Document KGryMje6V5xnJ3zKL2bkmED42

H OA G LAN D LONGO MOHAN, HONST A DOUTAS. U P ATTA I HI Y S I t LAW 40 Paterson Street New Brunswick, NJ 08901 Tel: (732) 545-4717 Fax: (732) 545-4579 www.tioaglandlongo.com Nora J. Grimbe'rgen Partner Environmental/Toxic Tort Department ngrinbergen@hoaglandlongo. com January 26,2015 Leah Kagan, Esq. Levy Knigsberg, LLP 800 Third Avenue, 11th Floor New York, NY 10022 Re: Gilvin, Janet vs. W h itta k e r C la rk & Daniels Our File No.: 6120330 - NJG Docket No.: MID-L-6187-14 Dear Ms. Kagan: Enclosed please find documents in response to Plaintiffs Request for Documents No. 13. Documents which are subject to the attomey/client privilege have been withheld accordingly. Very truly yours, NoraJ. rimergen /si NORA J. GR1MBERGEN NJG:ds cc: Moshe Maimon, Esq. @ Levy Knigsberg, LLP Robert E. Lytle, Esq. @ Szaferman, Lakind, Blumstein & Blader P.C. All Defense Counsel of Record PLAINTIFFS EXHIBIT WCD-24 New Brunswick, NJ New York, NY Buffalo, NY Philadelphia, PA Clinton, NJ Wall, NJ Hammonton, NJ JANET GILVIN COUNSEL LIST Ronald Hurst, Esq. Montgomery, McCracken, Walker & Rhoads, LLP 123 South Broad Street Avenue o f the Arts Philadelphia, PA 19109 John M. Leith, Esq. Mattson, Madden & Leith 33 Bleeker Street Millbum, NJ 07041 Diane F. Averell, Esq. Porzio, Bromberg & Newman, P.C. 100 Southgate Parkway PO Box 1997 Morristown, NJ 07962-1997 Anthony J. Caruso, Esq. Caruso Smith Edell Picini, P.C. 60 Route 46 East Fairfield, NJ 07004 Joseph T. Hanlon, Esq. Wilson, Elser, Moskowitz, Edelman & Dicker, LLP - Florham Park 200 Campus Drive Florham Park, NJ 07932-0668  * ) W V* JttaH tVttwrtnicm of Labi awi ladagtry JIViSIW OF WORKERS'iJOMPEHSATiQN C M ,! DtiitH, Hire Jtenay of*- JS`./-H) Hwfl.flYBt'S^UilM! PBtinoN \ L*} ? / J<vur?wU. Sfit^sre* 10th f lo o r iTF.!.,-.iiW:tv* ct! (2c i) 66-8ilAZS0j0Q^L, "wHITIv,;- KJKfY OF '..' >DR8k. >'" ------ i j^MbliKltei;r% cTam*&rflSiT^SST* --- .1w s m . 1 . ;:SC, ..,V-!v<s's r....... I *1J GLOBE XKDEICW CCMFA1W .........1 | | h ^ w w ^ S n c r d g r T 8 a -------- -- -- -- ] I i) P, 0, Box 1042 !?VT : . 0/030:.--!OOb S t f u r n e r e v U l a , Rev J e r s e y 08012 TOTHS V; Fsyfcic-f.fti; -i'.sr 8mpkFj,i.a*yo ivMj.iifiiVw. TEC"1 v '" " ' X`Vli5l s%- W: i... 5Kv'-' ..... .. iS,r- " , 1:..::< OtffKNKV ' !': 1 ffijuryir-jra# surisK'-igauxoiainth* . /'-Nft '.(CrfSci- ' .'. spppiatK*,iftfcr, and luaeadi&er r**ap.KstittlJyih.a,fcj: |`#.|itc AC opicosir* ptuulsae in :. ' 'v? , .. .. ..... ..... i*&*& 3nn .South PI >1;,.J '_. v--'--.^ivnd oi:fc-.-,r !.lulfer^oua subgCAt>>i*!*^ j "j.mii" .... ......... "|aw%P&S*'>'.vc1sk1 r sss'-> oo .. -*! -Su'vcot ialomedjsfctx.ticixar i i r fira e time In 9 jY&imRAAYBSiiUtVfJli """j>iiRMi'"''.{8K H 3Sv M)0 .J * J t e f t . . ____ ___ _____ !*. >- ___________ uber '*f : ' ' k ? r - k* tiwr has towa n p t i w m c? - -o k ;;...... .. ? s s * # ..im J a 8 s r.Y ,. ........... ......................... <rfsity St .. 5r toner(H&fit DID i | 5 ie copy if Pnitiir' ii cal aid (WAS ' i'j n. ' ;(."iatotmaf Swa?r,f. *'* (.;-. '$sttftchiid b*r?to yy irmptoy*1. i d l Yas C i l No 1 names and addrasses o:`p.1' Fd hosmui! | SamflBh K. RaniSj , 109 5* Mnnn Avenue, Eaac Orange, it, J. 07019 Z lease G. Mangona, M.O., 196 Paterson Avenue, East Rutherford, H. J, i m d Company Physicians and ofehara, yet to be determined. 07073 (OVER! r,9 c . mSCilt--43' "' O .. .t.. r- . *5 T ' WO ;4),-Vi -- l^fpartnwRt of Laber asd ladattty tViSt&N OF WORKERS' COMPENSATOR Off 38J Trcfitoa,Nr Jittsey0842S Wfcf-s#fi EMPLOY E E * S ^ S M PEOTIOM AiSWiSI 2S Journal Square, 10th floor __,{-auj^56~84go ........-- WHXTTn&fig, c:Ud!C 4 m n 2 i , ffic g J GLOBS tKBEHirrreCGKPAHY 5WTY OP RSSl&EfiCli: SliijilX&i'i ---- 1 $ isaess; 1000 Cflolidgs SrrsuiC | f f| i -'Sii YlsisfieMj IN-vt j'erssiy Q70&0~iQ0i) % i\ T O '^ .^ T aiH 'iiS isa ---..........- ~ -- ? , 0 Box 1045 Tarn&x'svills-,Sera J^rsiVv 08012 TG THE D m ,m *iOF T O iS S fiS ' C0WF12NSATI0N: Petitions?, aJkjfcg ti?Jd tb* PstJffcaw sustained as Injury by* arising out of and In the course of petitioner's employmer.; e-ir ^csVMtef?., peeeeirie under l-S. SS;lv*" ki5a,, nngptenieiitB a n d fmsa&dm eats, respectfullystates: TE OF ACCi^e'S-- From ''- : r ~ - ............ " i ; T ^ t i ^ y i A l H g R j K ? X ? M u S e : :..o presa-ftC. ' ' * J'J*"'|wi'!"?tfc &..t.. ^apioyaj-ij, pfsaj,aa8 i" H" " ... vi 'r e i t a n t e and the?.' dalafceg laaa __ |w r s sjw tbo wo: "" * " j p a n fc u x N to flp w o n t "i\ .;.Ti..lit--* L _ j . . . J. ______ 5s 7. . s'wsas lift.Ou 'iMiR^XrSfAsws'lSAu:hjukv nfertMOWntfVm K ovxambtSlw588E" fc*#5 uJSAjrsRjf* i .i&ttpXoryay'B new doatar informed petitioner for first tilt in |*A T ft< U ' W M W tE S T O W 1 fn -M P C iftA S Y O iaA B Ju V v )>AiO "" j P E S W A H S N * K is a b I u t y p a i d " i* istoiBana __ .,,,,,.1L J i s m ..-- ,*TM*, ,________ 3CEB3C E TITS riHARACTSE OJ? OJJTiEY: If th * bag been jwnpufcatkro or leas of atefalness of any nber or iwp2?rsiar,fc i f any pfcysi! fam io r. explain fully..... .......................... ... ....................... . loner <EPC !01D MOT s.k tipensaiSo at any Informal bearish copy in ?iii - .;r'?. treating phjrsteian'a port is attached hereto C 3 Tee [ 3 No cal air . NOT) fumishod by Petitioner's emplayef. nsncE -sskshof phyaieiens aad hospital Rameah l*i. Sattia,. K -D ., 109 S* Ifeian Avenue, East 0tanges if* J,, 07019 Jess G* Martgoaa. M.D,S 198 PAtsrsot). Avanu, E&at- Ut.herfojfda N, J. (7073 and Company Physicians and others* yef. to be determined. c 14*1 l ' * + i m v N t t r- *c Ze nsii-S, "i rrTM a'**1: rfc>' aTr. 4x >.** 03 *,*j'' T w.VS?r'.5tafSlU ft (OVER) f LAW OFFICES SALVATORE MARABONDO, ESQ. 26 Journal Square Jersey City, New Jersey 07306 (201) 656-8400 Attorney for Petitioner Petitioner -vs- WHITTAKER, CLARK fi DANIELS, Respondent NEW JERSEY DEPARTMENT OF LABOR & INDUSTRY DIVISION OF WORKERS' COMPENSATION Hudson County INTERROGATORIES TO: 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. 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- 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. -5 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 SS I, the undersigned, being duly sworn upon my oath, according to law, depose and says: 1 . I am the in the within action. 2. I 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 LAW OFFICES SALVATORE MARABONDO, ESQ. 26 Journal Square Jersey City, New Jersey 07306 (201) 656-8400 Attorney for Petitioner Petitioner -vs- WHITTAKER, CLARK & DANIELS, Respondent NEW JERSEY DEPARTMENT OF LABOR & INDUSTRY DIVISION OF WORKERS' COMPENSATION Hudson County 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. -1 - 1. 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 hint, 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. a) Were smoke, fumes, dust or any substances emitted from I the aforesaid oven, machinery or contrivance while in operation? I 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 - 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 I said tests, setting forth the dates on which they were performed | and by whom made. 3i i 5 | 11. Did the respondent prior, during and subsequent to the period of the petitioner's employment become aware of any 1 technical, scientific or industry literature or warnings `I regarding the health hazards and the potential health hazards of i 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 I detail what were said warnings or notifications, by whom they ! were made, and what course of action respondent took regarding I each. Annex copies of any such literature, notices or reports hereto. i - 5% fi x 4 5 c 5 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 ESSEX ss X, the undersigned, being duly sworn upon my oath, according to law, depose and says: 1. I am the in the within action. 2. I 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- i ! I Seflt<!*t>fr ;'% sso iincose-l please f iti i chiles of t*te *sew Jars?-* wasartfon Hai o rio l* fact Sb-tts** fo r; DestriBtiefi CftS te^ber CsiCiO Hydroxide Calcium Oxid Garbeo SUcfc Chromi ub> Quiete 1rot; r i do ^80ws*sm Oxid? S ilic a * Tr i so H Tate Titaolwm Si ox idt* ifc Oxide S iic a , Quarta 130$*M 1305-78-5 i.332-36-4 1309-38-9 J3W -17- 1393-49-4 1317-S-f 34307-96*$ t3f4S3*S7-7 3M -13-? 14808-60-7 We are h o e n c la ^ ^ pursuant to your reosm t imiter *hs "fti obt o Koow A ci" tocio? of our "Material Safety Seta Sheets* far s a t i n a i s for which os fact sgeH ^,re available frcw* the state: continued,, tesc rip ti * CAS iilBS&K Hint Raerte CadMara Sulfid Csrt'"iut Zc Silfidi Oarkniy Sulfid 7i3-8fi-5 I?9S-23-S I f w? can b? of fartftar s i stance, p i * contact us. Very truly yr-.urs* HTlftKH., et.K ft BWlXS, FH$/ep >cosare bc; Hr. S.J. Slppold Wr. H.C. Argyelan f. HcSooce Manager - T*cn1c*i Services P HEG b ?e 7 3 e RECfcHr?r-ofttERTIBED MAR. HOmIoKtUfHurHCriEUROfVjH'f.tKyi>rFiHAfLVtt';l=i 1.%-c?fteMropJ u n it e d s t a t e s p o s t a l s e r v ic e OFFICIAL BUSINESS SENDER INSTRUCTIONS PrtnJyour name. address and ZIP Coda In the spasa below. Complete hem* 1.2, 3, and 4 on the ravens. Attach to front of article If space permits, otherwise affla to back of article. Endorse article "Return Receipt Requested" adjacent to number. PENALTY FOR PRIVATE USE, 9300 RETURN TO & & Print Sender's name, address, and ZIP Coda in the space below. vTVVcxV n y . W U -^OkCVie\\ S o ^ V \ c U c - $ : vv\c\| V T X rrjbZn  SENDER: Complete item s 1 and 2 when additional services are desired,'and complete items 3 and 4, Put your address in the ` 'RETURN TO" Space on the reverse side, failure to do this will prevent this card from being returned to you. The return receipt fee w ill provide you the name o f the person delivered to and t he date of delivery. For additional fees the following services are available. Consult postmaster io r fees and check boxioslTcr additional service!} requested, 1. O Show to whom delivered, date, and addressee's address. 2. D Restricted D eliver/ ____________ _____ {Extracharge)^___ ____ _____________ (Extra charge) 3. rtolo Adffressgrf 4. Article Number to o 7371 Typof Service: . Q Registered Insured &ertified COD D Express Mail f l ReturnReceipt for Metchandlsi Always obtain signature of addressee or agent end DATE DELIVERED. 6. Addressee's Address (ONLY If requested and fee paid) 6. Signature -- Agent X 7 . Data of Delivi 3L PS Form 3 8 1 1 , Apr. 1989 2]J= + US.G.P.0.19S9-J36-015 & D O M E S T IC R E TU R N RECEIPT m- G A R Y P. N IK O L IS , M .D . MEDICAL DIRECTOR PARK PLAZA RADIOLOGY PARK PRO FESSIO N A L PLAZA SU ITE -- LLB 2509 PARK AVENUE S O U T H PLA IN FIELD , N E W JE R S E Y 0 7 0 8 0 (908) 753-2223 Octaber 7, 1991 Yogi Bakst i, M.D. 101 S&mpion Ave. South Plainfield, WJ 07060 Daze ox Bxam: 9/16/91 Examination: Chest Dear Dr Bak&hi, FA and lateral views of the chest dated 9/16/91 were submitted far review, The soft tissue and bony structures are within normal limits. The lung fields bilaterally show diffuse increased Interstitial markings. There appears to be pleural thickening Involving the right hemi-diaphragm. Flbrotic changes are appreciated in the right- apex. The hilar regions are prominent. The cardiac silhouette is i>ij normal. Campari son with prior chest film shows no significantinterval change. Interstitial fibrosis which may be secondary to pneumoconiosis. Clinical correlation is recommended. i i Impress!on: Chest: Diffuse interstitial changes in both lung 4 fields. These changes are chronic and there is no significant I interval change when compared, with a prior chest films. These I findings may be consistent with pneumoconiosis. 4 Very truly yours, GPN/lkl Gary F. Nikolis, M.D. Name J O H N F . S C A L E R A , NL D . SOI S A M P T O N A V E N U G I SO, P L A IN F IE L D , N. J, EMPLOYME/N-T .-*'1EX>A.MINATION RECORD ___ ... 1^ -'-________________ 2- Weiight J !.. 5 bid PiccLc 6, V isio n w ithout g la s s e s 7, V isio n w ith g la s s e s 8. C o lo r j` R - l 4 / . . . _ - L --1 .4 /......... R --20/.v i L - 20/ i . R --1 4 /........ L --1 4 /........... R - 2 0 / . . i ' . L -20/-2J. 9- D epth I I Cps, R ight Left Sex i?- i 250 M. S. W. D. r,-..- " 5 H eating L evels (D ecibels 1 500 1000 2000 4000 KEY: Normal 0 10- A p p e a ra n c e 11. Skin 12. E y es 13- E a r s / Drums 14. N ose 15. T h ro a t 16. T eeth /G u m s 17. N eck 18. C h e s t/B re a s ts 19. Heart 20. L ungs Abuor mal [x] Not Examined 21. A bdom en/ Scars 0 22. H ernias 23, Inguinal Rings Gil 24. E xt. G enitalia 0 25- Anus 0 26. R ectu m /P ro state 27. Extrem ities 28- B a ck a 29. R eflexes a 30. Blood ./ s . 31. U rine a 0 0' ED d 0 0 a git (U se this space to describe a ll d efe c ts) 1 . i, .r . . ; . , . A pproved R estrictions: FORM S~1 2 8 5 6 Not Approved | j Lim ited Q ,-~V L\ D ate Exam ined 19. J O H N F. S C A L E R , M. D. Exam iner JOHN F . S C A LE R , M. D, 101 S A M P T O N A V E N U E ^ S O .- P L A I N F I E L D , N . 4 .: " ' / ,'iv EMPLOYMENT EXAMINATION RCORD 6. Vision without glasses R -14/.S?- L - 1 4 / k . R ~20/-? _ L -20/.A C L 7. Vision with g la s se s 8. Color R-U/.^.C L-U/.*?-^ R --2 0 / ......... L --2 0 /............ ?. Depth I Cps. Right Left 250 500 1000 2000 4000 KEY; Notmal 10. A ppearance 11. Skin 12. Eyes 13.Ears/Drums 14. Nose 15. Threat 16. T eerh/G um s 17. Neck 19. C hest:/ B reasts 19.Heart 20. Lungs Abnormal [x] Not Examined Q 21.Abdomen /S c a rs 22. Hernias 23. Inguinal Rings 24. Ext. Genitalia 25.Anus 26. Rectum/ Prostate 27. Extremities 28- Back 29. Reflexes 30. Blood 31. Urine Id ID ED ID ID ID ID ID St ( Us e chis sp ace to d e s c rib a lT d efects ) Patient advised under treatment by PMD Approved [7 ] Restrictions: FORM S-12656 Not Approved Limited |~ J q -n Date Examined JOHN F. SC ALER , M. D. Examiner OCCUPATIONAL HISTORY PAST MEDICAL HISTORY RE-CH ECK S & SPE C IA L EXAMINATIONS -i L is t a ll em ployers lor whom ap p lican t w orked (or the la s t three years (Record nature and d ates of a ll in ju ries, operations and major illn e s s e s ) chest x-ray (PA&LAT) not done at pt's reques * J v . . *,v . . - Date of la s t immunization Indicate scars and disfigurem ents id. 'a.'via t-'ibsK>ciiw. Tetanus .................. .. None Q I cercify th a t I have n o t re c e iv e d Workman's C o m p en satio n , p en sio n or d am ag es fo t any in* jury or d ise a se except a s follow s: I further certify that I have receiv ed a ph y sical exam ination (including an audiom etrie exam ination), and have been inform ed of the re su lts of such exam ination, and th a t my occu* patronal an d m edical h isto rie s, a s recotded above, a te true and com plete. Witness Applicant 9- n - ^ o Dare W \f V~ I KA X --------- JO H N F . S C A L E R , M. p . 1 0 1 S A M P T O N A V E N U E S O .P L A I N F I E L D , N , J ., ' ' ,f..- EMPLOYMENT EXAMINATION RECORD .& .pa,n,3,.s-, Ad'i: 3BU1C ru is c $U /*(* 1 /a 6, Vision without glasses 7* Vision with g lasses Z 8. Color j R -1 4 /- V . L - 14/55. R -2 0 /.??. L -2 0 /.A X t R - 1 4 /.`kf. L - 1 4 / * R .. 2 0 /......... L - 2 0 /______ 9. Depth Q Cps. Rijht SH v * < r 5. Hearing L evis (Decibels) 250 500 1000 2000 Left 4000 10. Appearance 11.Skin 12. Eyes 13. E a rs / Drums 14. Nose 15. Throat 16. T e e th / Gums 17. Neck 18. C hest/JB reasts 19. Heart 20. Lungs Abdomen/ Scars Hernias Inguinal Rings Esc. Genitalia Anus Rectum/ Prostate E xtrem ities Back Reflexes Bijtl. Urine Approved Restrictions: FORM S -12856 Not Approved | J Limited | | Patient advised under treatment by PMD ? -n 9o-----19 X P J O H N F . S C A L E R , M. D . Date Examined Examiner O CC U FA TI6N A L HISTORY L ist a ll em ployers for whom applicant w orked for the la s t th ree years PA ST MEDICAL HISTORY (Record nature and dates of a ll injuries, o perations and majoc illn e s s e s ) RE-CHECKS & SPECIAL EXAMINATIONS chest x-ray (BA&LAT) not d o ne at pt's request *' *- *-- `h VY:- * , / , Date of la s t immunization Samllpox Tetanus o I certify th a t I h av e nor re c e iv e d W orkman's C om pensation, p en sio n or dam ages for any in jury or d ise a se except a s follow s: I farther certify th at I have received a physical exam ination (including an audiom em c exam ination), and have been inform ed of the re s u lts of such exam ination, and th a t my occu pational and m edical h isto rie s, a s recorded above, are true and com plete. Witness Applicant 9- f^-^o -- 0^j. = Indicate sc ars and disfigurem ents JOHN F . SCALER, 101 SAW PTGN A V EN U E SO. P L A IN F IE L D , N. J . . if EMPLOYMENT EXAMINATION RECORD KEY: Normal (V] Abnormal [x\ Not Examined Q 10, Appearance U . Skin , 12- Eyes L3, E ars/D rum s 14. Nose 15- Throat 16. T eeth/G um s 1?. Neck 15. C hest / Breasts 19. Hearr 2Q. Lungs qp Abdomen/Scars ip n Hernias ip zi Inguinal Rings c : E it. Genitalia D n zi Anus Q n Rectum/ Prostate P C] Extremities IP OE Back IP Reflexes Blood % Utine Approved ["*"] Not Approved [ | Limited Restriction si: FORM S-12856 (Use this space to describe all delects) Patient advised under treatment by PMD q~n 9o19 J O H N F . S C A L E R , M . D. Dare Examined Examiner SP'"'! 1 i Name JO H N F . S C A L E R , M. D . . .'-'--s:-; - '- - i .*. .'" . . . . . . - tO I SAM PTQN A V EN U E ; j,` .i-/'. u<..'i ' - . 'i. s j'n - , . SO._ F L .A IN F 1 E L , H. J . 6- Vision without g la sse s R ~ 14/-i*k .. L - w d . - R -2 0 /.& J. L - 20/ . ^ . . 7. Vision with glasses R -1 4 /A l... L -14/ W -. R 2 0 / - - . . . L --2 0 /- KEY: Normal g ] 10, Appearance 11, Shin 12, Eyes 13. Ears/Drums 1-4. Nose 15- Throat 16* Teeth / Gums 17. Neck 18- C h e s t/ Brea s e e 19. Heart 20. Lungs Abnormal [x] Nor Examined ,21* Abdom en/Scars S - /L2. Hernias .23a Inguinal Rings G f ,,24- Ext- G enitalia czf' /25. Anus ,26, Recta/ Prostate <27, Extrem ities 1 '28, Back I 29s Reflexes do. Blood 31. Urine g a 0 at S' Gf Ago Cps Right Left Employer Sot M. S. W. D. ~ ^ ^ y f s r r ^ ~ /A 5t Heating Level (Decibels} 250 500 1000 2000 4000 Approved Restrictions: FORM S-1ZB56 Not Approved 3 Limited ! I <?~ Z S . 19<Cl JO H N F . S C A L E R , M. . Date Examined Examiner OCCUPATIONAL HISTORY L ist all em ployers for whom applicant worked for the la s t th ree y ears PAST MEDICAL HISTORY (Record nature and dates of a ll injuries, operations and m ajor illn e sse s) RE-CHECKS & SPE C IA L EXAMINATIONS Xray of chest shows increased interstitial markings of the rt. lung field and lower left lung field sonsistent with fibrotic changes. - _i "- v,, -' - V^ ; , ,Jr / , -..1 ->`* . : *-r " .1. Date of la s t Immunization SamllpOX .................. .. Tetanus NOflC \ \ None [~~] 1 I certify th at I h a v e n o t re c e iv e d Workman*s C om p en satio n , p en sio n or d am ag es fot any in* jury or d ise ase ex cep t a s follow s: I farther certify that I have received a phy sical exam ination (including an audiom etric e x a m in a tio n }, and h a v e b e e n inform ed of die r e s u l t s of su ch ex am in atio n , a n d th a t my o c c u pational and m edical h isto rie s, as recorded above, are true and com plete. Witness Applicant ' q, ____________ Date .Name './'ir*-.-*'- 15 JO H N F . S C A L E R , M. D. *1 r . , - --i X-.C,-* -. > J --.- '.-J* jX R j 101 SA M FT O N A V E N U E: . SO , P L A IN F IE L D , hL J* g /2jp>f;I . , H TTHilgSi j 2. wcjgui s* tt" 1 m * Vision w it hour g la s se s R-1 4 / .. L -U /iL . R -2(1 / . sO . L - 2 0 / . * - . i 5* 0100a p ressu re 4- P ulse 7. Vision with g la s se s l 8. Color 0 R -1 4 /A l.. L -1 4 /iW -. R 2 0 / 1 . . . L - 2 0 / ......... 9. Depth Cps. Right Left 5. Hearing L evels (D ecibels) 250 500 1000 2000 KEY: Normal {vj Abnormal Qc] Not Examined Q I0 r Appearance 11. Skin 12. Eves 13* E ars/D rum s 14. Nose 15. Throat 16. Teeth/Gum s 17. Neck IB. C h e st/B re a s ts 19. Heart 20. Lungs / t ^21. Abdom en/Scars t A 2. Hernias t .23* Inguinal Rings t ,,24. E xt. G enitalia < ,25- Anus t, ,26* R e ctu m /P ro state K *21. Extrem ities t '28. Back t 29. Reflexes d 0 . Blood t 31. Urine 0" 3 Cj q t t t a Approved Nor Approved Q Limited Q ] Restrictions: F O R M S-1ZS56 (Use th is space to desert be a ll detects ) ,,4A_tco- 9 - 6~ Date Examined 19'2 JO H N P . SC A L E R , M. . Examiner 4000 OCCUPATIONAL HISTORY L ist a ll em ployers for whum ap p lican t w orked for the la s t th ree y e a rs PAST MEDICAL HISTORY (Record nature and d ates of a ll injuries, operations and major illn e ss e s) RE -C H E C K S St S P E C IA L EXAMINATIONS Xray of chest shows increased interstitial markings of the rt, lun field and lower left lung field sonsistent with fibretic changes. Dare of last immunization ______________________ _________ Sanllpox . . . . . . . . . . . __ . . . . . . . . . None j j Tetanus . . . . . . . . . . . . . . . . . --. . . . . None I certify th a t I have not received Workman's C om pensation, pension or dam ages fot any in jury or d ise a se except a s follow s: I further certify th at 1 have receiv ed a p h y sic al exam ination (including an audiom etrie exam ination), and have been inform ed of the re su lts of such exam ination, and th at my occu p atio n al and m edical h isto rie s, a s recorded above, a te true and com plete. W itness Applicant 4' zr-79________ Date I n d ic a te s c a r s and. d sfig u re men cs Warne Allures s JOHN F . S C A L E R , M. D. .1 tot SAMPTON AVENUE SO. P L A IN F IE L D , N . J. EMPLOYMENT EXAMINATION RECORD _______ ). Em ployer I. H taghi r- < } *\1* nitci*y m1 /Z* 5. Biood P ressu re / * 6/ p J 6. V ision w ithout g la s s e s 1. V isio n w ith g la s s e s 4. P u lse L "0 8. Color P T R - 1 4 /. k . L -14/i% .. R-20/.A*. L-20/Xi.- R --1 4 / . l - - L - U / L . R - 2 0 / / . . . . L --20/.......... 9. D epth ( I KEY; Normal 0 Abnormal 0 Not Exam ined Q] Cps. R ig h t 5. H earin g L e v e ls (D e c ib e ls) 250 500 10G 2000 Left . (Use this space to describe all defects) 10. A p p e a ra n c e 11. Skin 12. E y e s 13* E a r s /D m r a s 14. N ose 15. T h ro a t 16. T e e th /G u m s 17. Neck 18. C h e s t/B re a s ts 19. Heart 20. Lungs / j z T , 21. A bdom en/Scars L2. H e rn ia s [~X , 23. In g u in a l R ings 1 2 ^ ,2 4 . Ext G enitalia X2S ,-25- A n u s \'X . 26. R e c tu m /P ro s ta te V7\.sil. E x tre m itie s 0 / 2 8 . Back [Xf 29. R e fle x e s Q .- ^ O . Blood P j 31. U rine f cf cf a a 31. Uf OlM A pproved \.X\ Not Approved [ / ] Lim ited / ] R estrictions: FORM S-1 2S56 !r;VVy 6-- . 9 s' D ate Exam ined JOHN F . S C A L E R , M. D. Exam iner 4000 O CCU PA TI0N A L HISTORY L ise a l l e m p lo y e rs fot whom a p p lic a n e worked for the la s t th ree y e a rs PA ST MEDICAL HISTORY (Record nature and d ates of all injuries, operations and major illn e s s e s ) RE-CHECKS & SPE C IA L EXAMINATIONS SVlfcsKt; J <JL frfbS+i* A t TXw . Wt9 W - * cXv*dV-oj' Daif? of la s t immunization Tetanus . . . . . . . -- ............. .. D I certify th a t I h av e n o t re c e iv e d W orkm an's C om pensation, p en sio n or d am ages for any in jury or d ise a se except as follow s: I fu rth e r.c e rtify that I have re c e iv e d a p h y sic al exam ination (inc luding ail uudinW etric exarunrsnlKOi so d have been inform ed of the re s u lts of such exam ination, and char my occu pational and m edical h isto ries, a s recorded a to v e . are true and com plete. V ien en Applicant :]\ t fi *< Dati Indicate sc ars and disfigurem ents 'ni>f X jstiiudfxa fca 'w ' V t a n v o s ^ n h o t "6T' IrlV-b 0 paipnn SSszri-s w a o d :tuop5iJ)Eiy 0 piAoiddy ion 0 paAoiddy & C-x (s ia a p p | | b aqijasap or osad sigi asfl) Si * i>n; ' pooiaoc-'-"ph sa x a tia a '61 gaB *Z n iio aiiig -z aiaisojj/m nusg y ; snuy -ii ni*D * a ''ll JB r l u j l jetljnim {f pfi "Zi" J 3 Vsie ss/u a in o p q y `11 a C l pauitnexg ION E l iBmiouqy a n i 'OZ uasH `61 stesala/asaro y j gN " I om g/ipaaj, -gj tsojgx"SI ON>1 HKUQ/SJII3 -l *3 n MS 'l l a a n u sa d d y `01 l.rniON :AHS 0 qtdsa '6 -- m - T .. /K-N -*5^/0Z"T /" 000k OOOZ 0001 008 tqflH U Jl3 `8 Oil sdo ts ja q p a a ) s p t a y SuiteaH `j -j'pii-ty la*A0oid-fmtg'S w xas 9*V iffyi QH0D3H H01.VHIwvxa i1NawAOidwa f `U lm v u w i w - i j -n e a n u v A v M m a w w e m i sasssi*qtfMuo;r{A`L t !* itioqii uotSTA "9 a it n >iu `w u n - i v f i c * j u u n r awcN Karne JO H N F , 5C A L E R A , M. D. 101 S A M P T O N A V E N U E SO> P L A I N F I E L D , N . J . EMPLOYMEN-^EJfMUNATION RECORD S 'if ' fiy u* Vision without glasses r R-14/.3LA L -1 4 /j . Fressnie j I ruise Tr I ` 'A t. 7. Vision with g la s s e s 1 R -I4 /? irL .-I4 /* . >0 Color f" ? " " Right gating Levels (Dccibe 1s ) ~ ^ AW / m R - 2 0 / ......... L - 2 0 / ............ 9. Depth Q ] Left KEYi Normal [g) 10. Appearance 11. Skin 12. Eyes 13. E ars/D rum s 14. N ote 41J. Throat 16. Teeth/G um s 17. N k Ahnorraaffin Not Examined 21. Abdomen/Scat s f Kctnias HFT^ ,23. Inguinal Rings i? l 24. Ext, Genitalia P f * 25. Anus 26. Rectum/ Prostate PH 27. Extremities E f " *28. Back ST X3" Si " (b se this space to describe all d eiectsi X-r ^ < L ^ > r T & r, joC^^K. 18. C h e s t/ Breasts 19. H e u t' 20. Lungs (S) 29. Reflexes I.< ,30. Bleed 31. Urine a' S' Apptoved Q Restrictions: FORM 3-1288 Not Approved O Limited Date Examined JO H N F . SCA U ERA i M. D. Examiner SOUTH PLAINFIELD PRIMARY CARE CENTER J O H N F S C A L E R , M.D., P .A . Y O G I B A K SH I, M.D. 101 SAMPTON AVENUE SOUTH PLAINFIELD, NEW JERSEY 07080 TELEPHONE (201) 756-5207 October l, l98 7 Whittaker Clark & Daniels 1000 Coolidge Street South Plainfield, N.J. 07080 A T T : John Fitzpatrick Plant Manager RE : Dear Mr. Fitzpatrick: Please advise the above named patient of the following changes on his yearly x-ray examinat ion. Chest x-ray (PA & LAT ) No acute changes. Epithelial changes becoming more prominent. Sincerely your y John F. Scaler, M .D .,P .A . SO UTH PLAINFIELD PRIMARY CARE CENTER JOHN F. SCALER. M.D., P.A. YO G I BA KSH I, M.D. 101 S A M P T O N A V E N U E SO U T H PLAIN FIELD, NEW J E R SE Y 07080 T E L E P H O N E (201) 756-5207 October 1, 1987 Whittaker Clark & Daniels 1000 Coolidge Street So u t h Pl a i n f i e l d , IS.J . 07080 ATT: John Fitzpatrick Plant Manager 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. J o h n v, s c a i e r a , SO UTH PLAINFIELD PRIMARY CARE CENTER J O H N F. S C A L E R , M.D., P.A, Y O G I BA KSH I, M.O. 101 S A M P T O N A V E N U E SO UTH PLAINFIELD, NEW J E R S E Y 07080 T E LE P H O N E (201) 758-5207 October 1, 1987 Whittaker Clark & Daniels 1000 Coolidge Street South Plainfield, N.J. 07080 ATT: John Fitzpatrick Plant Manager RE : Dear Mr. Fitzpatrick: P l e a s e advise, the above named p atient of the following changes on his yearly x-ray examint ion. Chest x-ray (PA & LAT ) No acute changes. E p i t h e l i a l changes becoming more prominent. r I OCCU PA T10N A L HISTORY L is t a ll em ployers for whom ap p lican t worked for th e la s t three y ears PA ST MEDICAL HISTORY .^Record nature and d a te s of a ll in ju ries, operations and m ajor Illn e sses) RE-CHECKS & S P E C IA L EXAMINATIONS chest x-ray (PA & LAT ) No acute changes. Epithelial changes be coming more prominent. Date of last immunization Sam tlpojc____ . . . ______ _________ None I I Tetanus .................................. . None Q I certify th a t I h a re n o t received Workman's C om pensation, pension or dam ages for any in jury or d ise a a e ex cep t a s follow s: I further certify th a t [ h av e receiv ed a ,p h y s ic a l exam ination fineluding a n aa d isaict rie fex a mi n a r ia n ), an d h a v e b e e n inform ed o f th e r e s u l t s o f su c h e x a m in atio n , a n d t h a t my o c c u p ational and m edicalT histaties, a s recorded above, are true and com plete. f/fc/ y 2 ____ _________ ____________ Witnea* Applicant 9 ' I? Date indicate sc ats and disfigurem ents U|UIB*3 pttTjjmtiig Q a 'w `v u a i v o s *d N H o r 7 61 p**mi pAojddy io(4 9SBZ1-.& WOd JsuoTaJ|iiEay Q P^Aoiddy J3] upn Tt XunT'Oz poors ssxaijaH me -H W P n issa -az P >53 aisjsojj/tamaaij '$Z P ja WeH-61 is s a la / sa n o -81 >lN-Ll * w n )/ip a a i -9 j laoiqi -ii SliUy l P asoR -H *;|9)]Uao ' 3 VI P I sm arQ /siag -j sSurg jsajnSui -z JE ai3 -ti JD "HS `II a a n u a a ild v '8 1 p a im n tlja m ,~ )V m - U sS ija-| ......... / 0 Z ~ 1 ........../O Z -H -W' , mra oook oooz ODDI oof 0 fsjwpDSfi) (aaa-i OuiizaH ( sdo --7 ,*VV 'W-jr/V a *a -s -H d") pus T S T ^ rn m YJ <2.c 5 J8y CN033N NQIJLVNIWVX3 JLN3WA01dW3 T 'H 'O i a M N i V T d 'O S HC1N3AW N OAdW V S 101 SasasfS q ija u o j t ^ s a s s o il >noqi;i u o i3 [\ *p `Q 'W `V H B 'W O S `d N H O f aissN Name JO H N F . S C A L E R A , M, D . 101 SAM PTON A V E N U E SO, P L A IN F IE L D , N. J + EMPLOYMENT EXAMINATION RECORD Employai a JzMjibjdL. m L iL L a r k i M. S. W. D. S'ti I /9o 6, Vision without g lasses 7v Vision with g lasses 8. Color 0 L-XV.y.h K -1 4 / . L -1 4 /^ X R - 2 0 f.Orti L - 2 0 / J h . - R - 2 0 / ......... L - 2 0 A - - 9 Depth 0 KElfi Normal (v| Abnormal [3) Not Examined 0 10. Appearance 11. Skin 12- Byes 13. E a rs / Drums 14. Nnse 15. Throat 10. T e e th / Gam 17. Neck 18. C h e st/B reast* 19. Heart 20. Lungs . 0 0 21. Abdoroen/Scars GZf 22. Hernias a t 23. Ingoiasi Rings c d 24. Ext. Genitalia c t 25. Anus t z f 2$. R e ttu m / Prostate ceT 27. Extrem ities Ef 28. Back CD 29. R eflexes & 30. Blood d 31. Urine [H i US' D a a o nr or at oer CpGr. Right 5. Hearing L evels (Decibels) 25 500 1000 2000 1 Left (U se th is space to Je scrih e all defects ^ Approver! Q Restrictions: FORM S-I2S6S Not Approved I [ Limited Q Q -n 19 L ? JO H N P . S C A L E R , M. D. Date Examined Examinee 4000 J O H N F , S C A L E R , M. D. 101 S A M P T O N A V E N U E SO. P L A IN F IE L D , N . J. EMPLOYMENT EXAMINATION RECORD _____ kiQIL Employee M. S. D.. Hearing 1,Height 2- Weight 3. Blood P fo ssu te J4. P u lte 19P /V # > 6. V ision w ithout g la s s e s ?. V ision with g lasses 3 Color R ~ 14/--^- L - 1 4 /^ $ i R -1 4 /^ Y i> ' L --1 4 /?;/, R-20/.ib. L~20/.'&. R--20/.. L-20/..., 9. Depth Cps. Right Left V 15* Hearing L ev els (Decibels') 250 500 1000 Sf > 2000 4 QUO KEYi Normal [y] 10, A ppearance 11. Skin 12. Eyes 13. E a rs/D ru m s 14. N ose 1?. Throat 16, T e e th /G u m s 17. N eck 18 C h e s t/B r e a s ts 19, Heart 20. Lungs Abnormal [xj Not Examined Q 53-" 21. A bdom en/Sears $ 22, Hernias car 23. Inguinal Rings 0* 24. E x t. G enitalia E' 25- Anus ny 26. R ectu m /P ro state s' 27. E xtrem ities G3* 28. Back or 29. R eflexes GZ 30. Blood & 31. U tlne H3G GZ 3- G G Q> ta- at- (U se sp ace to d e sc rib e a ll d e fe c ts ) Approved R estrictions: FORM 5-12856 Not Approved | 1 O'"L im ite d 9 /9 /8 6 . 19* Dare Examined J O H N F . S C A L E R , My O* Examiner OCCUPATIONAL HISTORY L is t a ll em ployers for whom a p p lic a n t worked for the la st three y ears PA ST MEDICAL HISTORY R eco rd nature and dates of all Injuries, o p erations and major illn e s s e s ) RE-CHECKS & S P E C IA L EXAMINATIONS Xray Chest- Normal P ate of last immunization Samllpos ......................... ................ None T e tnus ....................................... ..........None Q certify) th a t I.have not received Workman's C om pensation, p e n sio n or dam ages for any in jury or d is e a s e ex cep t a s follow s: I fu rth e r c e r tify th a t h a v e re c e iv e d a p h y s ic a l e x a m in a tio n fin n ln d i n g i m nndirun c ii jL exam ination), an d h av e been informed of the re su lts of such exam ination, and th at my occu pa tionaljarid m edical h is to rie s .a s recorded above, are true and com plete. W itness A pplicant 9 /9 /8 6 Date ~ Indicate scars and disfigurem ents autiuiBxg "a 'W 'V H 3 " !VOS 'd NHOr panimene aauQ 61 ' 9 9 / 0 / 6 j paritari 9SG31-S WUOd :suor33pisij [ I pa*.cuddy aojt ^J/T] pSAoiddy V ?/7^'^5rvrr/7 IP1 " v u - i t a .pooia 'o i ,, saeaiJOH -gj JTJ k a `z J?U ssiliojsiixg 'ix yfTl aieisOJd/roniaag '9Z / snny `il J2! BtiEiiua^ -3 ' \ sSni^j ]turnSu[ -j ^ SEJ01H 'll Si*3S/u3inopqy -JZ /S] I~1 patiraexg U>N B (tstinouqv Snti-i oz n=H '61 sis v sig /) * a 10 "81 ipaN `LIsu in o / q i a s i '91 m i x '.I s ON YT snm i(-(/si*a `Si . ss>-<3 TX Bins 'U uucJE S ddv *01 ' 0 leiniON :A3W ......... / 6 Z - 1 .......... /OZ ---a * V 0 -T -q70Z -R rqiB onov OBOE 0001 oof 0 - , isia91=>a) SfisOT *tnEH sdo I K l U T O C E O IT a #a 's `rt M 1 **s ] H7T aaeoaa noiivniwvx3 iN3WA0idwa *p *N `O i a i d N I V I e i 'O S 3 n N 3 A V N O X dW V S 101 53SEB{* l|Jt UOISIfr 'I sa ssa ia inoifJJt uqtsi^ *9 O W `V U 3-IV O S ' d NHOr SUBM OCCUPATIONAL HISTORY L is t a ll em ployers for whom ap p lican t wockcd for the la s t three y e a rs PAST MEDICAL HISTORY (Record nature and d ates of a ll injuries, operations and major illn e ss e s) RE-CHECKS & SPE C IA L EXAMINATIONS Xray Chest- Normal D a te of la s t immani station Sa milpox ........................... ......... T e ta n u s --- n 1 c e r tify 1tnac i n av e not r e c e iv e d w o rk m an 's C om pensation* p e n s io n or d am a g e s For an y in jury or disease except a s follow s; 1 further certify that I have received a physical exam ination ^ifiginding .aa-w ^ rw w fflc e w m i n a a o ir), an d h ay e b e e n inform ed o f th e r e s u l t s of su c h e x a m in a tio n , an d th a t my o c c u p a tio n a L,aii<l m ed ical h is to r ie s * ,a s re c o rd e d a b o v e , a r e true an d co m p lete, Witness ' " Applicant " ~ 9 /9 /8 6 Date indicate scars and disfigurem ents Uftuexg W V fcB IV O S ^ NHOf pauituv^a -61 1 W O T " I psinun [ I paAcaddy qjfl 9SSZ1- JMtOd ;su o n a u js& y paAoidtiy p n h e El . pooia *of j m sarajia-H `6Z 5 faeg `91 ED ssiijissrrxH 'LZ S aicisorj /m inia '9 3 souv -ir BI1S11D30 *1*3 `*Z sSui-a lau in in i \i s|Ui3H 'ZZ si JE j/osw oyqv "!Z J S 1 pauiHiexa jos B ]EU)10tlqV sS uirj -oZ *H '61 i s e a i g / j s q ^ *m JP^N '1 su m o /q ia a j, `91 i9X `SI som s u itu a /s ig ! sita -zi WS "Il saasinadily -qi leaJOH :A 3X Sja-J ----- / oz- t --------/ o z - a ` j^ V O Z - T - C 7 0 Z - R ] H*ia y -^ n -n s s s s j q>t uotsiA "Z sa ss o 1!# jtiqi ttOtsiA 4p DtlOk OOZ 0001 001 0SZ {tqaaisacD s^axaT SupruaH * SAO t 'VJT^ /- S u x j v a -i -q 'it 's idojdiug TTDn anoD sy n o l l v n iw x s iN3WAcn<M3 *r `N `a i a l i r f N I V i c i 'O S 3 H N 3 A V NOXdW V S 101 * a 4V H H " IV O S d N H O f aUlBft O CCUPATIONAL HISTORY L is t a ll em ployers for whom a p p lic a n t worked for the la s t three y ears PAST MEDICAL HISTORY ^Record nature and"daces of a ll in ju ries, operations and m ajor illn e sse s) RE-CHECKS & S P E C IA L EXAMINATIONS Xray Chest - fo rm e l D a t* of U s t immunization. Sacnilpox Tetanus ....................................... I certify th a t 1 h av e n o t re c e iv e d W orkm an's C om pensation, p en sio n or d am ag es for any in jury or d ise a se except a s follow s: I fa rth e r c e rtify char t h a v e re c e iv e d a .p h y s ic a l ex am in atio n X teoludi a g an- awd iem et ric e a a im naH onr), an d h a v e b e e n inform ed o f the r e s u l t s o f su ch e x a m in a tio n , an d th a t nay o ccu - p a tio n a L a n d m ed ical h ie e o rie sJ.a s recorded a b o v e , a re true an d co m p lete. /> - _______ * Witness Applicant 9 /9 /8 6 Indicate scars and disfigurem ents O *W 'V U H I V O S ` d N H O C pautufc3 aisfl ~6I ` ------ 9 8 / 6 7 5 " pajnurl 9S ezi-S WHOd Q paApjddy 3QM ^ _ p f| |i3AOJdy auijn `i f /52 pania 'Of * 0 saxajjaa -Z XB SI d ssn intw ixg `z xFH atersJd/iom a '9Z X D *n u y `SZ s i|Bjtoj3 -JX3 -yr 1 *Sot^ ie!nSui -{Z ( 3 evrursK -zz ^ sieag/uam npqv "IZ ^ 0 ] pauiinisxg N leunouqy s*on-i 'OZ woaH "Bl srsealfl/tsai]3 -gl 31*N Z'l sm n g /t)faax '9 > w nu tl son `VI iSHiniQ/JJTS3 "gt s/H "Z1 ns ti aonnieaddy '01 18UHON :,t3N ................... 000 fr 000Z own 004 JJT 3it;a otz sd3 | T L Hr 'a * -s w S / c e - i ......... /O Z -H g ^ V O Z -l -^ ' -/OZ-H ffa*se*S qjito. uoisia. *L - rm sassejS ittoqjT/m uoist^ 'g ii6 1 9 m! `T " -------------------------------------- CT 3---------------- daOD3M NOLLVNIWVX3 iN3W A0ndW 3 r *n `a n a i H N i v n d -os b o n s a v N o x d w v s 1 0 1 ra `w 4v y 3 "t v o s d m h o r #lEjsJ OCCUPATIONAL HISTORY L is t a il em ployers for whom ap p lican t worked fqr the la s t three years PAST M EDICAL HISTORY R ecord nature an d 'd ates of a ll injuries, operations and m ajor illn e sse s) j RE'CHECKS & SPECIAL EXAMINATIONS X ray C h e s t- Normal Date Of Use immunisation Tetanus n CZj jury at d i s e a s e e x c e p t a s fo llo w s: I further certify that l have received a physical exam ination eicamiimutnr)*and have been inform ed of the re su lts of such exam ination, and th a t my occu p atio n al sa n d tiledlicaI h istories*, a s reco rd ed ab o v e, are true and co m p lete. Witness Applicant 9 /9 /8 6 Date Indicate sc ats and disfigurem ents UUIHIBX3 a 'v ` V W B T V O S *H N H O T p^irilUBXg 3JEQ "61 ' 9 97 5 7 5 " psiinn 9S8ZI-S MMO* ;suoii?TUS3,y Q p3Aiu<Jdy jon ^ g T j .paseuddy ijai I COOS' oooz 0001 00s 31*!S 016 si0 pn - l / 5H . pooifl 'Of J d B afjay -I ! qaefl '9 saptutw ug - zB3 j s is o ij / u tn is s a -91 yfTI snuy -it J23 Islftu9j> -1*3 `VZ j a sU fH [B O ;n*a| js B1UI3H 'll iBSS/naiopqv 'tr J3\ f~j paaxmX3 (x] jeuHOEiitv - saun-i -fll WH ;6I SJSBBta/^SSMO '81 qiN -T stun>/tpsax >91 JEDUSX.'SI aso(J > | sunna/SIE3 -l sX3 -Z1 HS 'TI 33UJc?ddy *0T 21 IEIU10N :A 3* ----- / 0 1 - 1 .......... / O l - y S 3 S 6 B J ipjJ. UOTS]j\ ' I *&V0Z- ', a & 2 V H -T s a s s e |S anpqtiAA tmrsfA 'i> I T77 w W1 ^a 'A s `Vi Mag 1 -------------- -- ---------------- -- O * ------------------ oyoDaa noiivniwvx3 iN3VUcndW3 r *n `anaM N iw id 'oe so nsa v NOidwvs toi a *w `V H 3 1 V O S NHor awefl JO H N F . S C A L E R , M. D. 101 S A M P T O N A V E N U E SO. P L A I N F I E L D , N. J . Name EMPLOYMENT EXAMINATION RECORD A ddress Age I, Helghc R ? Q S! "i o n 6. V ision without g la sse s CO , R --1 4 /-- / , L - 1 4 / J i - J i // /1i , / .j A.v-(7,' 7. V ision w ith g la s s e s R - H / i i . I L - 1 4 /A ;.. C ' 8. Cps. : Colot 3 Right ________ L iim ____________________ _ E m ployer Sex M. S. W. D. ,, P- - e a r i n g .-, M ? V /,* /I r .1 5. H earing L ev els (D ecib els) 250 500 1000 2000 4000 R - 2 0 /..i'I L -2 0 /.-/.V . R --2 0 / .......... L --2 0 / ............. 9. D epth 3 L eft KEY: Normal 10. A ppearance 11. Skin 12. E yes 13- E a rs/D ru m s 14. Nose 15. T h ro a t 16. T e e th /G u m s 17. N eck 18. C hest/B reasts 19. Heart 20. Lungs Abnormal [x| Not Exam ined Q r t ^ 21. A bdom en/Scat 22- H ern ia s t a " 23- Inguinal R ings [ a T 24- E x t. G enitalia (7T 2?. Anus VTY 26. R e c tu m /P ro s ta te GCK 27. E x trem ities Br 28. Back a r 29. R eflexes C Z 30. Blood ( 3 ' i 31. Urine I ta r 0T cy- ta j n' ra " Approved 0 ^ R estrictions: FORM S-128S6 N ot Approved I I Lim ited |Q / D ate Exam ined 19. JO H N F . S C A L E R , M. D. Exam iner m &\%r?v.. g OCCUPATIONAL HISTORY L is t a ll employers for whom applicant worked for the last three years PAST M EDICAL HISTORY ('Record nature and dates of a ll injuries, Toperations and nj^jor illnesses) RE-CHECKS & SPECIAL EXAMINATIONS X r a :r O b e ra i; c rc n ^ .l. D ate of la s t imm unization Samllpox __________ -___ ___ ... None 1 I Tetanus --- -- ---- ..........-- None Q 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 fiacludin.g~an~audiemetric examination'), and have been informed of the results of such examination, and that my occu pational ,and medical h is to rie s a s recorded above, are true and complete. Witness Applicant 9/ 9/36 D ate Indicate scars and disfigurements 'Name A ddress JOHN F, S C A LE R , M. O, 101 5A M P T O N A V E N U E SO. P L A J N F IE L D , N . J, EMPLOYMENT EXAMINATION RECORD wCD- a n n u a l Employer Hv?A te Sex M. S. W. D. in M L r, \- 5 '9 " 185 lu H e Vision without g lasses 7. Vision with g lasses Iri 8* CoIof r a R - 14/-.T.7-L - 1 4 / . . T it R - 1 4 /___ - L - 14 / ........... R --2 0 /.Vi. L-20/jS. R - 2 0 /......... L - 2 0 / ............ Cps. Right Leir 2J0 500 1000 . 3000 KEY: Normal ) Abnormal x| Not Examined Q IG. Appearance. 11. Skin 12. E y e s 13. E a rs /D ru m s 14. N ose 15, T h ro a t 16. T eeth/G um s 17. N e ik 18. C h e s t/B re a s ts 19. H eatt ; j 20. (.vats 1 ' iz f 21a Abdomen /S c a r s r i 22. H ernias tzf 23* Inguinal Rings eri 24> Ext. G enitalia r i 25. Anus r i. 26. R ectum /P rostate r i 27. Extremities r i 28. Back 29. R eflexes CE, 30. Blood r i 31, U tltte a 0 'd d & d ri r i. ri s S' ;I ; Approved [ 3 Not Approved [3 ] Limited 3^] R e stric tio n s: FO RM S-12B36 (U se tiiis space to d escrib e aU defectsV H ik . Date Examined C t7 JO HN F . SC A L ER , M. D. Examinee 4000 OCCUPATIONAL HISTORY L ist all em ployers for whom applicant worked for the la st thtee years PA ST MEDICAL HISTORY (Record nature and d ates of all injuries, operations and major illn esses) RE-CH ECK S & SPE C IA L EXAMINATIONS C h e s t x - r a y (PALAT) -, ; /',,e-- t fL*yJ ^ rt L' Date of la s t immutiLeanon SamUpon Tetanus . . . . . / . . L i ' . . . . . . . - u 1 cercliy th at I hav e not re c e iv e d W orkm an's C om p en satio n , pension or d am ag es for any in jury or d ise ase except a s follow s: 1 further certify that 1 have received a physical exam ination (including-an audiam ettic e x a m in a tio n ), an d h a v e been inform ed of th e r e s u l t s o f su c h ex am in atio n , and th a t my o c c u pational and m edical h isto rie s, a s recotded above, are true and com plete. ' . . j Witness m .r T 5 T Indicate scars and disfigurem ents t ' Name JO H N P , S C A L E R , M. D. 101 SAMPTON A V EN U E SO. P L A IN F IE L D , N, J . E M P L O Y M p ^ EXAMINATION RECORD L Height 2. Weight 5*9 " 185 6. Vistoti without g lasses p^"< R -1 4 /--* /:?-L - M /. zsiR L - 2 0 /- - 3. Blood R ressu re I I jc 7. V ision with g la s s e s R - 1 4 / .......... L --1 4 /R - 2 0 / _____L 2 0 / . 4. P ulse / rfI, S, Color Q )' 9. Depth Q Cpsu Right Left M. S. W. D. Ln i ,i.V.,? ... i -V | M fa \ ' 5. H earing L e v e ls (D ecibels) 230 300 1000 . 2000 4000 KET: Normal |vl 10. A ppearance- 11. Skin 12. Eyes 13. E a rs/D u n n s 14. Nome IS. Throat 16. T e e th /G u m s 17. Weak IS. C hest/B reasts 19. Heart i 20. flings 1 Abnormal (xj Not. Exam ined izf 21 A bdom en/Scars d 22. Hernias tzf 23 Inguinal R ings s ' 24* Ex t. G enitalia 25 Anus cf. 26. R ectum / P ro state OHf 27 E xtrem ities f . 28. Back z f 29 R eflexes tec. 30. Blood E3 0 K.1 d Ef dd cd. cf ET m 31. U tine 13" (U se this space"to escribe all defects) A p p ro v e d [ / ] Restrictions; F O R M S-12856 Mot A pproved [" J Limited 31 U Date Examined <r^ 19i JO H N F , S C A L E R , M. D. Examiner OCCUPATIONAL HISTORY L ist all em ployers lot whom ap p licant worked for the la s t three years PAST MEDICAL HISTORY ' (Record nature and d ates ot a ll in ju ries, operations and major illn e sse s) RE-CHECKS & SPE C IA L EXAMINATIONS Chest x-ray(PA&LAT) -,l / t -i -d O- ' ) JJ~U -ft!- r-<' y' fV i,... ./. / v " D ate of la st immunization S a m llp o i___ . . __y____J __________ None Tetanus .*,, None I i I certify th at I h a v e n o t receiv ed W orkm an's C om pensation, pension or dam ages for any in jury or d ise a se e x c e p t a s follow s: I further certify that 1 have received a p hysical examination (including an audiom etrie ex am in atio n ), an d h a v e been inform ed of th e r e s u lts of such exam in atio n , a n d th a t my o ccu pational and jnedical h istories, a s recorded _ ! 2 1 1^ A i W itness _____________ . . . . v i , . , . ___________ A pplicant ' / ,Vr D ate Indicate scats and disfigurem ents y Nam e J O H N F S C A L E R , NJ. D . 101 SAMPTON AVENUE SO. PL A IN FIE L D , N. J . EMPLOYMENT, EXAMNATtON RECORD p n r 11.? J. . Height 1/i } O~r ? 2. Weight I - 1? .1 - 1 3- B lood P re s s u re 1' ' iS- V is io n w ithout g la s s e s 7. V ision w ith g la s s e s 4. P u ls e 8. Color QU R - 1 4 / , . ; . . L --1 4 / ____; R --1 4 / .......... L - 1 4 / . . . l"t --20/.____ L - i o / . ; . . ' . R --2 0 / . ____L --2 0 / . _ . - - 9. D epth j 1 . Cps. Right Left 5 Hearing Lev els (D ecibels) 250 500 1000 2000 KEY: N o rm al [7] Ab nor mat [x] Not Exam ined Clise rhis space co describe a ll defects) 10. A ppearance 11. Skin 12. E y es 1?. E ars/D rum s 14. N ose 15. T h ro a t 16. T e e th / Guais I 7. N eck IS, C h e st/B re a sts 19. H eart 20. Lungs a " 21. A bdom en/Scars t 22. H ernias 0 23- Inguinal R ings o ' 24. Ext. G enitalia o ' 25- A nus r i 26. R ectu m /P ro state E l 27. Extrem ities r i . 28. Back 29. R eflexes p a , 30. Blood t 31. Urine FT o ', ri 0, t' ri S' 4000 Approved j j R estrictions: FORM 5-128SS ;--KFF-,-' kJ. 3S i?' -JTJ -J ' Not A pproved j__ | Lim ited [^ ] -- " . .-'. 'V . - D ate Exam ined 19 --- JOHN F . S C A L E R , NL D. Examiner <-.,i ^Si||2 OCCUPATIONAL HISTORY L is t a ll employers for whom applicant worked for the la s t three years PAST MEDICAL HISTORY (Record nature and dates of a ll injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS '"JIh. f- r - ^ - i r q y { }' ACT,/;.1]' i D ate of Iasi im m unization S m a llp o x ------------------------------------. . . N one []T1 T e ta n u s . . . . . . . . ' - i --------------. . . -- N one Q 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 daat 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. Indicate scars and disfigurements ; . * V - r Date OCl.fi -' L is t all employers for whom a p p lic a n t worked for the la st three y e a rs * ..l. ['Mm. . ... a iS T O R i (Record nature and dates of a li in ju rie s, operations and major illn e s s e s ) R G C iJ;.-- -1PC ..A L fcXAMlNM n . O h e st Xro.y --M /'If - Pa and L at sA. C-'l /?7 0 J " Date of la s t immunization Samllpox . . . ---- . . . . . . . . ---- . . . . . . Nona I I Tetanus ................. .............................. Kona I I 1 certify th at i have not received W orkm an's C om pensation, pension ot dam ages for any i n ' jury or d is e a s e ex cep t a s follow s: I further certify that I have receiv ed a p h y sical exam ination (including an audiom ertic exam ination), an d have been inform ed of the re s u lts of such exam ination, and th a t my o c c u p ational and m edical h isto rie s, a s reco rd ed above, are true and complete. ----------------- i --------------- Witness Applicant 9 /2 1 /8 4 Date Indicate scars and disfigurem ents O C lA h List a l l e m p lo y e rs for whom a p p lic a n t worked for the la s t three y ears , l -- . TORI (Record nature and dates. of a ll njuries, opera i.ions and m ajor iiin e s s e a ) K E -U ii-c ;4iti,,iAL liXAM lNAilUi- Chest Xray Pa and Lat '/ 9 S ~ - * 9 7 0 * Dace of lis e immunization Sami 1pox . e . * . .......................... Tetanus ..................................... I certify th a t 1 have n o t re c e iv e d W orkm an's C om p en satio n , p en sio n or dam ages for any in jury or d ise a se ex cep t aa follow s; 1 further certify that I have received a physical exam ination (including an audiom etric ex am in atio n ), and h a v e been inform ed of the r e s u lts of su c h e x a m in atio n , and th a t my o ccu pational and m edical h isto rie s, a s recorded above,'hre true and com plete- Witness __ ----4 Applicant 9 /2 1 /8 4 Dte Indicate sc ats and disfigurem ents ooot- J9u[oev3 - a -w `v M ^ t v o s ' d N H o r p su ra c ig JBQ "i f 1 7 9 /1 2 / 6 - [ I psAOJddy io n ssezi-s waod ;S D O |)9 T llS S > [ 2 3 P*.*OJddy 0007 oooi USI T M*!H OO CE S*D JB , a n n "I f 3 D poors -0i C3 a `61 E l P ^ofl '91 E l 171 SIJIUE3J3 *1 71 m s id /uioiqs^j *p2 P a "y `it a s B{|BI!U9Q ' 3 VZ ra suiH lUtnSuj -i p 13] SB|OJH 'll CD Pa Bj&ss/uaiuopqv '\z X.______ PSU1UB2 JON_____g ] ]BUUOdqy s t o n i "07 wvoH '6T SIEB310/JtJIO `81 J[S3fJ `X s tu n i/q js a j, '01 jeoiqX 'ST ssofi *H SWnJd/KJBg `1 SS3 >il WS "If u iiB s d ily "oi a jruuoisj :A3>[ V 0I~1 VOI - V /or. "i ^ t ' y o " H "T f V y j - 3 ! J ^ / H - a P W A,"`I 457H"a s3ssb qijA noi bA l s s o } 8 moi] jim notaia *9 aom OHODaa N0IJLVNmVX3 XH3WAOndW3 r `N `o i a i d N i v "c 'o s 3 H N 3 A V N O ld W V S l o i 'n 'W `w h ^ h v ^ -- -i ^wifN Mame A ddress J O H N F . S C A L E R , M. D. 101 SAMPTON AVENUE SO. P L A IN FIE L D , N. J. EMPLOYMENT EXAMINATION RECORD IH T H jH m '/ C u E m ployer M. S. W. D. 6. V ision without g lasses r>lZ7A 7. V ision with g la s s e s u IiT 22_ 8. Color \* R - 1 4 / . ~ C : L - u / M ? r R - 1 4 / r ^ - A L - U fJk!.. U ~ 1 0 L - 20 t R-iO v^ _ L --7 0 / _ 9. Depth CD K EY: N orm al [y] 10. A ppearance 11. Skin 12. E y es 13. E a rs /D ru m s 14. N ose 15. T h ro at 16. T eeth /G u m s 17. N eck 18. C h e s t/ B reasts 19. H eart 20, Lungs Abnormal [xj Not Exam ined ED 21, A b d o m e n /S c a rs ed 22. H ernias 23- Inguinal Rings 24. Ext. G enitalia 25. Anus 26. Rectum / P rostate SD 27. Extrem ities o 28. Back ID 29. Reflexes ED 30. Blood : 31. Urine ED O 0 Cps. R ight 5. H earin g L e v e ls (D e c ib e ls) 250 500 1000 2000 Left (U se th is sp ace to d escrib e a ll d efects) A pproved {"3 Not Approved [ R estrictions; FOR M S-iaa56 Lim ited []D Q / O 'l / Q/j- D are Exam ined 1 9 ----- JO H N F . S C A L E R , M. D. Exam iner 4000 O C C U PA TI0N A L HISTORY L is t all em ployer* for whom ap p lican t worked for the la s t three years PAST MEDICAL HISTORY {Record nature and d a te s of all injuries, operations and major illn esses) RE-CHECKS & SP E C IA L EXAMINATIONS cx (FA)-foLA'?) f o r m a l C -h e js ^ - . Dat^ of Iasi imfnuizatigp Smilpox Tetanus -*T7*.................. N one Q ................ .......... .......... None I certify th a t I have not re c e iv e d Workman's C om pensation, p ension or d am ag es for any in jury or d ise a se ex cep t a s follow s; I fu rth e r c e rtify t h a t I h a v e r e c e iv e d a p h y s ic a l ex am in atio n ( r n r h r h n g an--am K nm gtrie JiL d o n h an d h a v e b een in fo rm ed of th e r e s u l t s of su ch e x a m in a tio n , a n d th a t my o c c u - pat ^i and/m edical h isto ries, as recorded ahnvr Witness ^ 1U 1 _ S ~2TDtnate f i i me EMPLOYMENT EXAMINATION RECORD .VCD Annual Employer M, S, . Da s 'h na 6, Vision witboiH g lasses R - H '. . # . ? L-U/.-f.l R - 20 L - O /-i3 7. Vision with glasses R -1 4 /.* .* C T u / tS R - 2 0 2 ..........L - 2 0 / ............ _______ B, Color \Ls*r 9. Depth ^EpsRight Left 250 ..UT" KEY: Normal [vl ls A ppearance L Skin 12. E yes 13. E ars/D ru m s 14. N ose 15, T h ro at 16, T eeth /G u m s 1?* N eck 18, C h e s t/B rta s x s 19. H eart 20. Lungs boormai Not Examined Q G T 21. Abdoraen/Scais G0 " 22. H ern ias S ' 23. Inguinal Rings 3" 24. E xt. G en italis (ET 25. Anus 0 " 26. R ectu m 'P ro state 2" 27. Extrem ities J3- 20. Back e 2?, R eflexes 30, Blood 31, Urine t zf Zr zr a S' zr er zr 500 1000 2000 Approved W ~ Not Approved Restrictions: FORM S-12B5B Limited Q y ^ j , Dpi* Examined S 3 JO H N F* S C A L E R , M. D* Examiner 4000 OCCUPATIONAL HISTORY L is t a ll e m p lo y e rs foe whom a p p lic a n t worked for the la st three years PAST MEDICAL HISTORY (Record nature and dates of all injuries, operations and major illn e sse s) RE-CHECKS & SPECIAL EXAMINATIONS CX (P A )tlA T ) H Oc'mo-4 c Ine.*)" , D iti of las i minunizatioi _ Sam llp o x T e ta n u s T7Z------ ___ None ____________ .a a I certify th a t I have not receiv ed Workman's C om pensation, pension or dam ages for any in jury Or d i s e a s e e x c e p t a s fo llo w s: I fu tth e r te r r if y th a t I have re c e iv e d a p h y sic a l exam ination <im_lulling an" k u u iu in ttric io n L a n d have been informed of the re su lts of such exam ination, and that my occu pational aaQ 'm edical h isto rie s, a s recorded above, jare c m Witness Indicate scars and disfigurem ents I . Heighi 6. V ision without glaes.es R - 1 4 ' . . 7 L --1 4 /- . n R *3. h - 2 0 ' . s 3 0 7, Vis ton w ith glasses? R - 2 0 / ...........L - * 0 / 24S' K E V : Noimal |^} 10, Appearance 11. Skin 12. Eyes 13. Ears/D rum s 14- Nose 15. Throat 16- T e e ii/ Gums 1 ". Neel: 18. C hest/B reasts 19. H e; 20. Lungs Abnormal fx] Noi Examined E T 21. Abdomen/S e a rs E T 22. Homi as E T 23- Inguinal R ings E T 24. Ext. G e n italia E T 25. Anus 26. R ectum /P rostate f a ' 27. Extrem ities R 18. Back R 29. R eflexes B - 30. Blood 0 3X. U rine iz r aEf D er 0 cr A p p i o veil w ~ Not Approved Q R e s tric tio n s : FO R M S-12656 Limited Q EM PLOYM ENT EXAM INATIO N RECORD '.'.'CD A n n u a l Righi Sex M. S. * . D. ^ jd lft ______ 5. H earing L evels (D ecibels! 250 500 1000 2000 4000 Left (iVe th is s p a c e to describe all d efects) Cj ^ D ae1 Examined S 319*_= J O H N F . S C A L E R * M. D> Examiner Nam e JO H N F . S C A 1 .E R A , M. D. 101 S A M F T O N A V E N U E SO. PL.A1NF1ELD, N. J . EMPLOYMENT EXAMINATION RECORD '- C G '. r i m e d i A ddress 1. H e ig h t 2, Weight 3. Blood <P ressu re j 4. P u is e ^ -s' 'n / `T ' a . 3 3 / 9 3 6. V ision withouc g la s s e s 7, V ision w ith g la sse s 1 Ct 8. Color R - 14/.-iiCJ L - 14/.,, R - 1 4 / C - 1 4 / . "? S R - 20/. L - 2 0 /- 3& R --2 0 / .......... L - 2 0 / _____ 9 . D epth Q KEY: Normal Abnorm al [x] Not Exam ined Q 1 'G p s' S Right Sex M. S. W. D, TJf * 1 5. H earing L e v e ls (D ecib els) 250 500 I00 2000 4000 I (Use this space to describe a ll defects) 10. A ppearance 11. Skin 12. E y es 13. E a ts /D ru m s 14. N ose 15. T hroat 1(5. T e e th /G u m s 17. N eck IS. C h est/B reasts 19. H eart 20. Lungs 0 21. A bdom en/Scars 0 22. H ernias 0 - 23- In g u in al Rings 0 ' 24. E x t. G enitalia E T 25. Anus er 26. R e c tu m / P ro s ta te . 0 27. Extrem ities , 0 - 28- B ack B 29. Reflexes 0 - 30. Blood 0 - 31. Urine 0' S' 0 0' czr 0' or A pproved |7~X R estrictions: FORM S -12856 Not Approved [^ J Lim ited | j <i - l 3 - Dace Exam ined 19$ 3 JOHN F . S C A L E R , M. D. Exam iner OCCUPATIONAL HISTORY L is t a ll employers for whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature and dates of all injuries, operations and major illn e sse s) RE-CHECKS & SPECIAL EXAMINATIONS f \ Qsr m c u \ G Vi % V , Date of last immunisation SamUpoi . . . . J l . / . 9. rirr------- Tetanus . -- -- ---- Nono I I None 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 (wiLluding ail auiliumetric EionLand have been informed of the results of such examination, and that my occu- pati4id|l ai^m edieaLJfistories, as recorded above, are true and Witness C -/L 1 I ~ T l i D ate *23?r'*ZZ'-m rii. -, -v-' -"i-vT.-. V1: Indicate scars and disfigurements ;g i 1. Height - 5 ' / f ft 6. V isio n w ithout g la s s e s R -U /.S tJ. tL-20/.<O L-20/te^O 7. V ision w itb jjla s s e s R-1 4 / L -l R-20*._ ,, L - 2 0 / . KEY: Horo.it A bnorm al (x) Not Exam ined Q ]0. Appearance I t . Skin 12. E y e s 13. E ars/D ru m s 14. Nose 15. Throat 16. T e e th / Gums 17. Neck IS. C h est/B ie asts 19. Heart 20. Lungs / <21. A b d o m e n /S c a ts O ' 22. H ernias S ' ] 23- Inguinal Rings Q y 24. Ext. Genitalia 1 3 ' 25. Anus n r 26. R ectu m /P ro state n r 27. Extrem ities n r 28. Back n y 29. R eflexes 30. Blood ' 31- Urine O' g ' O' O' g- O' o '/ O' Approved [ 3 Ni A pproved Q Lim ited Q R estrictions: FO RM S-12S5fi EM PLO YM EN T E X A M IN A TIO N RECORD WCD- Annual c-'C pi. Right Sex M. S. S'. D. Hearing M 5, H earing L e v e ls {D ecibels) 250 500 1000 2000 Left 10/13/82 Date Examined 10 __ JO H N F . S C A L E R , M, D. E xam iner OCCUPATIONAL HISTORY L is t a ll em ployers foe whom a p p lic an t worked for the la st three years PAST MEDICAL HISTORY (Record nature and dates of all injuries, operations and major illn e sse s) RE-CHECKS fit SPEC IA L EXAMINATION ( Pa & Lat ) p c t-t b i- n c. L ^ Dar? of la s t in m a ^ tg r io ii Sam llpcx . ................None Tetanus - - ? . . ? l p n t h a . 3 g 0 > . None I certify th a t I have not re c e iv e d Workman's C om pensation, pension or dam ages for arty in jury or d ise ase except as follow s; I further certify that I have received a physical examination (including an audiometric exam ination), and have been inform ed of the re s u lts o f such exam ination, and th a t my occupaiional-and medical h isto rie s, a s recorded above, a re true and complete -- _i. 'r a J i__ A p p licant--------------------------------- -1 0 /1 3 /8 2 , Date In d icate scars and disfigarem encs Name EMPLOYMENT EXAMINATION RECORD WCD- Annual ]. H eigh: 3. Weight '< i " \ '/Si 6. V isio n w ithout g la s s e s R - 14/ . 2 Zj, h - U / ^ C ? R -20/.^? L-20/a^O / 3. Blood P r e s s u re 7. Vision w ith g lasses R - 14/*=5?. L - l4 /5 ? f= R - 2 0 c .. - - L --3 0 / KEY: Normal g j AbnDiflial [*) Nor Exam ined Q 10. Appearance 11. Skin 12. E y e s 13- E a rs /D ru m s 14. Nose 15. T h ro at 16. T e c tb /G u m s 17- N eck IB. C h e s t/B r e a s ts 19. H eart 20. Lungs / 21. A bdom en/Scars Q ' 22- Hernias G T 23- inguinal Rings a ' 24- Ext. G enitalia s ' 25- Anos 26. Rectum ./Prostate 27. Extrem ities 28. Back 29. R eflexes a - 30. Bleed & 31. Urine Q CD- Q E3S' QG> a 3 S' Approved 0 Not A pproved [3] L im ited [_J R estrictions: fo r m s-i2 ase (U se this space to d escribe all defects) 1 0 / 1 5 / 6 2 _ 19__ JO H N F. SCALER, M. D. B ate Examined E xam iner OCCUPATIONAL HISTORY L ist nil employers for whom applicant worked for the la s t three years PAST MEDICAL HISTORY (Record nature and dates of a ll injuries, operations and major illn e sse s) RE-CHECKS & SPECIAL EXAMINATION CX ( Pa & Lat ) l O c L ;y Date oi last immunisation Tetanus 3 . 7 m i K O g f t . None Q I certify th a t have not re c e iv e d Workman's Com pensation, pension or dam ages for any injtsry or d is e a s e except a s follow s: I further certify that I have received a physical examination (including an audiometrie exam ination), and have been inform ed of the re su lts of such exam ination, and th a t my occu pational .and medical h isto rie s, as recorded above, are true and compiete. -- J .. .fC>> < 1-- Hpttness A pplicant Date Indicate scars and disfigurements Name JOHN F . S C A L E R A , M, D. 101 SAM PTO N AVENUE SO. P L A IN F IE L D , N, J . EMPLOYMENT EXAMINATION RECORD vvGD- A nnual 2* ^ C lg lL 4. TM \ a. Bioc P resso re < - i, ............... ------------ ----------- - - -L-i.... J 6. V ision without g la sse s 7. V ision w ith g-ji^la s s e s R -1 4 /-1 ..1 L - 1 4 /. A /.. R - 1 4 / . - 1 ) . L --14 /'j R -2 0 /.i-?L L - io /,-.: R-20^ _ L -- 20/* 6. Color | 9. Depth | 1 KEY: N orm al |y] 10. A p p earan ce 11. Skin 12. E y e s 13. E a rs/D ru m s 14. N ose 15. T h ro a t 16. T e e th / Gums 17. N eck 18. C h e s t/B r e a s ts 19. H eart 20, L ungs Abnorm al [x] Not Exam ined 21. Abdomen /S c a rs 22. H ernias G T 23. Inguinal Rings Q ' j 24. Ext. G enitalia a " ' 25. Anus 26, R ectum / P ro state Q V 27. E xtrem ities Q ' " 28. Back O ' 29. R eflexes o 30. Blood C 3 ' 31. Urine CD g- a Q' G3 Q a C3 'G ps. Right Sex M. S. D. H e a r i n g M R ... 5. H eating L ev els (D ecibels) 250 ?00 1000 2000 Left (Use this space to describe all defects) L v. , 4000 Approved [C J Restrictions: FORM S-12856 Not Approved [ U Limited H ] 10/ 13/82 D are Examined 1 9 ----- JO H N F . S C A L E R A , M, D. Exam iner OCCUPATIONAL, HISTORY L is t a ll employers for whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature and dates of a ll injuries, operations and major illn e sse s! RE-CHECKS cx ( % tS PE C IA L EXAMINATIONS g,Lat ) Dace o la st im roui^zadofl Saailipox ___..................... ............N one Q T e ta n u s . .t. .9 1 Q f J ? l S ._ 3 - 5 Q . _ N one Q 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 (including an audiometrie examination), and have been informed of the results of such examination, and that my occupariond-nd medical histories, as recorded above, are true and complete. i - -W itness A pplicant 10/ 15/ 82^late Indicate scars and disfigurements JO H N F . S C A L E R , M. . 101 SA M PT O N A V E N U E : S O . P L A IN F IE L D , N , J . 1. ncigm ________ / ? / 6. Vision without glasses R -I4 /.?!j. L-U / f e R -2 0 /.L l - 20/#& . //a/ 2 7. V ision with g lasses 7> 8. Co lot lE j R - 1 4 / ..........L - 1 4 /............ R - 2 0 / ..........L -20/............ 9. Depth ED Cps. Right Left KEYt Normal 10* Appearance 11. Skin 12. Eyes 13. Ears/D rum s 14. Nose 15. Throat 16. Teecii/Gum s 17. Neck IS. Cheat/ Breasts 19. Heart 20. Lungs A bnorm al [x] Nor Examined Q e f 21. Abdomen/Scars O x -tMP o ' 22* Hernias f o ' 23* Inguinal Rings ra r 24. Ext. G enitalia cf sr C3f 25. Anus CD L^f" 26. R ectum /Prostate 27. Extrem ities eT 23. Back \z< z 29. Reflexes- 30. Blood cf X2 31. Urine o ne -- 5. Heating L evels (D ecibels) 250 . 500 1000 2000. jr -- Approved Q ] Restrictions: FORM S-12856 Nor Approved Q Limited Q j y~/y Date Examined J O H N F . S C A L E R , M. D . E xam iner 4000 JO H N P . S C A L E R , M. D . ...a 101 S A M P T O N A V E N U E -; V l ; H Z F 7 ^ 1 1 i p I K SO. PLA IN FIELD , N. J . EMPLOYMENT .EXAMIKATl ON RECORD . / AM e*! At t 1. H eight * // 6, Vision without glasses R -1 4 /-? jf. L - 14/ R -2 0 /-3 L - 20/L p, .pjiouii P re ssu re 7* Vision with glasses R - 1 4 / ..........L - 1 4 / . R --2 0 / ..........L --20/* 12^ 9- DPdi 0 KEY: Normal g ] 10. Appearance 11. Skin 12. Eyes 13. E ars/D tu m s 14. Nose 15* Throat 16. T eeth/G um s 17. Neck 18. C h e s t/B re a s ts 19. Heart 20. Lungs Abnormal [*} Not Examined s f 21. Abdom en/Scars s / 22. Hernias 0 / 23- Inguinal Rings 0 " 24a Ext. G enitalia C d 25- Anus n f 2. R ectum / Pros rate 27. Extremities [ 7 28. Back 29a Reflexes- 30. Blood s f 31. Urine St 2 / d\ et rfj E f, erf a O B '' Cps. Right Left 5* Heating Levels (D ecibels) 250 500 1000 2000 Approved Q 3 R estrictions: FORM S-12356 Not Approved [^ j Limited P I 9^/7 . 19 Date Examined JO H N F . S C A L E R , M. D. E xam iner 4000 Nam e JOHN F . S C A L E R , M. D. 101 SAMPTON AVENUE SO. PL A IN FIE L D , N. J. EMPLOYMENT EXAMINAT!ON RECORD y y / 79 / 6. V ision without g la sse s U - 1 4 /7 - L L - 14/--dl R - 2 0 / . `> i \ L - - 2 0 / 7 7 . f ' / v'Vt 7, Vision with g la sses R - 1 4 / .......... L --1 4 / ............. R --2 0 / .......... L --2 0 / . . . _ . 7 7-^ 8. C olor 0 ' " 9. Depth [7 ] K.EY: N orm al g ] 10. A p p earan ce 11. Skin 12. E y e s 13. E a ts /D ru m s 14. N ose 15- T h ro a t 16. T ee th /G u m s 17. N eck 18. C h e st/B re a sts 19. H eart 20. Lungs A bnorm al x] Nor Exam ined Q e T 21. Q "'" 22 c d 23 S 3 24 T 25 d 26 S ' 27 f 28 Back c d 29 d 30 c d 31 / *7 -A / Cps. R ight 5. H earing L e v e ls fD ecib els) 250 500 1000 2000 Left (Use this space to describe all defects) i t?' d J y y Approved Q Restrictions: FORM S- 12856 Not Approved [ 7 Lim ited Q 9 ~' 7 D ate Examined 19 JO H N F . S C A L E R , M. D. Exam iner 4000 T :*.:v i %/' : `t-v?-' -i--- v?-r. 'p g ^ : ^ > |g | J`l**sM* 6. Vision without glasses ? * Vision with g la sse s - 1 4 /.Y .^ r L - \ 4 / h i ? r R - 14S^V:>_ L - 1 4 / P & . 20/.'2Q- R --2 0 /..........L --2 0 / - 9. Depth KEVi Normal Q 10, Appearance 11. Skin 12. Eye 15, E ars/D ru m s 14. Nose 15, T hroat 16. Teeth /G am s 17. Neck 18. C h e s t/B re a sts 19. Heart J 20. Lungs Abnor mal jjtj Not Examined u e r 21. Abdomen/Scars e t 22. Hernias [7f 2 3 . Inguinal R ings S T 24. Ext. G enitalia erf 25. Anus e f 26. Rectum/ P rostate t z f 27. Extremities E f 18- Back E T 29. Reflexes G / 30. Blood l T 31. Urine El' Ef Ef a tzr CZf (2 O S' r.fiiF'S.UVi*cKV tXAi-!fiA.'iOi-i R tC O R D L-'U C Q __ ^CpsRight Z j j s. vp. nTT /y? 2JG H i<r7 5. H earing L e v e ls (D ecibels) 500 1000 2000 4000 Left (U se this space to describe all defects) Approved 3? R estrictions: j FORM S-12656 Not Approved j | Uralted [ ] 9-^r Date Examined ,2>1 9 J O H N F . S C A L E R A , M. D. E xam iner i J O H N P . S C A L E R . M . D . 101 5A M PT O N A V E N U E SO . P U A IN F IE C D , N . J . 6. Vision w ithout g la ss e s 7, Visioni ,,w(i.tMh gs Ulassssne ss R - 1 4 /- * f - V I. - 1 4 / . h i . R -l^ ^ L L -1 4 /.^ . R.-20/J&?. L - 2 0 / i f e - R --2 0 / ..........L --2 0/ - KEY: N om ai g ) iG. Appearance 11. Skin 12. Eyes 13. Ears /Drum s 14. Nose 15, Throat 16* T eeth/G um s 17. Neck 18. C h e st/B re a s ts 19. Heart 20. Lungs Abnormal [T) Not Examined 0 E f 21. Abdomen/Scars EST 22. Hernias r a r 25. Inguinal Rings 24. Em . Genitalia t ' 25 Abus c z f 26. Reenum /Pros tate tz f 27. Extremities t f 28. Back iz r 29. Reflexes car 30. Blood C t 31- Urine izf Ef Ef [t a ezr czf rt a ES' Approved R esttictioos: FORM 5*12856 Not Approved I Limited F ] Right a___ Sex ( J ) S. W. D. " T ^ f e /5 7 tS 1. H eating L evels (D ecibels) 250 JOO 1000 2000 Left (U se this space to describe all defects) 4000 9-^-r Date Examined . . S O JO H N F . S C A L E R , M. D. Examiner JOHN F . SC A LE R , M. D . 101 S A M P T O N A V E N U E *- ;-V,J. ',)![ `K &}'-r V* ^ vy SO. P L A IN F IE L D , N . J. .......rttal____ Sex Q l f S. VF. D. _ J; L Height fW. 6 Vision without g la s se s 7. Vision with' g lasses R - 14/.*f.V L - 14/ .V f.? R - I O /V ^ ? . L -20/ 2 Q . R --2 0 / ......... L - 2 0 /. KEY: Nonna! {7) Abnormal [x} Not Examined Q 10. Appearance 11. Skin 12. Eyes 13. E ars/D rum s 14. Nose 13. Throat 16. T eeth / Ginns 17. Neck 18. C h e st/B re a s ts 19. Hen 20. Lungs 0 21. Abdomen/ Scars 0 22. Hernia* mi 23- Inguinal Rings xz' 24* Ext. Genitalia ci 25* Anus czf 26. R ectum /Prostate XZi 27. Extremities (Tf 28. Back.- 0 29. Reflexes S3T 30. Blood cr 31. Deine izf ef EZf mf D 0 czf S' a Right tS " 5* H eating L e v e ls (D e c ib els) 250 500 1O0 2000 Left (U se this sp ace t d escrib e all 'defects^ 4000 Approved j^ J Restrictions; FORM S-I256 Not Approved \ Limited 2J D ate Examined 19 S JO H N F , S C A L E R , M. D . Examine 6. Vision without glasses r - h /.iTf -' Ji t -l R - 2 0 / J f e . L - 20/j?O. 7. Vision w ith'gjasses L --1 4 / 3 $ R --2 0 /..........L --2 0 / 9- Depth Q KEV: Normal 7j 10s Appearance 11. Skin 12. E yes 13. E a r s / Drums !4. Nose IJ. Throat 16, T eeth/G um s 17. Neck 18. C h e s !/B ie s s ts !9. Heart ; 20. Langs Abnormal [Tj Not Examined Q IZT 21. Abdomen/Scar* e f 22. Hernias O'" 23* inguinal Rings i z r 24. Ext. Genitalis Erf' 25. Anus E2f 26. R ectum /P rostate ezT 27. Extrem ities p i 28. Back S ' 29. Reflexes 3 T 30, Blood O ' 31. Urine 2f EZf nf EZ1 S' Ef O' (S '' EM PLOYA NT EXAMINATION RECORD IA j C i > __________ ^ Eropiovri f . _______ ' (j) s. w. a I nr I. / - H earing L ev els {Decibels! 500 1000 2000 4000 Right Left (U se this space to describe a ll d efects) Approved 3 S Restrictions! j F O R M S-I26SB Not ^Approved [__j I Limited [ 3 9->-r 19 S JO H N F . S C A L E R , M .D . Date Examined Examiner NttUfr;: JO H N F . S C A L E R , M. D . 101 S A M F T O N A V E N U E S O . P t - A I N F l B l l o . N . J . l,- Weigbi 3. Blood Pressure . Vision without glasse R - H / . V '. r L - U / J 'ri.?" R -2 0 c ? . L - 20/ 2o. gjasses R- L -U / ? . R - 2 0 / ..........L --2 0 / . 9- DeP * KEV: Normal 10. Appcnrance 11. Skin 12. Eyes 13. E a ts / Drums 14, Nose 15. Throat 16, Teeth/Gums 17. Neck IS. C hest/B reasts 19. Heart 20. Lungs Abftor mai [x] Not Examined ZT 21. A bdom en/Scars e r 22. Hernias car 23. inguinal Rings E f 24* E xt. G enitalia z f 25. Anus r z f 26. Rectum /Prostate E f 27. Extremities t r i 28. B a ck % E T 29. Reflexes [Z 30, Blood a r 31. Urine tzf ef eT ar a a tzr; [ZT S' SST Right 250 500 1000 2000 Left (U se th is space to describe all defects! Approved Q ] Restrictions: FORM $-12856 Noe A pproved [~~1 Limited P I Date Examined 1 9,2i_? JO H N F . S C A L E R , M. D , Examinee 4000 1 j : JO H N F , S C A L E R , M. O . 101 S A M P T O N A V E N U E I'1' '/ r.fc'? SO, PL A IN FIE L D , N. J . fcmplgyet ___ S. V. D. F ____ _____1_ -y l- H e is a : ,* i. IPeig,\r uuii Frensure f *. Pse Z i tto /fi fu V ision without g lasse? 7, Vision wih'gjLasses 1 R -1 4 /.* f.lr L 1 4 /.^ .? " R L - 1 4/ P^P.. 8. Colot \ j ^-Cp5Righe R - 2 0 /. I L--20/2 ?- R - 2 0 / ......... L --2 0 / ............ 9. Depth Q L eft 5 Heating Levels {Decibels) 250 500 1000 2000 KEY; Normal @ 10. A ppearance 11. Skin 12. Eyes 13. E a ts /1Drums 14. Nose 15. T hroat 16. T e e th / Gums 17. Neck IS. C hest/B reasts 19. Heart 20. Lungs Abnormal [5 Not Examined Q Zf 2L Abdomen/Sears ET 22. Hernias rzr' 23. Inguinal Rings S ' 24. Ext. Genitalia e f 25. Anus T 26* Rectum/ Prostate Zf 27. Extremities e f 28. Back S ' 29. Reflexes S ' 30. Blood o r 31. Urine Z zf Ef S' a BT sr S' S' (U se th is space to d escrib e all d efects) Approved (__I Restriction s: FORM S-12B56 Not Approved I I Limited I 1 9->-r Date Examined 19 S O JO H N F . S C A L E R , M. D . Examiner 4000 OCCUPATIONAL HISTORY L is t a ll em ployers for whom applicant w orked for the la s t th re e y ears PA ST MEDICAL HISTORY (R ecord nature and dates of all injuries, o p eratio n s and major illn e ss e s) R E-CH ECK S & SP E C IA L EXAMINATIONS Dare of la s t immunisation Samllpox . . . . . . . . . ...................None o Tetanus I c e r tify th a t 1 h a v e not re c e iv e d Workman' s C o m p e n sa tio n , p en sio n < d am ag es for any in* jury or d ise ase except a s follow s: I fu rth er certify chat I h a v e re c e iv e d a p h y sic a l ex am in atio n fimshp e: d h a v e b e e n in fo rm ed o f rbe r e s u l t s of s u c h e x a m in a tio n , a n d th a t my o c c u - .onnl an d m ed ical h is to r ie s , a s recorded ab ove, a re tru e and com plete. Witness Applicant yzfji) 1 Date Indicate scars and disfigurem ents M arne J O H N F . S C A L E R , M. D. 101 SAM PTON AVENUE SO. P L A IN F IE L D , N. J. EMPLOYMENT EXAMINATION RECORD R e 0 ____________ _ Employee S. W. D. 1. e ig h t i V/ ' 2. Weight , t*i f " a's s iS. V isio n w ithout gL asses 3. B iood P r e s s u r e j /*) ,, J , 1 7. V ision Tvittf g la s s e s P u lse 7^ 8. Color f R - 14 /.Y .r L - u / . f r / . f " R -2 0 /.y fe . L -2 0 /J 3 . L --14/ R - 2 0 / ...........L - 2 0 / 9. Depth Q KEY: N orm al ]v] 10. A ppearance 11- Skin 12. E y es 13. E a r s / Drums 14. N ose 15. T h ro a t 16. T e e th / Gums 17. Neck 18. C h e s t/ B reasts 19. H eart 20. L ungs A bnorm al jjx} Not Exam ined Q S ' 21. Abdomen / S cars ED 22. H ernias Q ' 23. Inguinal Rings [ 3 24. E xt. G e n ita lia Q 25. Anus E f 26. R ectum / P ro state 27. E xtrem ities 3 28. B ack ED 29. R eflexes O ' 30. Blood Q 31. U rine eJ E fl a ET G3 Q J' a Cps. Right 5. H earing L ev els (D ecibels) 2 50 300 10 2000 Left (Use this space co describe a ll defects1) Approved 1 I R estrictions: FORM S-128S6 Not Approved [ L im ited [~~] - 19 2 T > JO H N F . S C A L E R , M. D. Date Examined Exam iner 4000 Name JO H N F . S C A L E R , M. D . 101 SAMFTON AVENUE SO. P L A fN F !E L D , N. J. EXAMINATION RECORD A ddress P 1. H eig h t f 2. Weight 6. V ision wiihout g la sses R -1 4 /.S iL L -U /^ W L R - 20/. J2v. L - 20/ 3- Blood P re s s u re I / 7. V isio n w ith g la s s e s 4. P u lse 3 8. C o lo r f''"" R - 1 4 / ^ . . . L - 1 4 / iA 'X ^ R --2 0 / .......... 1 . - 2 0 / ____ 9. D epth L ] KEY: Norm al [vj A bnorm al Nor Exam ined Q 10. A p p earan ce H . Skin 12. E y es 13. E a r s / Drums 14. N o se 15. T h ro at 16. T e e th / Ginns 17. N eck 18. C h e s t/ B reasts 19. H ea rt 20. L ungs 21. A bdom en/Scars 22. H ernias a 23. Inguinal Rings 24. E x t. G enitalia n . 25. Anus 26. R ectum / P rostate 27. E xtrem ities 28. B ack 29. R eflexes 30. Blood a 31. Urine n G3* Em ployer Cps. R ight /V 5. Hearing L e v e ls ^Decibels') 250 500 1000 2000 Le it (U se th is sp a c e to d escrib e a ll d e fe c ts) 4000 Approved Q J R estrictions: FORM S-12856 Not Approved [ L im ited 1 9 ---- JOHN F . S C A L E R , M. D. Date Examined Exam iner i!:'!** Name A ddress JOHN F . S C A L E R , M, D. 101 SAMPTON AVENUE SO. PL A IN FIE L D , N. J . EMPLOYMENT EXAMINATION RECORD Wh i t a c k e r a n d E m ployer C l pi r k 1. H e ig h t 2, Weight 3. B lood P re s s u re i. P u U e 6. V isio n w ithout g la s s e s 7. V ision w ith g la s s e s 8. C olor Q R - 1 4 / - . . ::_ L --1 4 / .......... R - 1 4 / ___1 . L --1 4 / _____ R --2 0 / - ____ L - 20 R - 2 0 / ...........L - 2 0 / ............. 9. D ep th j I KEY; Normal [v| 10. A ppearance 11. Skin 12. E y es 13. E a rs/D ra m s 14. N ose 15. T hroat 16. T e e th /G u m s 17. N eck 18. C h e s t/B re a s ts 19. H eart 20. Lungs Abnormal 0 Not Examined s ' 21- A b d o m e n /S c a rs t 22. H ern ias t 23. Inguinal Rings t 24. Ext. G enitalia t ' 25. Anus t ' 26. R ectum /Prostate t 27. Extrem ities t 28. Back t 29. R eflexes t 30. Blood m 31. Urine t Df O' t t CD Cps. Right 3. H ea rin g L e v e ls (D e c ib e ls) 2 f50 500 1000 2000 Left (U se th is sp ace to d escrib e all d e fe c ts ) Approved [ ^ j N ot Approved [[^] Lim ited Q D ate Exam ined 19-- JO H N F . S C A L E R , M. D. Exam iner 4000 t^Vijii.T w* -M H OCCUPATIONAL HISTORY L is t a il employers for whom applicant worked for the last three years PAST MEDICAL HISTORY (Record nature and daces of a ll Injuries, operations and major illnesses) RE-CHECKS & SPECIAL EXAMINATIONS chest x-ray (PA & LAT ) Ho acute changes. Epithelial changes be coming more prominent:. D ate of la s t im m unization S am llp ox__ . . . . . . . . ________. . . . . Mone f~ l Tetanus _____. . . . . . . . . -- . . . . . . . None 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 (including an audiometrie examination), and have been informed of the results of such examination, and that tny occu pational and medical histories, as recorded above, are true and complete. Witness A pplicant Date Indicate scars and disfigurements . aue. J O H N F . S C A L R A , M. D. --.--J--ri,..--ri 1, Height 2, Weight 3. ffcod P ressure 4. Pulse ia /f D l*>/s h 6. Vision without g la s se s 7. Vision with g lasses -9 R - U / S . L - 14 / t.. R - U /'? .... L - 1 4 /A Y -5 R -I0/_j?V t L~ 2 0 /w ta- R --2 0 / ......... L --2 0 / . 9- Depth Q KEY: Nona al 0 10. Appearance U . Skin 12. Eyes 13- E a rs / Drums 14. Nose 15* Throat 16. T eeth/G um s 17. Neck 16 C h e st/B re a s ts 19. Hean 20. Eungs Abnormal g} Not Examined m 24a A bdom en/Scats CZ3 22, Hernias SET' 23. Inguinal Rings o 24* Ext* G enitalia E l 25- Anus E3 26. R ectu m /P ro state t . 27. Extremities 28. Back. t . 29. Reflexes t 30. Blood t 31. Urina t t. a t a oizr Qr S3- Cps. Right' 5. Hearing L evels {Decibels) 250 300 1000 2000 Left (U se this space to descube all defects) Approved [ 3 R estrictions: FORM S-12SS6 Hot Approved I I Limited Dace Examined JO H N F . SC A U E R A, M. O . Examiner 4000 OCCUPATIONAL HISTORY L is t a ll em ployers for whom app lican t worked for th e la s t th ree y ears PA ST MEDICAL HISTORY (Record nature and d ates of a ll injuries, operations and m ajor illn e ss e s) R E -C H E C K S St S P E C IA L EXAMINATIONS Data of Last immunization SooriTfiox - . . . . . . . . . . . . . . . . . T etanus ---------------------------- 1 certify th a t I h ave n o t receiv ed Workman's C om pensation, pension or dam ages for any in jury or d is e a s e ex cep t as follow s: I fu rth e r c e r tify th a t 1 h a v e r e c e iv e d a p h y s i c a l e x a m in a tio n (in n h id ing aw e w m M tr e ' vniTrrnri~n 1 and h av e been informed o f th e r e s u lts of such exam ination, and th a t my occu pational and m edical h isto rie s, a s recorded above, are true and com plete. Witness Applicant Date Indicate sc a ts and disfigurem ents . Name-' JO H N F . S C A U E R A . M. . 101 SAM PTON A V E N U E SO. PL A IN FIE L D , N. J. >X-. 6- V isio n w ithout g la s s e s 7 V ision w idt g la s s e s R - U A & L L - 1 4 1"9&.. R - 2 0 / - JtQ. L --2 0 / 2 a . R -1 4 /^ .r. L -1 4 / .y .j R - 2 0 / .......... L --2 0 / ............. KEY: Normal g ] 10v Appearance 11. Skin 12. Eye* 1?. Eats/D rum s 14. Nose 15* Throat 16, T e e th / Gums 17. Neck 18, C hest/B reasts 19. H ein 20. Lungs Abnormal [ g Not Examined Q e T 21. Abdomen/Scars ( z f 22. Hernias z r ' 23. Inguinal Rings 1 3 24, Ext. Genitalia 3 . 25. Anus 26. R ectum /P rostate 27- Extrem ities d 28, Back. ( z f 29. R etleres d 30. Blood R ' 3L Urine q d 3' 13ezr O' a & Approved 3 ] Not Approved f~] Limited R esrtictioos: FO R M S-1 2 3 5 6 (U se th is p S c co d e s c rib e a ll d e f e c ts ) t I M 2 . Date Examined / JOHN F . SC A LER A , M. D. Examiner OCCUPATIONAL HISTORY L is t a ll em ployers for whom ap p licant worked (or the la s t th ree years PA ST MEDICAL HISTORY (Record nature and dates of a ll injuries, operations and major illn e ss e s) 2<S<X_ RE-CHECKS & SPE C IA L EXAMINATIONS Q.-ttJ' TCtA^cyl (*} Dace of la s t immunization -&awti7gox~~.. . . . . . . . . . . . . . . . T etanus ---------- - -- . . . . . . . o I c e rtify th a t I have not receiv ed Workman's C om pensation, pension or dam ages for any in jury or d ise a se ex cep t a s follow s: I fu rth e r c e rtify th a t I h a v e r e c e iv e d a p h y s ic a l e x a m in a tio n -(iiw ln d ia g - r i MW tttic - f T ~ : r[u i vn-) and h a v e b e e n inform ed of th e r e s u l t s of s u c h ex am in atio n , an d th a t my o c c u pational and m edical h isto ries, as recorded above, are true and com plete. Witness A pplicant 9 ' 9 -? 9 Dae Indicate scars and disfigurem ents