeso Bl-iXk hrm ii/& Oxide Iroo fe id e ^ s w s i Ojdif $11 ic a * T H a e H Tak Titaiw fi o k x k o m e O&He SI l e s , *r*;r rm - v - i D 0S-7& .S 1,332*8^*4 u oa-ts-!? n m -v -i nm -m -4 l 7-85-9 143Q7-6** 134S3-7-? 3314-13*? l4 8 0 8 - G -7 m &rp. 4 h D el}*ifiif jjyrsuaot to your rg ^u est nder th e "iH^ht to Kiww Aci* croies af cur "Hat*tal Safety teta Sfciets* for taterUH f o r h>Mcfi as f a c t s h e e ts w f e aval ta b le f r m tb e S ta te : C0HHted.,.. Ar. trilli."3$?; $?^sif *t s**y>. V} r*7iV?: !?<*.* Qtacr ip tim H i M Q m rtz Cnits S1f<te Ga-Ha# H c SifiisCa<?;1fr- Selfcpiws Sulfile CSS iur*hf .Mr,.. *< 73!-f^ l?0S-r;3- 12SHM.3- 3.244?-.??-? ff w? car * o# feirlftar sHtwtc, Iw contact us Very truly yfujf*, KitiMtfn, ,*jrk * ewias, tee. FHfi/ep Erclosar F. fetsnole 8aft&r - TtcMcal Services 3 bc: Wr. G.<. Blppod I5 Wr. H.C, Argyelan 'I S| 31 ft m i P N5 t ? a ? 3 B JSECWi f'ORCERTfiF!B>MAIL NO WOTtiHIE UGYSU-&fW./ICF> iww*m b m o m .-iv (Si.v Hr.-wrflc} Return Receipt shcwKig to whom. Oates and Address o i Daltoery TOTAL Postage and Fees Postmark or Dato -rrf !V*j,f' i v." 1 : I UNITED STATES POSTAL SERVICE OFFICIAL BUSINESS SENDER INSTRUCTIONS Prlrcyour namt, addma ami ZIP Coda In tbs spec below. Cemplats Itama 1.2,3, and 4 on the rauama. Attach to front of Milcl* If spaca ' pamalta, othanefca affix to back of artfete. Endorse artiste "Return Raoolpt Ruquaatad" adjacent to number. PENALTY FOR PRIVATE USE, 300 RETURN TO Print Sumter's name, addroas, and ZIP Coda in the apace below. A Y < x W s ..L y .C ,\ Q,cV> e\^ A.QQ>. SvVrp #V V\cUc$\tN& | VTA tnp&o i x i- t G A R Y P. NIKOUS. M.D. MEDICAL DIRECTOR PARK PLAZA RADIO LOG Y PARK PROFESSIONAL PLAZA SUITE -- LLB 2509 PARK AVENUE SOUTH PLAINFIELD, NEW JERSEY 07060 (90S) 753-2223 O c to b e r 7, 1892 Yog-1 Baksh, M.D. 101 Sampton Ave. South Platniield, MJ 07060 i EBt Willie Mallory Date of Exam:. 9/16/92 Examination: Chest Dear Dr. Bakshi, ; PA and lateral views of the chest dated 9/16/91 were submitted for S review. \ The soft tissue and bony structures are within normal limits. The | lung fields bilaterally show diffuse increased interstitial I markings. There appears to be pleural thickening involving the right hemi-dlaphragm. Fibrcitic changes are appreciated in the right apex. The hilar regions are prominent. The cardiac silhouette is normal. Comparison with prior chest film shows no significant interval change. Interstitial fibrosis which may be secondary to pneumoconiosis. Clinical correlation is recommended. Impression: Chest; Diffuse interstitial changes in both lung fields. These changes are chronic and there is no significant interval change when compared with a prior chest films. These findings may be consistent with pneumoconiosis. Very truly yours, tftNKK''Yv['`-H ;W-VKWWWtW- \fuu iUtffk:i iW'^nu 'H^ajiijUAiM' GPM/lkl Gary P. Mi kalis, M.D. iams JOH N F. SCALER, M. D. 10? SAMPTON AVENUE SO, PLA IN FIELD , N. J. EMPLOYMENT EXAMINATION RECORD n o -H o -v , Address _J i :/ 1, Height :A x l 2. Weight / *7 L - -* -v x ' x - 3* Blood Pressure 4. P ulse ^ 6. V ision without glasses 7. Vision with g lasses 8. Color .1..- j' R --1 . 4 / . . . . . L - 1 4 / ____ R - 2 0 / . ' 2 i L - 20/ . - 4 :-, R --1 4 /......... L - 1 4 / ........... R - 2 0 / , . . . i L - 2 Q / - . i . 9. Depth KEY: N o m ai [vj 10. A ppearance 11. Skin 12. E yes 13- E ars/D ru m s 14. Nose 15. T hroat 16. T eeth /G u m s 17. Neck 18. C h e s t/B r e a s ts 19. H eart 20. Lungs Abnormal [x] Not Examined Q 21. Abdomen/Scars G 3 22. Hernias CD 23. Inguinal Rings CD 24 Ext. Genitalia CD 25. Anus 26. Rectum / Prostate 27. Extremities 0 28. Back 29. Reflexes t 30. Blood C3.' 31. Urine Q CD, 0 t t a ED 0 ET Age iw, Cps. Right Sex / 'h 250 Employer M. S, W, D. ' ' *\ *<** ' ' '^ *. I ^ ----* f 5. Heating L evels (D ecibels! 500 1000 2000 4000 Left (U se this sp ace to d escrib e a ll d efec ts) 1. I / r'ii -. Approved & R estrictio n s: FORM S-12856 Not Approved 1 [ Limited 3 3 6 D ate Examined 19.___ JO H N F . S C A L E R , M . D . Examiner '.h>. KgjjjS**** JOHN F . SCA t. ERA, M. D. 101 SAMPTON AVENUE ' SO. P^iI.NJFlBLp. N; JiVf EMPLOYMENT EXAMINATION RECORD .',rA;4*Qi,/Vf}V,V,,!*\"*'*`'\'V.'*>*-A`\%,f vV,`L?:';<'**j iy.^ . ^X- ~ST*SFif-i KEY: Notmal 0 10. Appeacaoce H . Skin 12. Eyes 13. Edfs/Dtum* 14. Nose 15. Throat 16. Teeth/ Guns 17. Neck 18. C h est/B reasts 19. Heart 20. Lungs Ep Abdomea/Scars C3 Hernias C3 Inguinal Rings c: Sat. Genitalia n Anus H Rectum/ Pros este m Extremities Oi Back Reflexes Blood. Usine Approved Q Restrictions: FORM S -12056 Not Approved [~~] Limited I I (Use this space to itesccibe ali defects) Patient advised under treatment by PMD . 1 ? ? 9 JOHN F . SCALER, M. D. Date Examined Examiner OCCUPATIONAL HISTORY L ist ail employers for whom applicant worked for Ac last three years PAST MEDICAL HISTORY (Record nature and dates of a ll Injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS chest x-ray (PA&LAT) not done at pt's request Date of last immunisation SamUpox . ' i'X Z Z ii'............. None ' Tetanus . / . X A .................None a I certify that I have not received Workman's Compensation, pension or damages fdt any in jury or disease except as follows: I further, certify that I have received a physical examination (including an audiometric examination), and have been informed of the results of such examination, and that my occu pational and medical histories, as recorded above, are true and complete. Witness Applicant 9 - /7 -*20 Date Indicate scats and disfigurements JO H N F . S C A L E R , M. D. '101 SAMPTQN A V EN UEl ; SO.- P L A IN F IE L D , N . 4. ; " ' / . '. p :~ \ EMPLQYMr gXAMINAT1N RECORD : .i. - i i i t ------ -------- , I , . . . . , ,-- . . . . . . I. Height i<J- &t~s*7'< s ^ a 2. W eight 3- Blood Ptessure 4. Pulse /2> ' 'V eo a 6. Vision without glasses 7. Vision with glasses *8v ccioi ror R-14/.53?- L-14/ fe. R- U/Skf. L- I4/.*?X* R-20/$P.- L-20/.ko. R -! 0 /....... L -2 0 /... 9. Depth ( 3 Cps. Right Left 5. Hearing Levels (Decibels) 250 300 - 1000 2000 4000 KEY: Normal Abnormal {xj Not Examined Q (Use this space to describe all. defects) 10, Appearance 1). Skin 12. Eyes 13. E ars/D rum s 14. Nose 13. Throat 16. Teeth/G um s 17. Neck 18. C h e st/B reasts 19. Heart 20. Longs Abdomen/Scars Hernias Inguinal Rings E st. Genitalia Anus Rectum/ Prostate Extremities Back Reflexes Blood Urine b S' Patient advised, under treatment by PHD Approved [ " [ Restriction ss FORM S*f2896 Noe Approved Q Limited f ""l <?~/7 9o.19 JOHN P. SCALER, M. O. Date Examined Examinee iI OCCUPATIONAL HISTORY PAST MEDICAL HISTORY RE-CHECKS & SPECIAL EXAMINATIONS J Lise a ll employers for whom applicant worked for the la s t three years (Record nature and dates of a ll injuries, operations and major illn e sse s) chest x-ray (FA&LAT) not done at pt's reques- 1* 1 s ' **.. . ^ r'-v-*' '. 4J"1tV*A*1* 1 Date of last Immunization Samllpox . . . . . . . . . . . y .. . . . . . . . None l~~I Indicate dears and disigutements a Tetanus . . . . . . . . . . . . . None I 1 1 certify th at I have not received Workman's Compensation, pension or damages fot any in jury or disease except as follows: I further certify that X have received a physical examination (including an audiometric examination ),and have been informed of the results of such examination, and that my occu pational and medical h istories, ns recorded above, ate true and complete. Witness Applicant Sitt ........................ ___________________________________________________________ I JO H N F . S C A L E R , M. D. 101 SAMPTON AVENUE SO. PLAINFIELD, N. J . . f U t i L l~ 0 Addrca s <f L L / i C - V i u T ... 2, Weight ir3.' Blood Pressure /< r. a /S6 ^A o a 6, Visloo without glasses 7. Vision with glasse a, Color j 3 " . K-M/.k L - U / k . R-14/.2: L-14/ 1 4 R-20/.B?. L--20/.XL R--2/-- . . . L --20/ 9. Depth EMPLOYMENT EXAMINATION RECORD Whittaker. Clark & Daniels Employer _. \ Age Sex M. S. W. D. * S f /V , 5 Hearing Levels (Decibels) Cps. 250 500 1000 2000 4000 Right Left KEY' Normal [g Abnormal [Y) Not Examined Q (Use this space to ttesefibe all defects) Id. Appearance 11. Skin . 12. Eyes 13> Eats/Drums 14.Nose 15. Throat 16. Teeth/Gams 17. Neck IS. Cheat/ Breasts 19. Heart 20. Lungs Abdomen/ Scars Hernias Inguinal Rings Ext. Genitalis Anus Rcctum/Prosttue Extremities Back Reflexes Blood Urine Y Patient advised under treatment by PMD Approved {^} Restrictions: FORM. $-12856 Not Approved Q Limited Q ] .199o JOHN F . SCALER, M. O. Date Examined E xam iner JOHN P. S C A L E R , M. D. 101 SAMPTON AVENUE: . SO., P L A lN FI EL.0, N . J . AddtCJS * Age Sex M, S. V. D. -- y r m F z r * TM ---------- 3 h i# $ 7 s r . 0*4 1. Height 2. Weight j 3. Blood Pleasure J* t t* $n /Z i 1r ~ A o 6. Vision without glasses 7. Vision with g la sse s 4. Pulse L% R -1 4 /.k . L -1 4 /i& .,, R -20/. . L -2 0 /J & .- R - U /M - . L -1 4 //.. R~20/.. L--20/. 9. Depth Q & Cps. Right Left /A 5. Hearing Levels (Decibels) 250 500 1000 2000 4000 KEYi Normal 0 Abnormal [r] Not Examined f~l (Use this spaceto describe all defects) 20. Appearance 11. Skin 12. Eyes 13. Ears/Drums 14. Nose 15. Throat US. Teeth/G um s 17. Neck IS. Chesc/Breasts 19. Heart 20. Lungs e f ,21, Abdomen/Scars oC A . Hernia* tzr 23. Inguinal Rings ,24. Exr. G enitalia m 1%Anus s ' ,26. R ectum /P rostate f t rn . Extremities '28. Back 29. Reflexes f a Blood 1 31. Urine ef erf cf a a a O' ezr at a 1a . wApproved Not Approved Q Limited O Restrictions: F O R M S* 1 2 8 5 6 ~ Z-S~ .29't JOHN P . SCALER, M. D. Dace Examined Examinee OCCUPATISNAL HISTORY List all employers (or whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature and daces of a ll injuries, operations end major illn esses) < RE-CHECKS c SPECIAL EXAMINATIONS Xray o chest shows increased interstitial markings of the rt, lun, field and lower left lung field sonsistent with fibrotic changes. Da ot Use imtnuEuatioa Samlipox -- www.TM.. . . . . . . . . ... None Q T etanus.................... None J I certify that I have not received Workman's Compensation, pension or damages fot any in* jury or disease except as follows: I further certify that I have received a physical examination (including an audiometric examination), and have been informed of the resu lts of such examination, and that my occu pational and medical histories, a s recorded above, a te true and complete. Witness Applicant OS a Indicate sears and disfigurements (. _ 1 K/ JK JOHN F . SCALIERA, M. D '"ll.^7...*.*\ 101 SAMPTON AVENUE , SO.. PLA IN FIELD , N . J. .S-ir.iKv iaWyLfr .. Address h* /i ___________________ Age Sex -- ar& 7 .-1 .' --- ------------------------ 3 1. Haight S // ' 2. Weight 6. Vision vrfa&oot glasses sr. . O tti* . t & , Blood Pressure 4. Pulse ___ 7. Vision with glasses it R - 1 4 / J > ] L I-- 1 4 / & .. R -2 0 /. . L -2 0 /3 * .. R -I4 /.-- L -1 4 /A f.. R --2 0 / L - 2 0 / .......... 9. Depth f~l Cps. Right Left /A 5. Heating Levels {Decibels! 250 500 1000 2000 4009 KEY! Normal g ) Abnormal fxl Not Examined [ 3 (Us this space to describe oil defects) 10. Appearance 11. Shin 12.Eyes 13. Eat/Drums 14. Nose 15. Throat 16. T eeth / Gums 17. Neck IS. Chest/Breasts 19. Heart 2D. Lunge p 'f * ,21, Abdomcn/Sears O f x t . Hernias I 4 ,21. Inguinal Rings r?T ,24. Ext, Genitalia ( 2 f ,25. Anus f / ,26. Recmm/ Prostate r e r >27. Extremities 2 L '28- Back 29. Retienes V , <$0. Blood 3 31. Otine I' a ei r a Approved Resnietioea: FORM S-1 ZB56 Not Approved Q Limited Q 2.<T lpC JOHN P . SCAL.ERA, M. D. BateExamined ' Examiner OCCUPATI0NAL HISTORY List all employer fot whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature and dates of all injuries, operations and major illnesses) RE-CHECKS St SPECIAL EXAMINATIONS Xray of chest shows increased interstitial markings of the rt. lung field and lower left lung fieldconsistent with fibrotic changes. Date of last immunization Samllpox . . . . -- . . . . . . . . . . . . . . . . None f~T Totanns . . . . . . . . . . . . . . . . . . . . . . . . Non 3 I certify that I have not receiver! Workman's Compensation, pension or damages fot any in* jury or disease except as follows: I further certify that I have received a physical examination (including an audiometric examination), and have been informed of the resu lts of such examination, and that my occu pational and medical histories, as recorded above, are true and complete. Tiroes Applicant ' 25~-0aTt9_____________ Indicate scats and disfigurements Name f l IJJ A L , ,,-s' Address JOHN F. SCALER, M. D. -J V t L, 4- / <r 101 SANJPTON AVENUE SO. PL A IN FIE L D , N . J. EMPLOYMENT EXAMINATION RECORD Age Sex . ________ ______ E m p lo y er M. S. W, D. w ^rrxr 3 -lfc f'JgtSP&jfr i. Height 2. Weight 5 /7 it* 6. V ision without g la sse s P Otiti 1 ir 3. Blood Pressure 4. Pulse ' ViL., V.. / & > ______ 7. Vision with g la sse s 8. Colot P f R -1 4 /.t?k . L -1 4 /& .. R - I 4 / A . L -1 4 /.4 /- R -20/.& & . L--20/! * .. R --20 / . ' . . . . L --2 0 / . . . 9. Depth Q KEY: Normal Abnormal [sj Not Examined Q r Cps. Right // 5 Hearing Levels (Decibels! 250 500 1000 2000 Left (U se this sp ace to d escrib e a ll d efects) | 4000 I 1 10. A ppearance 11. Skin 12. E yes 13. Ears/Drum s 14. N ose 15. T hroat 16. T e e th / Gums 17. N eck 18. C h e s t/ B reasts 19. M ean 20. Lungs / e r : . Abdomen / Scars I A f l l . Hernias ~fp fy ,23. Inguinal Rings \~pf ,24. Ext. Genitalia CZF /25. Anus VJ\ , 26. R ectum / P rostate [2L,<Z7. Extremities 2 L '28. Back P V 29. Reflexes M ' j 'So. Blood P i 31. Urine Sr a a Sr C2f x a A Approved N ot Approved Q Lim ited Q R estrictio n s: FORM S-12856 Spl SC*. ' ir.vxtr." ;'vs:>5gr 9 Date Examined id i JO H N F . S C A L E R , M, D. Examiner K E a r. 2332^10--rjr. Cj&a'^^vw'rvsraSjv:.s.fadgspes.^vS-SirifrVjr',1 'M wSVjl- ' Y W A iA'?.*%--- * OCCUPATIONAL HISTORY L is t all employers for whom applicant worked for the lasr three years PAST MEDICAL HISTORY (Record H arare and. dates of a ll injuries, operations and major illn e sse s) RE-CHECKS & SPECIAL EXAMINATIONS VT Date of la st immunization _______________________________ S am ilpox ....... ............................... .. None Tetanus -------------------------------None I certify that I have not received Workman's Compensation, pension or damages fot any in jury or d isea se except as follows: I further certify that I have received a physical examination (including an audiometrie examination), and have been informed of the results of such examination, and that my occu pational and medical h istories, as recorded above, are true aind complete. W itness Applicant __________ Date ' Indicate scars and disfigurements OCCUPATfeNAL HISTORY L ist all employee* {or -whom applicant worked for the test three years PAST MEDICAL HISTORY (Record nature and dates of alt injuries, operations and major illnesses) RE-CHECKS * SPECIAL EXAMINATIONS VI7 " * . x-r a y 'At UtrVoYCi / n o cUo-^* A )/**" + cXvsmW- j l+*hf> Date of last mmuaiistion SamUpox . . . -- -- O - * - ------ . . . . None I"1*! Tetsnaa -- None (31 1 certify that I have not received Workman's Compensation, pension or damages lor any in jury or disease except as follows: l farther .certify that l have received a physical examination (inahtding aa ituiKoBTettic esamimlllutp, and have been informed of the results of such examination, and that my occu pational and medical histories, a s recorded a&ove, are true and complete. Witness Applicant Indicate scat* and disfigurements -------- kit 'i t ** 3 ? jaBjtft*# 0 *m `v a a - i v o s ^ N H O f ~^-v'o<=i; w <? puitBB*au*a *61' a *8i Q pM|w n 9fBZI~S M N04 aao;i9{))94){ Q . pasosddy tati . Q paaoiddy < suini 'tei3* pooja -ot' S*X"fa Va `82 sapjtttMisg 'f 1siststug /mrasn y j stray *CZ !l t"a ' a TZ Jf& s*|HjaufuSui-{C_J3D ss;tna|| !' ^3 sieas/usinopqv sinn-j ,*H*! Bitaatg/tsaig)*8j >PN *t s u i n o -pt 'iswtu. f t aN >1 SBtua/araa {{ <3-n PIS T1 ssuuusddy `ot 000 0092 0001 ooi tasaofd*uAig'<g'''H ' Jja i tto sa g , j u j < o *8 0(2 do - jf/o z -T -/oz~ n trasse)* 1)1) uo;*|A `L w j y n -n , sses(f inoqj( bojsiX `9 A */ u k$ tag aSy i& r '+ ir p -j' ~ 4 2 rA ib f~ ( I , . ________ sssippv oaoDiH Hoii^iw^lHawAondwa *#**m <nMimttaiw<Mi*4*91 sm uiA w ma t siuiw ia i >n *tw `wvra~wrie *i m uap am*K Nane JOHN F . SCALBRA, M. 0 , 101 SAMFTON AVENUE SO. PLA IN FIELD , N. J . _M t i l r t o a j - , . , U Ja .LLJ *^- A ddress *1 t EM PLOYM EN T EXAMINATION RECORD O d d t> . A* W--.1---- 33&> } - tA is r & O & & as&<~ r % --- itsistkimE /?*! ft 6. V isio n without glassKegs ^ | 77.. VViilsiSionnn iwb(itUh fgclia*s"ses 6 [^*70* r - m / 4 ? U l - 1 4 / J f t . R-U/?#!r1.-14/.%?. Cpa. Righi R-JO/.jif? L-20/S&. R--2 0 / ----- L --2 0 /. W D I Left KEY; Nomati jg) Abnormal jg) Not Examined Q 10. Appearance 11. Skin 12.Eyes 13. E itt/O nuii 14. Nos# 1$,throaty 15. Teett)/Guma 17, Neck IS. Chest/Bisects 19. Keen ' 20.lungs 25*" ,21. Abdomen/Scats eS tflP*"2. Hernias BET ,23. Inguinal Rings Ipf* 24. Ext, Genitalia 23. Anus P*f, 2S. Rectem/Prostate Pn ^27. Extretolries g f *28. Back 5s0 29. Reflexes m. Blood 31. Brine _^ ii S t's X3t D P X `r<y^) 250 500 JOOO 2000 is space to desetibe all defects) O n 'bC^'-k. 4000 Appwwsd Restrictions: FORM 8 .(2 8 8 8 Not Approved Limited j~T . 19. Date Examined JOHN F . SCALER, M. D. Bxftniijier ii I) iKi SOUTH PLAINFIELD PRIMARY CARE CENTER JOHN F. SCALJERA, M.D., P.A, YOGI BAKSHI, M.D, 101 SAMPTON AVENUE SOUTH PLAINFIELD, NEW JERSEY 07080 TELEPHONE (201) 758-5207 October l, 1987 Whittaker Clark & Daniels 1000 Coolidge Street South Plainfield, N.J. 07080 ATT: John Fitzpatrick Plant Manager RE: Willie Mallory Dear Mr. Fitzpatrick: Please advise the above named patient of the following changes on his yearly x-ray examination. Chest x-ray (PA & LAT ) No acute changes. Epithelial changes becoming more prominent. Sincerely your, y John F . Scalera, M.D.,P.A. SOUTH PLAINFIELD PRIMARY CARE CEN TER JOHN F. SCALER, M.O., P.A. VOQ! BAKSHI, M.O. 101 SAMPTON AVENUE SOUTH PLAINFIELD, NEW JERSEY 07080 TELEPHONE 201) 766-5207 October i , 1987 Whittaker Clark & Daniels 1000 C oolidge S t r e e t Souch P l a in f i e l d , N.J. 07080 ATT: John F i t z p a t r i c k P l a n t Manager RE: W i l l i e M a l l o r y Dear Mr* F i t z p a t r i c k : P l e a s e a d v i s e t h e above named p a t i e n t o f the f o ll o w i n g changes on h is y e a r ly x -r a y examination. Ch est x - r a y (PA & LAT ) No a c u t e ch an g es * E p i t h e l i a l c h a n g e s becoming more p r o m i n e n t . r C e f i 'T b ^ M o SOUTH PLAINFIELD PRIMARY CARE CENTER JOHN F. SCALERA, M.D., P.A. YOGI 8AKSHI, M.D. 101 SAMPTON AVENUE SOUTH PLAINFIELD, NEWJERSEY 07080 TELEPHONE (201) 756-5207 October 1, 1987 Whittaker Clark & Daniels 000 Cooiidge Street South P l a in f i e l d , N.J. 07080 ATT: John F i t z p a t r i c k P l a n t Manager RE: W i l l i e Mall or y Dear Mr. F i t z p a t r i c k ! P l e a s e a d v i s e the above named p a t i e n t o f the f o l l o w i n g changes on h i s y e a r ly x - r a y examint ion . Chest x ~r ay (FA & EAT ) No a c u t e c h a n g e s . E p i t h e l i a l ch a ng e s becoming more prominentr i Tc M \ p poV o '/js 'J OCCUPATIONAL HISTORY L ist a ll employers for whom applicant wotted for the la s t three years PAST MEDICAL HISTORY (Record nature and dates of alt Injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS c h e s t x - r a y ( P A & LAX ) No a c u t e c h a n g e s . E p ith e lia l changes be com ing more p ro m in e n t. Date of last lwnualxatlan ' Saudlpox . . . ----- . . . -------- - None Tetanus . . . . . . . . . . . . . . . . . . . . . . . . Noae Q I certify that I have not received Workman's Compensation, pension or damages for any in* jury or disease except ns follows! > I further certify that I have received a, physical examination fineM in g air andiawetri Examination ), and have been informed of the .results Of such examination, and that my occu pational and tnedicaHiitftones, a s recorded above, are true and complete. t/ft/ Witaeaa _ ........ .................. ............................................... Applicant ;9 Date Indicate scars and disfigurements isupnaxa pu}aii3 a a *t ' `VHH-IVOS 'd NHOf 7 f>in 9S8Zk.S WWOjI uo|ia]n8)t Q pMorddyioH Q pa&oiddy (9 & 9 ja p |y aqfjagap 03 aagds gjq? asfl) ] p -stuun tun'i-at JB* favatfag Ifi pH 11BH 'SI stssa>B/>sanO.'8I n *>*S sajiimanxg P D aiBieoid/mai# P pR i|MN'II smno/ipaoi*9J isoliliTl Pa Sftfty oR M a P , nmin/sisa-fl a Bcgg|tti{A9ai P sala' c {{{ PIS 'U m J & ^ d . aansiaaddy *01 dm v OOOV 000Z ooet oof Oil (|aqp*Q) s p a a i aiisaa -j sia t o S 'A, /- *v. a *. `s `H V* *S>S p u a -TiagH-ip'Jnfrf:T iH ----------------------- iT m*Ta sda 8y "*6 /O Z -T ......../0Z --H rm -n g n>l<0 '8 aasaspt q i; bo]S{a *j> aasaait inoqtf uo|s)A *9 06/ I .M_ l, _a_m__a_s_a r_j poar- -g, ______ min "t I ><? I f f y \? y < t*js 7 P f t W*iaH -oftttr-* w trni- ssajppy N 0 3 N N0I1VNIWVX3 lN3W A01dW 3 r ' n `a n a i d N i v n d -o s h h n s a v n o x <jw vs i o i o *w `r a a n v o s 'd N H or am*n P Kme JOHN F . SCALER, M. P . 101 HAMPTON AVENUE SO. PLAINFIELD, N . J, EMPLOYMENT EXAMINATION RECORD Address.................. -- a l l o t s .... l U w -------------------------------- Age 3 I. Height /Ja e h 2. weight S 'ti" /$ 0 ir . c m * 3. Blood Pressore 4. Pulse to hl Cps. Employe Sex M. S. V. D. / /-4L iU 250 /4 f 5. Heating Levels (Decibels) 500 1000 2000 4000 R-U/.&. L-14/S f.h R - 1 4 / - L - I 4 / X R-20/.ki L-20/-?fel_ R - 2 0 / .........L --20/ 9. Depth LEV; Nonna! |g | . 10. Appearance 11. Skin 12. Eyes 15. E s t /Drum 14. Nose 15. Throat Id. Teeth/Gum 17. Meek ' 18. C h est/B reasts 1?. Heatt 20. Lungs Abnormal |g} Hot Examined Q . oaf 21. Abdomen/Scats s 22. Hetniaa n f 23. Inguinal Sings g/ 24 Ext. Genitalia t 25. Anus u 20. Rectum/Pros tate f 27* Extremities GZf 28. Back B3 29. Reflexes did 30. Blood c f 31. Urine tsf o' D D O nt Of a asr Left (Use (his space to describe all ticfecia) Approved Q Not Approved Q Restrictions: FORM S-1Z8S6 , Limited Q Date Examined JOHN F . SCALER, M. D. Examine! JO H N F . S C A L E R , M, D. 101 SA M PTO N A V E N U E SO, P L A IN F IE L D , N . J . Maine EMPLOYMENT EXAMINATION RECORD Address L4>. o . & 6 is" Mallory, Millie i. Height 2. Weight 3. Blood P ressure 4 Pulse 5 ' 9 ,! 190 /.%/ 6, Visto without glasses 7. V is io n rich g la s s e s 8. CoioTH" R~W .T$. L -U /g.% r -i/?X l - u/%L Age 55 Cps. Right _____ liCIL E m p lo y e* Sex M. S. W. D. Te a r in g M ik J 3 5. Heosiag Levels (Decibels') -, hi 250 500 1000 2000 R - 2 0 / . 3 b . L - 2 0 /.V ? ? . R --2 0 /......... L - 2 0 / _____ . Depth Q 3 Lofi 4000 KEY: Nomai Abnormal [*} Not Examined Q (u se this space to describe all defects) 10 Appearance U , Skin 12.Eyes 13> Ears/Drums 14. Nose 15. Tbroat 16. Teeth/Gwe* 17. Neck 18. C hest/B reasts 19. Heart 20Lungs sr'- Abdomen/Scats 22. Hernias tsf 23. inguinal Rings S f 24. Ext* Genitalia 25. Anus a y 26. Rectum/ Prostate a y .2 7 Extremities G3- Back a y Reflexes a y Blood i 32*Urine u sy m nr az* or m' S' Approved ' f Not Approved P I Restrictions: F O R M S-12856 United t'"' 9 / 9 / 8 6 _____ t. Date Examined JOHN F . SCALER M. O. Examiner OCCUPATIONAL HISTORY Lise all employees foe whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature anil dates of all injuries, operations and major illnesses} RE-CHECKS & SFECAL EXAMINATIONS Xray C h e st- Normal D ate o f la s t im m unization T etanus jury or disease except as follows: I further certify that i have received a physical neanuaation Unaiudiafi an midtotnewic examination}, and have been informed of the tesults of such examination, and that my occu* pationaluuid medical h isto ries,as recorded above, are true and complete. Witness Applicant 9/9/86 Date ~ Indicate scars and disfigurements 9302i-S WHOd laaiwBxa paaimern ajsn :suop5iS9H 3-3 a 'w `v a a - i v o s d n h o t -i --- 98757? J H pajimn j ] pascudidv30K PaAO,`*i V "Hft is /O ioni -oi .POO0 os i3 weH *61 2 mD sasnU ozk D H 8Z -EH ] cajifwauag 'i 1/23 aietmud/ojtu3h *9eJ5 enuy*tz a e|(n|tt9'asg' j z 3 5I figoi^isainao`SZ sa^aioH*ZZ S 3 S V S J0 /IS 9 IO '8T H*N'LV stung/ipasx '91 >soix -$j son 'H sum>Q/s 2 ! , Ag-Zl PIS T I <03 tJB3g/O0ttiopqv izLS) aanereaddy *0| paopimrg iQjvt ] leimouqv '2D t""n ask >jn n W>a0 `d " V O Z - I .........../ 0 Z ~ 8 - f i g - m - l -q70Z~li 11*18 P ,0t3 SMB8* IJJItt K s m ~* *1 safffifi|9moipiaooisja *9 OODV -------- oooz 0001 OO ou tsiaapsa)s(i3T8u|<bh ' H sdg <ii / o i i 06t stud*v arnssaij pooja '{ 1*1^T a i T O A `XioxifiK n6 >qiHn 3 c - SuT anab ? r u -s *h *as fly ssatppy Z F T v F J Z r ~ ^ t i v J J T y t f f / h? T T F TEST daooaa NOtiVNmvxa iNawioiawa solaci r -N 'c n a w N i v i d * o s a n tia A V N o x d w v s io i a -w 'W H 3 1 V O S *si N H O f OCCUPATIONAL HISTORY L ist all employers for whom applicant worked for the la s t three years PAST MEDICAL HISTORY (Record oacure and dates of a ll injuries, ' operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS Xray C h est- Normal Date a i test immunlsatioa Tetanus . . . . . . . . . . . . . . . . . . I certify1that I have not received Workman's Compensation, pension or damages for any in jury or disease except as follows: I further certify that I have received a physical examination jinoluding an nudiernettic esomitia tiiinr), and have been informed of the results of such examination, and that my occu- pationaLarid medical h isto ries, as recorded above, ate true sad complete. Witness _____ __________________ Applicant 9/9/86 rr"J. Indicate scars and disfigurements wajiBSxg a w `v a a n v o s a N H o r pattiuwrg -- 1 ------------- 9 9 7 6 T B p!in 9B821-S W a O i ienonoi59H [ ] pBAOjddy3Q& ^ PaA*<tV pn 'if a . po<na-ot j a ] saxaijaa M . M ns*a-a j m sa;i]oeaX3 '1 M M oneta /am iaag -$Z /CO sion-j -(jj wH `SI stasata/t*<0 -g J|aaH `i l s u m o / i p a a x *91 tsetIX`,1 JS y ' i t J2 a som -yi m H*>Ioa3 `*3 IrZ jm snm ifj/eregt -{j su;y teninani -z M . **a t i & *re SWS Tt >1 CB issg/uauspqv T aauamadev*0T pauiuisxg ION ED lmKM<lV B9 leaiOR :X3M ja-i qiesa `S " - / O Z - T V0-8 q ' / qz- - i - q ^ v o z - a 7^m~T jTA^m-a OOSfr oooz 0001 eoi 0 (im p o q ) ata*a-i fn|iaH ~{ ed^ - S ",<0 '8 caesstS qilA uoiaA `L aasBB|V inotut ttOJSlA *S 1. 0 2 /W f aslnd T ainesaid poaia -f (561 ~ u65 1 _____miMT '^ - x 3 raxwaisajieAaoj`uiiin's 'W W& S a2y axiiTjii 'p y -? '/jz r -- ssatppy W j j t i v f n z i ~y z g -- ' in w & dH033a H0I1YNIWVX3 lH3WA01dW3 - f 'H `a n a t a l N I V I e l 'O S a n N 3 A t f NOJLsiWVS 1 0 1 a * w *v 3 h v d s N H or C&BSSrWt'KuS.iafiffiW.te'ttw i'W*waiv ;5&3O*5fi*.ii.`aatfb: OCCUPATIONAL HISTORY Lis* all employers foe whom applicant worked tor the last three years PAST MEDICAL HISTORY Record nature and'dates of all injuries, operations and major illnesses) RE-CHECKS &SPECIAL EXAMINATIONS Xray C h e st- Normal Date of last iramuulKation Sam llpe*................... .................. .. None Tetanus ....................................Hone l certify that I have not received Workmani's Compensation, pension or damages for any iaary or disease except as follows: I further certify that I have received a physical examination fk ts lsdiog an awHseettic examination), and have been informed of the results of such examination, and thac my occu* patronaLandmedical histories^,as recorded above, are true and complete. Witness --------------- Applicant 9/9/86 Dttte Indicate scars and disfigurements jauforexg *a*w 'vasnvosr *d NHor patnurexg *$ -61'-- 9 9 7 5 7 5 " pajpan I IpjAojtfdy 9S8CI-S WtOd ;9tl0t39{SS)l T]]paAOjfWy m m m & ja m M a xs aopn *1 JS2 poeta "oe jm H '6 x n *>*8 *8* j b sapimamg -u XD 38J80J/injaay *$ x n *nuV `iZ & *situ9 ***3 *n JED siurjj j<u|n*i>i ! m !H "It $ mas/oawopqy '\z Q p3BUR83 3Off g ] |g<flJdO^V . sSnn-1 >0J u sa 'I sjsBWQ/jsato *8 *N `LX itung/nssix >91 leoojx/K asoM *VI sumi(j/eja ! , *3 TI s *n w eaddy 'OT Jf=T Qt)a '6 VO-T vor-d j^VO-T OCOf DOOZ 0001 oos ose (H ay aaq ) s;T 8tl|tsaH j m*ia sdO ;^Ai-T y f ^ y n - n d r /vt-n % y m ~* - f l 10,03 18 s a s se j* h h c o rsj^ s s s s e t* n e q t] enfSlA `9 itfT /kf (561 1.6 1 6 aind am ssaij pooig "C J<igia`z i*iaH `I y j7 T y $ S StIT.TIB ^a ** 's "W HDfT W *s a*y 0TIIIPI `^ O t I R 89ippV ...;;-- W sn m '& V ..7.... J Z 0*0033 N0UYNIWVX3 1H3WA0*WW3 stmsft r *n `c n a i s t N i w i d *os a n N S A w N o x d w v s i o i ' a *w `v a a n v o s ' a N H o r OCCUPATIONAL HISTORY L ist all employers for whom applicant worked tor the last three years PAST MEDICAL HISTORY ^Record nature and'dates of all injuries) operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS Xray C h e s t- Normal _x ! tW'^.'!S^ jb4f^T?fc*wiiI`N-**i !'*:ju.'-vSu Dai* of last immunization Tetanus . . . . . . . . . . . . . . . . . . 1 certify that I have not received Workman's Compensation, pension ot damages for any In jury or disease except as follows: I further certify that I have received a .physical examination .fjasluding an surtrometric examination), and have been Informed of the results of such examination, and that my occu- pationaKand medicaljhistories^aa recorded above, ate true and complete. .... J l Witness Applicant 9/9/86 bate " OD Indicate scars and disfigurements ranpusxg Q -w `VHSTVOS 'A NHOr paujraeig aitfl <si 997575" 9S8ZI-S W UOi rsuopopisau J 1 paron | | pSAoJddy lofj > 0 panoiddy a m .'CD zd *-S JB m M -CB *pn *te pna of ZD S 3 IJ 8 >iz ZB '(a ZD sap|tua>Wg 'Ll i m s v n s e r j/ brush "OZjZB *nuy -I JZS i|)tbso "JX3 *yc ja sSorg |uinSu[ SBtursK `ZZ a $ sreas/uataopqy '%z''as Q paoraaxgaoH 'g j jawronoy smn -or HBOH -6t S]saiQ /5*ai|o -81 *>H "'t stano/tpla `91 ao H |x :{t oBoa -M senna/asg -fit . a/g ' WS ' l l soutnaaddy "M IS 1uhok A3X coot ooo: 0001 OOf >J1 | 1 <pdaa ' .......... / oz- t -- v o z - h `o ^ v o z - i - c^ - / o z-* h $ /n -n m *iu n ,# o 051 Bd3 qX e assaj* tfl| o o rsi^ s a s s a ia inotinM u o ist^ $ 061 -u6ifi m rw 3crc.rei j^a*X0ojd'uAtg-S ' M 55 *S By mw aaoD3a NouvHiwvxa inawAoitiwa T *N `Cn3UINIV~M 'OS 3DN3AV NOAdWVS 101 8TTTFA `XaoiiBM <ttip py Y&rr'W...7 Z 'Q 'm `VM31VOS 'ri NHOT ataaN 'Si#: Name JO H N F . SC A L E R , M. D. tO l SAM PTON AVENUE SO. PL A IN F IE L D , N. J . EMPLOYMENT EXAMINATION RECORD .2 1 Address .. / / yV 2 * t r / i r r c . "Je .J ' * .< 1. Height " , f q it M a il o r " ', M il l i e t- Weight 1,. ~-.-'\is 3 'il / 4. Pulse >T 6. Vision without glasses 7. Vision with g la sse s 8. Colot Q f*Ci .-t- Ci R --1 4 /--- ,'. L - 1 4 / - - ! 2 R - 1 4 / 1 . `S- L - 1 4 / 1 / . Age ""t L`f Cps. Right vJG D Employer Sox M. S. W. D._t e a r i n g - -, ...-< V ../....g...M........-..... 5- Hearing Levels (D ecibels) , ,, 250 500 1000 2000 4000 R - 2 0 A ..b - L --20 / .V- R --2 0 /......... L --2 0 / _____ 9. Depth Q Left KEY; Norms! 10. Appearance 11. Skin 12. Eyes 13- E ars/D rum s 14. Nose 15. T hroat 16. T e e th / Gums 17. Neck /18. C hest B reasts 19. Heart 20. Lungs Abnormal Nor Examined Q S'"21. Abdomen/Scats m 22. Hernias Kf 23. Inguinal Rings tar 24. Ext. Genitalia ef 25. Anus n r 26. R ectum /Prostate s' 27. Extremities S 28. Back 29. Reflexes nn rr 30. Blood US' 31. Urine so>r / SWr G2f S' S' B2r S n T (,/_>L-stJOHL- Approved \ 2 f R estrictio n s; FORM S-12856 Not Approved [ 1 Ih- -- Limited 19. D ate Examined JO H N F . S C A L E N A , M. D. Examiner -z*"L* *I *"75r\ V"-I-*7-/^*:^??^*lL*'-*-*--") *'X&SSSs&i'v* 'd&SZl ;fegWSrf^S j r v,* .y i ,-1^5Afr .`c g g y lv .L sm .vS^tSS.t;-l-triKZiLzyjZL SSCC*."^2 OCCUPATIONAL HISTORY L is t all employers for whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature and dates o a ll injuries, operations and major illn e sse s) RE-CHECKS & SPECIAL EXAMINATIONS C l ^ y T : c Q =T; 2 Date of la s t immunization Samllpox ___________ None [ i Tetanus - ---------None Q I certify that I have not received Workman's Compensation, pension or damages for any in jury or d isease except as follows; I further certify that I have received a physical examination ^iacluding^an.-audfotnetric exa&ftar&enr), and have been informed of the results of such examination, and that my occu- pational-rand medical h istories,,as recorded above, are true and complete. /'^ ^9 j Witness Applicant 9/9/36 bate Indicate scars and disfigurements t JO H N F . S C A L E R , ivi, D , 10t SAMPTON AVENUE SO. PLAINFIELD, N. J . 'N am e Address M allory,, W illie 526 H alstead S t E. Orange 5 '9 I 1. Weight 185 3- Blood Pressure 4. False 6. Vision wiritoul glasaeA 7. Vision with glasses 8, Color Q R - U t. ! 'k - L - 1 4 / - . i n R - 14/........L --14/. EMPLOYMENT EXAMINAT]OH RECORD WOD- annual Age Se* m. s. w. a H: i.,-i ,i,| 54 M iti L i : ." i \ " 5. Hearing Levels (Decitele! Cpa. Right 25 500 1000 . 2000 4000 i R-o/.^i. L-20/.-1S1 R--20/........L --20/. 9. Depth Left , KEY: Notruai 0 Abnormal ! N Examined 0 (Use (Iris space o iiescribe ail defect) 10. Appestane: 11. Skin 12. Eyes IS* Hers/Drum 14. Noae 15. Throat 16. Teeth/Gume 17. Nook 18. Chest/Breastft 19. Heart 20. unga e f 21. Abdomen/Seer e f 22. Hernia e f 23. Inguinal Rings 24. Ext. Genitalia 4g/ 25. Anus 26. Rectum/ Prostate m 27. Extremities tsf. 28. Rack & 29. Reflexes % 30. Blood - (ST 31. Urine a 3 ' Ef rf ef ei 3 el. 4 (0 mr Approved Q Restrictions: FORM S-12656 Not Approved Q Limited [31 'hi ,19&J JOHN F. SCALER, M. 0 . Date Examined Eiamioei 3 1 OCCUPATIONAL HISTORY PAST MEDICAL HISTORY RE-CHECKS St SPECIAL EXAMINATIONS L ist all employers {or whom applicant ' (Record nature and dates of all injuries, worked for the last three years operations and major illnesses) Cheat x-ray (PA&LA3?) -,* <i :yt J "r'l* 5 1 1 1 Date of last Immunization Samllpox ......... Hone Q Tetanus . . . . - / . h i - --/ ------------None Q I certify that I have not received Workman's Compensation, pension ot damages for any in jury or disease except as follows: Indicate scars and disfigurements I further certify that 1 have received a physical examination (including -an and!metric examination), and have been informed of the results of such examination, and that my occu- Date J JO H N P . S C A U S R A , M. O. 101 SAM PTON A V E N U E SO. PL .A IN F IE U D , N . J . ' Nam e Address Mallory Willie 326 H a l s t e a d St E. O r a n g e 1. Height inajE 3- Blood Rressore 5 `9 " 185 31h e L?. 6, Vision without lasses 7. Vision wirb glasses 8> Color f ^ ' R--uz.H'.l- L - n / . j h R --1 4 /..........L - 1 4 / - EMPL0YM|^ EXAMINATION RECORD - annual Ags 54 Cpa. Right Sex M. 5. W. D. {"i t 's t V , M ,J U - L P S* Hearing Levels (Decibels) 250 500 1000 . 2000 R - 2 0 / .,V i . L - 2 0 Ak L T H ~ 2 0 /.........L --2/- 9. Depth U lt / i- 4000 KEY: Normal g j Abnormal 0 Hot Examined P I {Use tills space to describe all defects) 10. Appearance. 11. Skis 12. E yes 13* Ear*/Prom s i4. Note 15. Throat 10. Teeth/G um s IT. N eik IB. C h e s t/ Breasts 19, Heart 1 ! 20. Lungs * t 2! Abdomen/Scars t 22 Hernias G f 23* Inguinal Rings t 24. Ext. Genitalia t . 25. Anus 4 26. Rectum/Prostate m 27. Extremities t . 28. Back 0 29* Reflexes iss. 30. Blood t 31. Urine m s O ' t t t t t . t m M Approved [ 3 Restrictions: P O M S-1 28S6 Hot Approved [ 3 Limited 3 J h i. C r. 19i* JO H N F . SC A L E R , M. O. Date Examined Examiner OCCUPATIONAL HISTORY L ist all employers for whom applicant worked for the la st three years PAST MEDICAL HISTORY >(Record nature and dates of all injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS C hest x -r a y (PA&XAT) v; ../e '-y w u j -.:- .'Us'tC-Ci;-, ? c"*>** -'/,' V1'**. / -*_ ` (/ J 1 a *''f Date of last itnmunizanoo Smallpox . . . . . Telami* . . . . . . . . None ........... None Q I certify that I have not received Workman's Compensation, pension or damages lot any in jury or disease except a s follows: 1 farther certify that 1 have received a physical examination (including-an nudiemeHic examination), and have been informed of the results of such examination, and that my occu pational and medical histories, as recorded abovy, are true end complete. ___:_______ v . L i flNtness i i i ___ v / k ...' -- * ' " Applicant Indicate scats and disfigurements (6 > i Kj Nsime Address JOHN F. SCAUERA, M. D. 01 SMPTON AVENUE SO. PL.A1NFIEUD, N. J. 7 1 o :c y , v i l lift f t i 3 t j i 0 , T '3X C p EMPLOYMENT EXAMINATION RECORD '/CIO- ftnriL? 1 Age ! Sex t-'A n Employer M. S. W. D. i" 5 1. Height 1.- tn--f! ! 2, height 6. V ision without glasses 3. Blood Pressure 7, yision with g la sse s 4. Pulse 8. Color t ! R - 1 4 / - . J - . L --1 4 /___ J R --1 4 /......... L - 1 4 /. Cps. Right 5. Hearing L evels (Decibels) 250 500 1000 2000 4000 L --20/.'.'- R - 2 0 /___ _ L --2 0 /. 9. Depth ( i ] Left KEY: Normal g ] - Abnormal Not Examined Q fUse this space to describe all defects! 10. Appearance 11. Skin 12. E yes 13. E a rs /D ram s 14. Nosse 15. T h ro at 16. T eeth /G u m s 17. N eck 18. C h t s t / Breasts 19. H eart 20. Lungs r i 21. Abdomen/Scars CD 22- Hernias GE3 23> inguinal Rings G f 24. Ext. Genitalia r i 25. Amis r i 26. R ectum /Prostate r i 27. Extremities r i . 28. Back a 29. R eflexes c s . 30. Blood r i 31. Urine n ri. ri r i, ri ri 0" Approved [ U R estrictio n s: FORM S-12656 Sfi ' Not Approved [" | -SSri ^V sa> Limited iI j-, 19 ~--. JOHN F. SCALER, M. D. D ate Examined Examiner ;5iv. ''&sti ^tjmfiWV'r&yr..%y.--*f*e.ra't-o^l SsV'aK-S^K^-ii-. OCt.b, ,' L ist all employers for whom applicant worked for the last three years . . . U U u . . ..,,riUSTORi (Record nature and dates of all injuries, operations and major illnesses) KE-Cii;.. . . -iP ltU /O . t.\.-VMlNA i to, Chest Xray jh j iohi", Pa and Lat /9 jr * - S 9 7& Dat* of Jest icRmoDieatica Samllpox . . . ------. . . . . . . . . . . o a I certify that 1have not received Workman's Compensation, pension or damages (or any in* jury or disease except as follows: 1 further certify that I have received a physical examination (including an audiometric examination), and have been Informed of the results of such examination, and that my occu pational and medical histories, as recorded above, are true and complete, Witness -- --- i r--------------------------- Applicant 9/21/84 Date Indiente scars and disfigurements >ju>fli6axkUM2icjii/kki,t: tXXUi Lis 11 employees for whom applicant worked for the last three years .............................. ..TORI (Record nature and dates of all injuries, operations and major illnesses) fist**__ /9 f~ * - * 9 7 0 RE-aa^ HPtl.iAL iiXAMINA'lJU*. C hest Xray Pa and la t Date of last Inuaunisatioo Sam llpox........... ................................ None f~l Tetanus -- None l~*l I certify that I have not received Workman's Compensation, pension or damages for any in* jury or disease except s s follows! I further certify that I have received a physical examination (including an audiomecric examination), and have been informed of the results o f such examination, and that my occu pational and medical histories, a s recorded above, fcrs true and complete, Witness ----- i - ---- 5 Applicant 9/21/8*1 Date Indicate scats and disfigurements Jautinexg a *w`vwaivos -a Nor paoraatg also "61 tr8/US/6 f^ri j"j pmuddy wu 9B*Zt-S WHOd :suo!|r>sug m Kyvorddv (siosjap a aqtraaap ot aoeds s;m asfl) , s m GD O E3 aojrn ~xt poota *o s*i; *sz 1**8 'SZ tapiiB M P J J szsisozd /tunida^ "V ;sz GD C3 ta B C3 P G3 0 a Ufa jsujnioj 'i t 0 m sspnaj! -zz 0 a sisog^uaiuqpqv 'I? P poiniasxg jN [xj i&iuiottqy J)H "61 I )8 i3 ia /W H 3 *81 *>H `LI s u i a /0X *91 BOJqx *l\ so u `I stdSiQ /sJsg ( sadg -zi WS *11 aoueleaddy *01 G3 1m>ou :a 3 >1*1 mda "6 v o z -- i ......... / o r - / o z - *, -V 0Z - B 000 ooor 000! ( gl*<t!>a) oof 0SZ >U|ieH *S nfra -sd;> fT /H - i j f . y p n - * J Q "oT sssSBf* qjTM. noistA 'L L 1U.I ainesaid poo]g 1 ^j*/I" 8 sassfSr tnoqiiM uotsja *9 lOjott1 *11*1*11'! K Szii eSirocto *3 pBaq.sxoH a \# *s *w xaS ... a* r..,,, sswppv (I O #1 QHOD3 N0UVNIWVX3 XNlWA01tfW3 *r *n 'c n a M N iv ic i *oe grtNSAv Nojywws ini T IT O ` AtoiTBM *n 'VMmvn*. *-i *Ti-trfr dUJWtf J O H N F. SCAL.ERA, M. D. 1 0 1 S A M P T O N A V E N U E S O . P U A 1 N F 1 E U D , N . J . Name Address :&.U.cr:?v EMPLOYMENT EXAMINATION RECORD / 0 I) Age Sex Employer M. S. W. D. NO i-, ! f j" S * O i e a i i g e 1. Height J 5 t{ 1. Weighr /& 3> Blood P ressure i>!Z 7 3 6. Vision without glasses 7. Vision with g la sse s 4. Pulse 17 8, Colot O ' R - 1 4 /rjf-i L -1 4 /.'it - 7-," *? Cps. Right H 5 Hearing Levels (Decibels) 250 500 1000 2000 4000 ' R -2 0 /.J ? * ? L - 2 0 /J?5i_ R --2 0 /......... 1 . - 2 0 / . . . 9, Depth O Left KEY ! Normal 10. A ppearance 11. Skin 12. E yes 13, E ars/D ru m s 14. N ose 15. T hroat 16. T e e th / Gams 17. N eck 18. C h e st/B re a sts 19. H eart 20. Lungs Abnormal {xj Not Examined Q E3 21. Abdomen/Scars 22. Hernias Q 23. inguinal Rings 24. Ext. Genitalia a 2?. Anus 26. Rectum/ Prostate 27. Extremities a 28. Back t 29. Reflexes 30. Blood 31. Urine FL*-*%J fU E3 a a o ef (Use this space to describe ail defects) Approved [ 2 R estrictio n s; FORM 5-12356 Not Approved f~~| limited 1 j Q/2'l /cfy D ate Examined 19----- JO H N F . S C A L E R , M. D, Examiner OCCUPATIONAL HISTORY L ist all employers for whom'Bppltcant worked for the la st three years PAST MEDICAL HISTORY (Record nature and dares of all injuries, operations and major illnesses) RE-CHECKS Sc SPECIAL EXAMINATIONS cx (FA)XA?) nocma-i ciie-s}-. Date of last immunisation SSatmnlliplpoo] * ------............................................None __T__e_ta_n_u_s__ None I I I certify that I have not received Workman's Compensation, pension or damages for any in jury or disease except as follows: I further certify that I have received a physical examination (in. lulling'"an amliuwr iric -anam StlonL and have been informed of the results of such examination, and that my occuPa t*FP aijfymedical histories, as recorded abrove,-aaire true antd complete. Witness A pplicant Indicate scars and disfigurements Nane Ko"l "t/v p i? . ';h` I l i o Address 326 H a lste S t. 2 . O ran g e, K .J . 3. Blood P ressi s 'n its 1/35/g j 6, Vision without glasses 7. V..i.s..i.o.n...w..i.t.h .(.l.a..s.s..e..s. 8, Color 5 3 ^ L-14/.JT R - 1A/ M/ _ ? i $ r a o i.j ? l - 2 0 / . j3 R _ 3 0 /......... k --2 0 /........... 9. Depth Q KEV: Normal jg) Abnormal g j Not Examined MM< IX EMPLOYMENT EXAMINATION RECORD V.'CD A n n u a l _________ ;______ Employer------------------------------------ A*e Sex U. S. . D. no K ..... PSRight 250 500 1000 2000 4000 Lcfi L i ......... 10. Appearance U . Skin 12. Eyes 15 E sts/D ram s 14* Kose 15, Throat Id. Teeth/Oums 17 Neck 18. C h e st/ Breasts 19. Heatt 2d Lungs e r 21. Abdomen/ScaS xsr 22. Hernias E T 23 Inguinal Ring* e r 24. Ext. Genitalis E T 25. Anus 3r 26. Rectum *Prostate P ' 27. Extremities ja- 28, Back 29. Reflexes B * 30. Blood 0 31. Urine ts ES 0Ef er ES- & or Approved w R ssuiciiotss: FORM S-128S5 Not Approved Limited Q Gj,, , S319 JOHN F . SCALER, M. D. Date Examined Examiner RE-CKECKS & SPECIAL EXAMINATIONS CX (PA )aiA T ) no^moul chesS^- , I certify that I have not receive! Workman's Compensation, pension or damages for any in jury or disease except a s follows: I further certify that I have received a physical examination (rncUuIitrjj Ml audivmiruic Ion),and have been informed of the results of such examination, and that my occu- patiVp^l atyymedical histories, a s recorded above .^are Due and cog Witness Indicate scars and disfigureraenrts Mattie t(W A < Address ' 5 ? .S H a l s t e c S t . E . O r a n t e , J. Height 2. height 5* Blood Pressure S " lt // ? 2 . 3 3 /? 3 6 Vision without glasses 7. Vision tvith.iisisses l.J . 4. P ulse r 8. Coi R -1 4 '.. ^ L -1 4 /. 3 1 R-14 / .?: - 14/ ? R wiO LjjlO L -Z 0 /- Q R --2 0 /......... 1 . - 2 0 / ......... 9. D e p th f"~l KEV: Nonnnl 0 10. Appearance U - Skin 12. Eyes 15* Eets/Drurop 14. N*se IS. Tbtost 26. Teeth/Gums 1 ?. Neck 16 C h est/B reasts 19. Hestt 26 Lungs Abnormal 0 Not Emmined n r 21. Afcdomen/Scars 1ST. 22 Hernias ET 23. Inguinal Ring az r 24* Ext* Genitalia ET 25- Anus 26. Rectum/ Prostate t r 27. Extremities J0 - 28* Bsck t a - 29* Reflexes a - 30. Blood G3- 31. Urine er 3 et D JO er ET er or I*V EMPLOYMENT EXAMINATION RECORD '--'GO Annual Age CO Eight 5ex M. S. V. D. V i* - > ^ jd jT 5. Heariflg Levels (Decibels! / _ 230 500 1000 200 4060 Left Utee thi* space to describe 11 defects) Approved w ~ Not Appioved C l Restrictions: FORM S 't 2896 Limited Q 1 , .19' 3 JOHN F . SCALER, M. D. D ate Examined Examiner J O H N F . S C A U E R A , M . D . O SAM PTON A V EN U E SO, PL.A1NF1EL.0, N. J . Name Address = .... EMPLOYMENT EXAMINATION RECORD '.-CD Age Sex Employs M. S. W. D. . ; V ' b J I ^ l - S u O i 7. 1. Height 2. Weight ' >r m 6, Vision withouc g la sses r - u / . 3 }3 L - 14/ . . 7 R-20/-JlPL-2Q /-S& b , O i'- 3 x2 0 , - . J * j 3. Blood Pressure 4. Pulse x" 35/95 7. Vision with gla sses k & Color R~i4/3jt'Cr-14/ R--20/..... L-20/......... 9. Depth Q r:f;> J E 2 Z .____ Right Left 5- Hearing L evels (Decibels) / 250 500 1000 2000 4000 KEY: Normal g j 10. Appearance 11. Skin 12. Eyes 13. Ears/Drums 14. Nose 15. Throat 16. T eeth / Gums. 17. Neck 18. Chest/Breasts 19. Heart 20. Lungs Abnormal g ) Not Examined Q E 3 21. Abdomen/Scars 0 22. Hernias 0 " 23- Inguinal Rings 0 ' 24. Ext. Genitalia E T 25. Anus 26.E3 " Rectum/Prostate O ' 27. Extremities X3 - 28- Back B 29. Reflexes O 30. Blood S 31. Urine a E 3` S' er a a >S B ET S ' cr (Use this space to describe a ll defects) Approved JJ Restrictions; FORM S- 12856 Not Approved Q Lim ited Q Date Examined 19S 3 JOHN F . S C A L E R , M. D. Examiner V .W A". S rtw :' S5H -/} .:=Z- V ? .jK B ft // lJ* ** ^yy^^^J****** *"7 * ^s'-:-SSS^J-ZS^-JSrSr* . ** " " y*/.- i^s^' JWN ~, itr.l.L'vrt, Iti. t^. Name M allory, W illie Address 326 H alstead S t r e e t , E a st Orange 1. H ei|ht 2. Weight y s ` s " YS Z- 3. Blood P re asm e /. /u ? 6. V isio n without glasses 7. Vision w ith jls s /e s Pulse 7 c<? a Color j v f R ~ U / - i i j . L - 14/ ssriC^; R -,1 4 /^ ? . L-14/C5'ft? R - 2 0 / . ? Q L - 20/<*> R --20c., -- L - 2 0 / . . -- 9. Depth K E Y : Norms! (g Abnocffial [x} uNot Examined EMPLOYMENT EXAMINATION RECORD WOD- Annual Age 51 yCps, Riht Sex j M. S. VP. D. H e a r in g Mj r -'77' 5s Hearin* Levels {Decibels) 2S 0 500 1000 2000 i Leit (lise this space to describe ail defectsJ 20. Appearance 11. Skin 12. E yes 15. Esrs/Dtums 14. Nose IS- Throat 16. Teeth/Gums 17. Neck 18. Chest/Breasts 29. Heart 20. Lunas / > ' 21. AW om en/Scars o ' 22- Hernias m ' 23. Inguinal Rings s ' 24. Ext. Genitalia 0 25. Anus c r 26, Rectum/Prostate n y 27. Extremities n r 28. Back c y 29. Reilexe* a ' 30. Blood C 3 ' 31. Urine Q m- Q Q- O' Q O' E3 a' Approved 3 Not Approved Q lim ited Q Restrictions: FORM S-12856 1 0 /1 3 /8 2 19- Date Examined JO H N IF. S C A L E R , M. D . Examiner OCCUPAT10NAL HISTORY L ist all employers for whom applicant worked for the la s t three years PAST MEDICAL HISTORY (Record nature and dates of all injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATION cx ( Pa & Lat ) vLe-ci. p c -,-, y i cid* mTt s' waa(>t>* jtjcvW Date oi last immunjtailoit --i------.................._ . .. SaoiUpDX ................. ......................None |, _t M^ T--e-tan--us-,W--.....r.iP..,,I..vh S .. g Ow.. Sope ^Q ! certify that I have not received Workman's Compensation, pension or damages for any in jury or disease except as follows: I farther certify that l have received a physical examination (including an audiometrie examinaelogi), and bave been informed o! the results of such examination, and that my occu pational .and medical histories, as recorded above, are true and complete -- i f ' ? ( 1--- . "Witness Applicant - 4 0 / 1 5 / 8 2""*bate Indicate scars and disfigurements i Name M allory, W illie Address Age 326 H alstead S t r e e t , E a st Orange 51 1. Height 2. Weight - 3. Blood Presse 4. Pulse 3W f " /SI ' / 3 o /S .3 6 Vision without glasses 7. Vision witbjtlasAs R - H / . S ^ L- U / J R--14/ *3r2. L -W C % 4 . ' 7 & /C ps. 8. Color Q 7 Right R -2 0 /. ? 6 1 .-2 0 /4 ^3 0 R -2 0 c .. . - -- 2 0 /------ 9. Depth Left KEY; Normal 0 Abnormal I Not Examined Q EMPLOYMENT EXAMINATION RECORD WCD- Annual Sex M. S. D. H e a r in g M ht P / r 5* Mearlos Levels (Decibels) 250 500 1000 2000 1 , i 11i n 111i n i 30. Appearance 11. Skin 12. Eyes 23. Ears/Drum s 14. Nose 15. Throat id. Teeth/Gums 17. Neck 18. Chest/B reasts 19. Heart 29. Lungs / s y *21. A bdoaeo/Seare ' 22. Hernias ral 23. Inguinal Rings C 3 '' 24> Ext* Genitalia s' 25. Anus D a ' 26. Rectum/ Prostate ClK 27. Extremities O' 28. Back EK 29. Reflexes GJ' 30. Blood 3y 31. Urine Q- 13- Q a S' E3' Q. D O 131 9 r Approved Q Not Approved Q Limited Q Restrictions: FORM S~t2856 1 0 /1 5 /8 2 19- Date Examined JOHN F . SCALER, M. D. Examiner OCCUPATIONAL HISTORY L ist all employers for whom applicant worked for the la st three years PAST MEDICAL HISTORY {Record nature and dares of all injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATION OX ( p a & l a t ) wCA-i, b .-C .11-1-1, ( S | i'tCci** J Dat of last iiniuti^cativa Samllpox - a - . J . ................. None Tetanus . -2. .{RODt i l JS,. S&CL- Nun* r~1 I certify that I have not received Workman's Compensation, pension or damages for any i n - " jury or disease except a s follows: 1 furdier certify that I have received a physical examination {including an audiometrie examination), and have been informed of die results of such examination, and that my occu- panonal.and medical histories, a s recorded above, are true and complete -- ,,l . i f 4 J i __ _ ..... . witness Applicant ------3 r Q / - 1 5 / 8 a c - Indicate scars and disfigurements I \W rv ! w f / JOHN F , SCA LER , M. D 101 SAM FTO N AV EN UE SO. P L A IN F IE L D , N, J , Name EMPLOYMENT EXAMINATION RECORD Mallory, Millie viCD- Annual Employer Address Age Sex M. S. W. D. Hearing 326 Halstead Street, Bast Orange 51 M aY b V 1. Height 2. Weight 3- Blood P ressare J *, J /. . T> ` `* . . M, -- . -, / ' "'S. **.-1.2 -,.'-- .......... 6. Vision without glasses 7. Vision with g lasses 4. Pulse 8. Color R Cps. Right 5. Hearing L evels (D ecibels) 250 500 1000 2000 4000 R - H /.J '.i L -1 4 /. i-- R - 1 4 / j l i L L -lA /'A 'X i R - JO/-S-, io /^ X : R - 2 0 /. - L --2 0 /.......... 9. Depth 1 I Left ... KEY: N o m a i (y) Abnormal Not Examined g ) (U se this sp ace to describe a il d efec ts) 10. Appearance 11. Skin 12. E yes 13. E ars/D rum s 14. Nose 15. T hroat 16, T e e th / Gums 17. N eck IS. C h e st/B reasts 19. H eart 20, Lungs E K 21. Abdom en/Scats Q -1 22. Hernias G3 23. Inguinal Rings O ' ' 24. Ext. Genitalia S ' 25- Anus ny.26, R ectum /P rostate ny 27, Extremities cy 28. Back c m 29, Reflexes m] 30, Blood * 31. Urine R 3 Q- D O' O P O o o' Approved fC |` R e strictio n s: FORM S -12856 Not Approved Q Limited 10/ 15/82 in D ate Examined JOHN F . S C A L E R , M. D Examiner Name ......................................... . ... JOHN P . SCAL.ERA, M. D. 101 SAMPTON AVENUE SO. RIIa INPIEUD, N . J. w. 3K a l. Height k fffi^ r ^ a -b r jf. 2. weight 3* Blood Pressure 4< Pulse 6. Vision without glasses //0A * 7. Vision with glasses ... R -u L-M /4& R -28/.2& L -2 0 /2 & . R --1 4 /..........L - / . R --20/------ L - 20/. 9. Depth KEY: Normal 0 Abnormal [} Not Examined o 10. Appestane* 11, Skin 12. Eyes 13, Eaes/Drums U . Nose 15- Throat 10, Teeth/Gum s 17. Neck 18. C h e st/Breaste 19. Heart 20. Lub&s e f 21. Abdomen/Scats t 3 / 22. Hernias O ' 23. Inguinal Slags 34. Est. Genitalia U f 25* Anus 26. Rectum/Prostate 27. EntrentUles 28. Back I 29. Reflexes- 30. Blood t a f 31. Urine xst\ ni ' a I S" . Cpg. Right 5. Hearing Levels (Decibels) 250 500 1000 2000 4000 Lelt (Use this space to describe ali dejects) J ! _ , Approved Q Restrictions; PQHM S-t2B 56 Rot Approved PI Limited Q 9 ^y 193 7 JOHN P . SCALER, M. D. Oste Examined Examiner OCCUPATIONAL HISTORY L ist all employers lot whom applicant worked for the Inst three years PAST MEDICAL HISTORY (Record nature and dates of a ll injuries, operations and major illnesses) RE-CHECKS St SPECIAL EXAMINATIONS <2^ "7 ' . V,e *. tv. ; T' 'V Date oflast imraunlxation Smallpox---- - y . . -- . -- -- T etanus------/ . Z 3 ^ . ------ I certify that I have not received Workman's Compensation, pension i t damages for any in jury or diseuse except as follows; I further certify that 1 have received a physical examination (including an audiomettic examination), and have been informed of the results of such examination, and that my occu pational and medical histories, a s recorded above, are true and complete. Witness Applicant ...z/Z.:|Z Date .< 5 5 2 ^ Name JOHN F . SC A LER , M. D. . ,,5, ' V _j.-u. ; `.--,,....i > '>. jMvp'*.',, . " "..".V * -i . , . ' T " v 1 #* >. ^ V ' l`> 101 SAMPTON AVENUE SO. P A IN F ^ e u D , N* J* . Address 1 Height J ftisT ^ /h 0 ~ ' 2. Weight ?. Blood Pressare 4. Poise & .1 L _____ /<?/ " a I ___ 6. Visio without glosses 7. Vision Ufa glasses ? 8. Cofa R ~ 1 4 /.? X L - 14/ & R -20/.2A L -20/#?.. R - 1 4 / ......... L --1 4 /. R - 2 0 / . . . . . L --2 0 /. 9. Depth 0 KEYi Notntai |gj 10. Appearance 11. Skin 12. Eyes 15. E ars/D rum s 14. Nose 15. Thtoai 16. T e c ii/ Gums 17. Neck 18. C hest/ Breasts 19. Heatt 20. Langs Abnormal QEJ Not Examined e T 21. Abdomcn/Scars O ' 22. Hernias O ' 23. Inguinal Rings iar 24. Ext. Genitalia 3f 25, Anus u f 26. Rectum/ Prostate QU 27. Extremities Ef! 28. Back 29. Reflexes- d 30. Blood ezT J l. Urine G? Gf cf ET o a. Dl Ef Cf D OB' Age D , Cps. Right Sex M. S. W. D. / y v ' >. Resting Levels (Decibels) 20 500 1000 2000 4000 Lett (Use this space to describe all defectsi... / y Approved 0 Restrictions: FORM S-128S6 Not Approved 0 limited j 0 9 ~ '7 1937 JOHN F . SC ALENA , M. 0 , Date Examined Examiner OCCUPATI0NAL HISTORY List nil employers {or whom applicant worked {or die iast three years PAST MEDICAL HISTORY (Record nature and dates of all injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS t*U i-V 7 ' Dace a! last imcuioization T e ta n u s ----- Z S f 2 C ,, ------I certify that t have not received Workman's Compensation, pension hr damages for any in jury or d isease except as follows: 1 {archer certify that I have received a physical examination (including an andioraettic examination), and have been informed of the results of such examination, and that my occu pational and medical histories, as recorded above, are true and complete, Witness Applicant f S ? '& / bate Indicate scars and disfigurements Name Address JOHN F. SCALER, M, D. L-i--' L * L y 101 SAMPTON AVENUE SO. PLAINFIELD, N. J. EMPLOYMENT tE,X#lNATl ON RECORD ___________ ^ * Ls* Employer / ''-y 'jJ C 1. H eight f 'i '/ kJ '* 7 / . > / ' / f 2. Weight / c/ / >.- A i f s s <:~ 3. Blood P ressure 4. Pulse /jr*/*A*' / y/ SJ. 7 6. Vision without g lasses 7. Vision with g lasses 8. Color jMf R - 1 4 /. - L -1 4 / R --2 0 /. 'X X L - 2 0 / 'JX-: . R - 1 4 /......... L --1 4 /. R --2 0 /----- - L --2 0 /. 9. Depth Q Cps. S i gilt Left 5. Hearing L evels (D ecibels) 250 500 1000 2000 4000 KEY: Normal y] 10. Appearance 11. Skin 12. E yes 13. E a r s / Drums 14. N ose 15. T hroat 16. T eeth/G um s 17. Neck 18. C h e s t/B re a s ts 19. H eart 20. Lungs Abnormal Q Not Examined Q e f 21. Abdomen/Scars o ' ' 22. Hernias o r 23. Inguinal Rings G3' 24. Ext. Genitalia czf 25. Anus I2f, 26. R ectum /Prostate e f ] 27. Extremities 28. Back z i 29. Reflexes ' 30. Blood e T 31. Urine S' Hf nf C3T Q n tf ef cf a SB* ft (Use this space to describe all defects) f* ,,.-t, 7'"; X' L/ Approved f | R estrictio n s: FORM S -12856 Not Approved ! I Limited ( ! /y C/ D ate Examined 19 JOHN F. SCALER, M. D. Examiner *? m m Wj& m V?-" 17 Height -L L 0 / 2 d/hL^Teo ~ 2, Weijhr ^ L.L I t St ,, O / ? / ? , * ' c 3. Blood Pressure J 4* Puise /fc s T 6. Visin cubane jlg ss e t 7 Vision wtlf gjssses Zi: R. Color R- l4 /* f.r 1 .- I V ^ . i ' R - m V:*. L -2 4 /? ? . R - 2 0 /J te . L-20/j P.. R--20/..*. L - 2 0 /... 9. Depth K E Y i Normal g | 10. Appearance U. Skin 22. E yes 13. Ears/Drum s 14. Nose 15. Throat 16. T eeth/Com s 17. Neck 18. C hest/fijreasta 19. Heart 20. Longs Abutmal [j Not Examined n e r 21 Abdomen/Scats e f 22. Hernias c a r 23. Ingainai Rings c a r 24. Ext. Genitalia G f 25. Aatts t a r 20. Rectum/Prostate Gf 27. Bxtremtries E 28. Back E f 29. Refieres & 50. Blood Q ' 51. Urine ef ef ef ET Q tar czf tar a? crvtFfc.-*;*1iCipi * XAAi/'tf-iA'nC K R C O R D i/ c o -- Eattflinu Age Sex (JV s. D. 4^ jtft _Cl*. Right 250 500 loao 2000 4000 Left Approved I i. jR e s tr ic tio n s ! ROHM S -12856 Km Approved Q i Limited I"1 29 Dnte Examined JOHN F . SCALENA. M. D. Examiner Si - I l t i *ti esnj-lrw rrs to: whom a p p lic a n t wtrfeirt! for the la s t three y e a rs f-r.- , | (Record smmr? and Jatc? of all ; operations and major jJb,?* m C , hCiAL i'.KiiMirxATK&S { / .- - A ............. Oat? Qf last inusutii%tioz2 SanrHpox t . ' TV.......... T .^ "08a - .......................................................................................................... - J ________ ' " ' / - r - y a . j r - . . . t , , , , ( V U O C I I CMfy that I have ant received Workman's Compensation, pension /d a m a g e s 70IV V T V ' jury er disease except hb foUows: J 1 1 have rcceived a Physical examination f ................. " " forraed oi^ f fesu1" ^ *h examination, and Sit^onal and medical h isto n es, as recorded above, axe trae and complete. ------ *.. v f u- isjlnl M! li Ii 5r .*i :.v .--< i . .. . , Kaaw.;:-- JOHN F . SC ALER , M. D. 101 SAMPTON AVENUE. ; j - v . Ai *'V s V . ^ j Y '& V '^ W ^ SO. PUUNFI&L.D N. J . Address / "iTfeTgb! S ~ t~ & P a? V/ 6 . Vision without glasses jg0g- 7. Vision w ith'gjasses S . - U / f ^ h__-_l_i_/_M___. 2 4 R-14FT7;X L -1 4 /2 R - 2 0 /J te . L--20/ R--2 0 /........ L --20/. 6 eT 2L*l 9. Depth KEY: Normal 0 10. Appearance U . Skin 12. Eyes 13. Ears/Drams 14. Nose 15. Throat 1$. Teerh/ Gums 17. Neck 18. Chest/ Breasts 19. Heart 20. Lungs Abnormal [SJ Not Examined z r 21. Abdomen/Scara zr 22. Hernias c a r 23, Inguinal Kings t a r 24. Ext. Genitalia e f 23. Anns e T 26. Rectum/Prostate tzf 27 Extremities ZS 28. Back _ izr 29. Reflexes X2f 30. Blood w 31. Utlne zr Ef zf sr 0 n tar czf ta* OB' Age U Cpa. Right- nmpiovet Sex Q j) s. w. a - ff} ts ' 5 Hearing Levels (Decibels) 250 500 1000 2000 Left (Use this space to descritte a defects/ Approved Q Restrictions; FOBM 8-1260 Not Approved Q Limited j I , z I _______ 2 ? JO H N F . S C A L E R , M. Da Dace Examined Examiner 4000 OCCUPATIONAL HISTORY L ist ail employers for whom applicant worked for the last three yeats PAST MEDICAL HISTORY {Record nature and dates of a ll injuries, operations and major illnesses) RE-CHECKS SPECIAL EXAMINATIONS / J r IT i 1 Date of last iffutmiustaiiett Samlipox Tet.no None ............... None I certify that 1 have not received Workman* Compensation, pension dr damages for any in* jury ot disease except a s follows: Indicate scars and disfigurements tyM M M M ntaunl have been informed of the resalts of such examination, and that my occu pational and medical histories, a s recorded above, are true and complete. I Witness Applicant 4rl ^ 1 &w \J V. J 9 /is7 * > Date _ -Naiw; JOHN F , SC A LER A , M. O. 101 SAMPTON AV ENUS. ' SO. PL A IN PIE L D , N . J . f', f . / K S r i lA J tA a ^ k * . , . f k L L o g y " 0 ] l l \ '^' Addceaa Age 3 ^ 4 , J /H -s r e # $7~ & ^ 0 /e jf< ~ < sc 1. Height . Weight 3, Blood Pressure 4. Pulse i2. r // 6 Vision without glosses K-14/f.^C r.-14/.f^J? K -20/JI?. L.-20/J3Q!- 7. Vision w ith'glasses R-U & rfl?. L -H /i f t - 20 /........L --20/.......... 7^ 9, Depth I I j:p * . E ig h t Left i Employer Sex ( J j) S. W. 0. .....7 ........... >7 /fits ' 5. Hearing Levels (Decibels) 250 500 1000 2000 4000 KEY! Normal g ] 10. Appearance 11. Skin 12 Eyes 13, E ire/D rum s 14. Nose 15. Throat 1<S. T eeth/ Gums 17. Neck 18. C h e st/ B reasts 19. Heart 20. Luigs Abnormal [x] Hoi Examined Cj e r 21. Abdomett/Scars er 22. Hernias ni 23. Inguinal Rings e t 24. Ext. Genitalis tz 25. Anus e T 26. Recetun/Prostate IZf 27. Extremities e r 28. Back ET 29. Reflexes C2f 30. Blood C? 31. Urine f ef Ef s' o car ezr S' M Approved Q Restrictions! FORM 3-12856 Hot Approved Q Limited Q 9 - ^ - r ____ ,, 2 ? JO H N P . S C A L E R A , M, D . Date Examined Examiner OCCUPATIONAL HISTORY L ist all employees for whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature and dates of all injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS Daps at last immunization S a m U p o x ------- j. . . . . . . . . . None Tetanus . . . / S / . 5 1 certify th at I have not received Workman's Compensation, pension dr damages for any in* jury or disease except as follows: 1 further certify that I have received a physical examination (im^aM*V>sMmamlHWiMic esaMMMMmteand have been informed of the results of such examination, and that my occu* tional and medical histories, a s recorded above, are true and complete. Witness Applicant"' V zf}i> wue Indicate scars and disfigurements Address 1. Height , > 2. weight aTV/ /& & 6. Vision without glasses. $ T ~ r _ O / Z / f ' - ' G C~ . Blood Pressure 4. Puis /^ /f 7. Vision with g jam es S -I4 /.^ L -W ,^ R .-14> . L ~ I 4 /.^ L R -20/a?. I-- 20/ j? Q . R - 2 0 / . . . . . L --20/_ 9. Depth Q KEY: Noimel 2 10. Appearance 11. Skin 12. Eyes 13. Ears/Drums 14. Nose 1J. Throat 10. Teerh/Cums 17. Neck 18. Chest/B re n s 19. Heart 20. Longa Abnormal I Not Examined Q e r 21. Abdomen/Scai* e f 22. Hernias E3" 23. Inguinal Rings B f 24. Ext. Genitalia e f 25. Anos iz f 26. Rectum/Prostate tZf 27. Extremities E 28. Back e f 29. Rcllexes 2" 30. Blood C2^ 31. Urine .Ef ef ef X3S O 0 0 GT ET EMPLOYMENT examination record iX j C b ^ f.mpK*v < Age Sex CMJ S. . D. -j. /f Right /57/r 5. Heating Level* (Decibels) 250 500 1000 2000 4000 Left (Use this space to describe a ild e ic c ts) Approved Q , Restrictions: j FORM S -II8de Not Approved ! I J Limited Q 19 Date Exataiced JOHN F . 5CALERA, M. D. Cssmtuer JOHN F . SC A LER , M. . 10? SAMPTON AVENUE ,-i -' SO. PLAINFIELD, N. J. r$ L L o a y Address ^/fi-sTtrp X. Height 2, Weight IM fLLt $T~ B ^ } . Blood Pressure 4. Pulse Age 4 r //' 6. Vision without glasses 7* Vision with'glasses R-i4/.*f.1r L - u/Ai.'b R ~i4W iSL L -14/ R -2 0 /J fe . L - 20/.3CL 8 - 2 0 / ........L -2 0 / EFT8. Color J1 Righe . Depth Left Sex p a m n w ----y ~ ; - / f j / S * ' 5* He&ting Levels (Decibels) 250 500 1000 2000 4000 KEY: Nonriel g] Abnormal Q[J Not Examined Q js e t(us space to describe all defects) 10. Appearance 11. Skin 12. Eyes 13. Eats/Drums 14. Nose IS. Throat 16. Teeth/Gums 17. Neck 18 Chest/ Breasts 19. Heart 20. Lungs ET 21* Abdomen/Scars 0 22. Hernias CT 23. Inguinal Rings EST 24 Ext. Genitalia c f 25 Anas tzf 26. Rectum/Prostate m 27. Extremities z f 28. Bank.- er 29. Reflexes tar 30. Blood cr 31. Urine tzf. ef Ef er a D tzr, E2f csr a OS' Approved Q Restrictions; FORM 6-12856 Not Approved 1 I Limited | | 19 Dste Examined JOHN Po SCAI-ERA M. D. Examiner Name JO H N F . SCALER M. D . 101 SAMFTON AVENUE SO. PL A IN FIE L D , N. J. EMPLOYAjM|NT_Ej^MNATI OH RECORD Address X - L o L 3 L fd fy t ,\ T tr 1. Height ( 2. Weight M L t r 5 / z r t f ^ <c cr~ 3. Blood P ressure 4. Pulse iT V / s is " A ? /# ii. Vision without g lasses 7. Vision w itu g lasses R - l 4 / * f - ' h L - u / J r f . ' h ' R - 1 4 # ^ * > - L --1 4 / i ^ P . . R -2 0 /Jfc? ,, L - 2 0 / R --2 0 / ......... L --2 0 / ............ ? D ep th ,Cps. Right Left . Employer, . . . _________ h 5. Hearing Levels tDecibels) 25(1 500 1000 2000 4000 KEY; Normal ]v) 10. Appearance 11. Skin 12. E yes 13, E a r s / Drums 14. Nose 15. T hroat 16. T e e th / Gums 17. Neck 18. C h e st/B re a sts 19. Heart 20. Lungs Abnormal [x} Not Examined | j E 3 ` 21. Abdom en/Scars E 3 22. Hernias Q ' 23. Inguinal Rings S 3 24. Ext. G enitalia a 25. Anus a ' 26. R ectum /P rostate 0 27. Extremities e5 2S. Back 3 29. Reflexes O ' 30, Blood Lad 31. Urine a a' 3" a s' S' a BBT iTIitf t h i s s n a r e r o Approved. J Restrictions; FORM S-12856 Not Approved Limited 3 -. -sxs--isy-f s . - . - . _____ _ _ -y^gcyy-tr-psga^ ^ --- 19 JOHN F . SCALER, M. D. D ate Examined Examiner .` ''/-E * '* sB sT&'v: <xs-1 sr-'SvS^'jsa.w.rsv Name JOHN F. SCALER, ML D. lt S A M P T O N A V E N U E SO. PLAINFIELD, N. J. EXAMINATION RECORD Address 77 i. Height 2. Weight 6. V ision without g lasses 3. Blood Pressure 4. Pulse 3 7. Vision w ith g lasses 8. Colei R - 1 4 / - S 2 s- L - I 4 / L R -20/.jdV . L.-20/J5L R - 1 4 / T L C L - 1 /& L R --2 0 / _____ L --2 0 / 9. Depth jT] KEY: Normal 10. Appearance 11. Skin 12. E yes 13- E ars/D eem s 14. N ose 15, T hroat 16. T eeth /G ain s 17. Neck 18. C h e s t/B ie a s ts 19. H eart 20. Lungs Abnormal Not Examined 3 n 21. Abdomen/ Scars 22. Hernias a 23. Inguinal Rings n 24. E xt. G enitalia a. 25. Anus 0 26. R ectum /Prostate 27. Extrem ities 28. Back a' 29. Reflexes a 30. Blood 0 31. Urine ' O a a a n & Cps. Right E m ployer / V i . S > 5. Hearing Levels t'Decibelsl 250 500 : 1000 2000 4000 Left (Use this space to describe a ll defects) Approved Qjj Not Approved [ | Limited [ 3 19---- JOHN F * S C A L R A t M^D. Date Examined Exam iner 2r?iC Jora_~.t y 3^r^5c sjfe^ ^ S g S g g ^ S n Date ,? l'fe'/f Bate JO H N F . SCA LER , M. D. 101 SAMPTON A V EN U E . SO . P L A IN F IE L D , N. J , _ _ _ , "W f Z l' ' "" r 5 i 1. Height 32G t p U ^ L * i M ' ____ ITf55t Y n w w i 4* H i // /f? 3M . 5. Vision without glasse 7 Vision with classes &. Color R-14/JS- L~U/3t$L. R- U / . . L M / V -if R -2 0 /- < L - 20/ J a . R ~ 2 0 /. .,, L --20/........ 9. Depth KEY: Normal 2 Abnormal I Noe Examined f"1 10 Appearance H. Skin 12. Eyes 13- Ears/Drams 14. Nose 15 Throat 16. Teeth/Gums 17. Neck IB. Chest/Breasts 19. Heart 20. Lungs b C 21. Abdomen/Scars e T 22. Hernias e T 23. Inguinal Ring. C3 24. Ext. Genitalia E l 25. Ana* t 26. Rectum/ Prostate d 27. Extremities t 28. Back. Ef. 29. Rellenes Q 30. Blood 0 31. Urine 0 0 t 0 D Q GH ET O' li Cps. Right" Left - , M. &. W. D. | ' ,/ ! 5. Heating Levels (Decibel) 250 500 ! 1000 2000 I I 4000 Approved Q Restrictions: FORM $-12856 Not Approved I 1 Limited n J I M ir Date Examined f JOHN F . SCALER, M, O, Examiner OCCUPATIONAL HISTORY L ist nil employers lot whom applicant worked, (or die lnsc three years PAST MEDICAL HISTORY (Record nature and dates of a ll injuries, operations and major illnesses) ___ RE-CHECKS & SPECIAL EXAMINATIONS f i/ W A/ Date of last immunization ^M d ^ S T 1. .................... .*.. None ] Tetanus . . . . . . . . . . . . . . . . . . . . . . . . Mens I certify that I have not received Workman's Compensation, pension or damages lot any in jury or disease except as follows: .'V *.->* Cv Indicate scars and disfigurements eiffimfrvfttT5fflT-)| and have been informed of the results of such examination, and dint my occu pational and medical histories, as recorded above, are true and complete. Witness Applicant ' jS p h \f 9- zw *' ..Name AdlCBS JO H N K. SC A L E R A, M. D . 101 SAMPTON AVEN UE s a . P L A IN FIE L D . N . J . * * ` "j* -`* rrt nwV- ' ,'.,!;r7vi 'l**'V**.*,*< Y l^ flt' .}C' -y ` ' ' ?m m Employer Age Sex M. S. W. Insight ^ 2. Weight 3. Bffaod Pleasure 4. Puise . 9 .- 5. Hearing Levels (Decibels) // / f ? 6. Vision without glasses 7, Vision with glasses "' .........F* . . Color F f R -Z 4 /4 B * . L-4/3&- R - 1 4 /J ..f . L -1 4 /A S L " Cps, Right 2}0 100 1000 2000 4000 R-20/.j?<< L-. 20/ , 3 a . R--2 0 /... . L --2 0 /........ Depth Left KEYi Notmal g] Abnormal @ Not Examined (Use this space to describe ail defects) 10a Appearance 11. Skin 12, Eyes 13. Eats/Damps 14. Nose 15. throat IS. Teeth/Cums 17. Neck 18. Chest/ Breasts 19. Heart 20. Lungs m 21. Abdomen/Scats t 22. Hetnins t 23s Inguinal Rings 1ZJ 24. Ext. Genitalia a. 2$. Anus t 26. Rectum/ Prostate t . 27. Exttemities d 28* Back. tzj; 29. Reflexes o 30. Blood t 31. Urine t - a izr 0 ra- ar d d S3 Approved Q Restrictions: FORM S-12856 Not Approved I I Limited [ j 1M2S- Date Examined / JOHN F . SCAL.BRA, M. O. Examiner OCCUPATIONAL HISTORY L ist all employers Cur whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature and dates of ail injuries, operations and major illnesses) /lA c t-------- RE-CHECKS fit SPECIAL EXAMINATIONS d i ^ J / fC jL A < /L ^ ) C Date of last iiumnnixafioa JUwxttot"- - - - - None 3 1 certify that I have not received Workman's Compensation, pension or damages for any in jury or disease except as follows: emuMMte), and have been infotmed of the resu lts of such examination, and that my occu pational and medical histories, as recorded above, are true and complete. Witness Applicant Date Indicate scars and disfigurements 1 ^ ... ) (S ^ w Vv ~ A ylX --