Document VjLgKnLax48xrVZOBLkBJQop4

O .D . 9976 OHIO DEPARTMENT OF HEALTH V CERTIFICATE QF INDUSTRIAL. OR OCCUPATIONAL DISEASE S-S>- $ N A M E O F P A T IE N T --------- R ec*a " ** ^ i n z A D D R ESS: S' tvre' e*t *an^d No....-.', S 7 7 1 W e s t 3 S t r e e t c ity or' vi1,a^ Cl e v e l a n d , O h i o ; ' PERSONAL AND STATISTICAL PARTICULARS Sex A ge- r- - Color Country of Birth M ale ,, 2 4 W hite. U .S . Of A'/ -i Single, married, widowed or divorced (write the word) S in g le ., Occupat i on . (a) P resen t trade, profession .or woik (in which disease'was acquired) '...Tr.UC.fe.Dr.IS S C .______________________ Particular kind of work in such trade, etc.......... H a n d l i n g -- MEDICAL CERTIFICATE OF DISEASE ` v Diagnosis of present illness.....ll?'.^....?.P.i-?..???.i.?i___ :.----Chief symptoms and conditions__.i i e a ^ n e s s o f ^ i i B ji^ -an d -l-eg sT--par-al-ys.i-s-of--t-h9--r-t--side--of--tbe .fa o e .,~ d ila te d -r.ig h t-..p u p il.r ..jdis.ttjr.banoe-of . .sE .ee.cb ......................... .............................................. ......Vj.. D ate first symptoms appeared__MarC.b..l.*..JL9.3.3.............. -- Gaaolina...&..Oil..--------------- _____ r.... Complicating Diseases (such as alcoholism, syphilis, tuber Date of entering present occupation......__S e p i. ~ 1 9 3 2 ____ culosis, etc.)......... S o n s ._______________________________ Employer's name......Hi.g!^y...Q.il....C.O Stny......_______ Address 3 9 7 0 J e n n i n g s R o a d ' Business (kind of goods made or work done)...0.i.l....&_______ G asolin e Jobbers (b) Previous occupations : Name of occupations S o lin e O il C o . (Warehouse Entered : Left (year) (year) a n d -lo a d General or Oi ) Go . .....L929... -0 9 3 1 -. ---rcry- -TO't'3" Previous illns sses, if any, due to occupation: Disease or illness , ' Year Lead P o iso n in g 1930 What in your opinion caused this affliction?___C .9.Q Stant exp os tire t o E th y l Gaso l in e _______ D uration (actual, estimated)___ S-MBaks...... (Check which) Additional facts...................... .......... ....... ........... Date of diagnosis-.............M^r.ch._.l i ._-------------------, 193S._ (Signed) . - . K e t e r s b a l l a ................... . m . d . IncL Hy. 3--15M--3-32 - Mar-r -l- S , 193-3-- (Address) ...2d4a-...^....2 -S t r gg-{; - Mail to STA TE D IR EC TO R O F H EA LTH , Columbus. For Instructions See O ther Side