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7CM Epidemiological Scud/ - Individual '..'ark History
Form o - workers known to have died (please attach copy of death certificate)
1. Cate of birth o i - o
Status at lice of death:
5. Employed __________________________________
2. Date hired
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6. P.etired (give date)
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3. Date of death q / . / j -4^
7. Terminated (give data)
4. Place of death Ol-^cuv-&
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8. If death certificate is not available, please give name of worker
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so that death certificate car. be obtained, Ilo contact will be made
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with relatives or attending physician..
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Job history with estimated exposure
Title
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