Document LKBLXgOrG7j8Gje3o4XqkdEb3

!*;i UA-VjDfUCt'JUW.T CO ,`T'" rst-- ,, .. Form No. 2Dc 0 tOOCfc ^ACI. NfWAK. H. J. 67102 <4 State of New Jexsey .:C*K3USAT0N Department of Labok and Industet- f KT *H. N. J. , r n /? \" t* *\ C T* Nt r\ a ( ^ Division of Woikmen's Compensati^Jjj j] * jj EMPLOYEE'S CLAIM PETITION FOR COMPENSATION | i PLAINTIFF'S " EXHIBIT N61086 JERRY KICHAEL DS CARO, . Petitioner, vs. ;; Selfrittfiurcd (FUacS^4n*uraee Company) _. KATXOJIAL GYPSUM. COMPAHY*j Drasin,_Varshav,..Auerbach & Rudnick (Attorney lor Petitioner) _______ _ .Respondent J 3315 Highway #35, Bczlet, N.J...07730 (Address) To the Division of Woekmen's Compensation: Petitioner, alleging that he sustained an injury by an accident arising out of and in the course of bis employment with the respondent, compensable under R.S. 34:15-7, et seq,, supplements and amendments, respectfully states: JERRY HXCSEAL DE CARO 143-10-6220 1. Name....... ...... ..........- -______________________- ...---------Soc Security No._______________ ________ 2. Residence Address: (a) Street Address, (b) County___ Mprril 119 Washington Street __^ __ Morris tbvn9"Rew Jersey .(c) City or Town. tTMiS CLAIM PETITION CANNOT at PNOCtSSm WITHOUT THIS INFORMATION) 3. Sex___ !L.... 4. Age 56 5. Marital StatusKarrlsd. g, QceupationJShippAPS Toreaan (at tint of accident) 7. KW RATI0HAL GYPSUM COMPACT (a) Address 30 Division Avenue -^Millington, Hew Jersey (b) Elding' " " ';.... _ . 8. Did employer have notice or knowledge of injury?--^^?. $. Place of accidental injury Millington Plant 10. Describe the accident Vorked in asbestos On what date?___ 1968 _ iw- *r * 11. Date petitioner stopped work__ 1971 ___________________ 12. Describe extent and character of injury. If there has been amputation or loss of usefulness of any member or impairment of any physical function, fully . 13- Wages or earnings--Compensation paid: Rate $ 40.00 Weak Temporary disability---------------------- -------------------- Permanent disability*........................... ........ ............ 14. Was medical aid required?.. _.?*?...... Was employer requested to furnish same? _ .7*.* Was it furnished?------^HOL. . If so, between what dates? _ Hoy* 1968 - Decesber 1968 If not, what sum was expended?______ _______________ ____ 15. Give flames sod addresses of physicians and hospital Dr. Mlebcal St*tn Dr. Cox Dr. Wright Rlvor&tde Hospital Srinr Bamcbas Hospital St. Clfiir Hospital 16. What other facts are there -which you believe important? Your petitioner therefore prays tbae the Division of Workmen's Compensation wil* determine the amount of compensation due your petitioner from said respondent, under Revised Statutes of New Jersey, Title 54, Chapter 15 and the Acts supplemental thereto and amendatory thereof, and that your petitioner may be awarded his costs in this proceeding, and such other or further relief as may be proper. State of New Jexscy. County of ,y (Petitioner) /^JERRYs'/TIE CARO ss. ................... JESSY HXCSSAL BE CAtO of full age being duly sworn according to law, on his oath deposes and says: That he is die petitioner named in the foregoing petition; that he has read the same and is familiar syith the contents thereof; and that the matters and things therein set forth ere true ac cording to the best of his knowledge and belief. '-.I O' /?, ----------- /lC____T____(_P_e_t_it_io_n__e_r)_ F-RRY HE' CARO Subscribed and sworn to before me this.. of Jeaoery fifteenth - day KAETiS ^S^-KiDKiCE An Attarnsy-a&~LE....o. Jlew Jersey____ (This affidavit may be sworn to before any person authorized to administer * Mfh 1 Notice To The Respondent: The foregoing claim petition has been presented by the petitioner to the Division of Work* men's Compensation for hearing and determination. Unless an answer in duplicate is filed with the Secretary of the Division, labor and Industry Building, Box W, Trenton, N. J. 08625, WITHIN '0 DAYS, THE PETITIONER WILL PROCEED WITH PROOF OF CLAIM ACCORDING* TO LAW AND MAY OBTAIN JUDGMENT AGAINST YOU. Division of Workmen's Compensation