Document X7JnBEVXpa2eG9a6Y1LG3XDER

*au-stati oma amv cn. JC8 HMM ST. MWAJUC IM Fas No. 20c Sun orNrrJnsnr On ' 0 (Do *oe Si to) oiY.qr workmen's DviinaNr or Liboi iot Inajlj1j^KT0H( HJ. DmsxoK or WoinaK'j CoMPZNSixggf g ^P.Wo_2CZX2T4 utc * EMPXOYEE'S ffiBSWmON FOR COMPENSATION j PSh*o0*r, i (Kibu of Inssnuxc* Compony) PLAINTIFF'S EXHIBIT NG108N YS. yynftCTT. rw!TrM rnxyy.w - glee, ClanVenhora, l^aric &_0afcsgaon (Attorn? fa Fcwioatr) 205 BTOdSfc., Red Bonk, M, 3. 07701 ItaftoaiM*. J A v. - (Addrwt) To tbz Dmsxox of Woxkmxk*$ Compensation: Petitioner, alleging that he sasained an injury by an accident arising oat of and in the course of his employment with the respondent, compensable under 2L S. Me 15--7, erseq,, supplements and amendments, respectfully states: 1, NatTir 9*mr**a_____________ .2 Residence Address______ COlaabla toad, (Stmt Addne) !Soc Security No. 147*09--43CS (Smaarsot Count?) auKlng Ridge, a. J. (Cit? a Tews) 3. s--* ^ 4* Age_Si~_ 5. Marital Sams_________ A Occupation--Poretwi <Ctagct acridmt) 7. Name of employer --K&fclgPfil ,fiSfftniB .CWTEBy ............... .. (a) AddressSfl. Pivinian *wbw, Mill!n^tan. K. J. (b) Business Anbnnte* elding A Did employer hare notice os knowledge of injury? Tffg__ On whar di>_ since 1934 9. Place of accidental injury KillJLn?SC>fl.Pl*nt Date 10. Describe the accident _ Asbaatosll _ _ __ __ 1L Date petitioner stopped workDate returned to work__________________________________________ . 12. Describe extent end character of injury. If there has been amputation or of usefulness of any mrmhrf or impairment of any physical function, fully _Anbgtoin______________ ____ 13. Wages or --wimy 89>0 .per Temporary dmhBwy-- KtsiRvJ* psd; Here - KnglJiuiTP Permanent disability Baximsi 14. Was medical aid 7ea Was employer requested to furnish ** _____ Was it furnished?-----2&S--If so, between what date? __________________ ;__________ If not, whatsum was expended? -_______ __________________________________ _________ 15. Gire >-- and ddmw> of physicians * hospital Pr* Robert B. Tgftncia, 120 Scagtlt Avenue, Staroit, *?. J. 16. What ocher fagg tre there which yoa believe important? --Fffei fiQBCn.was. figsfc. notified that he had asbestosia in 1955. Your peririoner preys that the Division of Workmen's Compensation will determine the smount of doe toot petitioner from said respondent, under Rented Statutes of New jersey. Title 34, Chapter 15, and die Acs supplemental thereto and amendatory thereof, and that your petitioner may be awarded his costs in this and such other or further relief as may be proper. State of New Jersey, fUi County of *ggreB? */ SS. CLRKC&T auCGEBXO. nf full age being duly sworn according to law, on his oath deposes and says: That he is the pcacioner named in the foregoing petition; that he has read the same and is familiar with die contens thereof; end that the mitten and things therein set forth are true ac cording to die best of his knowledge and belief. ^^e*****^ Ate*** (PtHaadtr? Subscribed and sworn 10 before ^^Tl fn ij_ /_____ this. day yp. C/L . (This affidavit may be sworn to before ffprraBV wmilC_QF HEW JERSEY \ Earn March 6*1323 To the Respondent: The foregoing daim petition has been presented by the petitioner to die Division of Workmen's Compensation for haring end determination. Unless an answer in duplicate is filed within ten davs after the scmce crf this pennon and notice, with the Secretary of the Division, in the State House at Trenton, die petitioner will proceed with proof of * according to law. Division op Workmen's Compensation