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PART I
FOR OCCUPATIONAL DISEASE ONLY
state or Ohio
D.mSiS.
Bureau of Workmen s Compensation
First Notice of Death and Preliminary Application
EMPLOYER'S REPORT
EiMnc of employer:..!:;-?...Philip. C.s r-.v
irC.Cc-vnonY
(Namt ** a)<Mra on intureoce Ctnilirsi*)
2. Office Address:
.........Vt.ai'nc...Ay?.. H^rilton................... Cir.t l...............pi:ip
iNeeiker)
(Stitn)
tCovatyi
(Cuy)
(Stau;
3. Nature of business :..:.n.M` V.lr
........... Type o! Organisation:-PP............
i Psrm.et. Coal Miner. Mh. Mf* . e*<->
' * Cetp. or Individual owe
DECEASED EMPLOYE
Unri *',r
?l
4. Name: ____________......................................................-...... -......
(Finti
IMsiiitlnsHil)
5. Home Addreu:
.......... -.............. .yi.nsin/.at^
IKwaiker)
tSmet)
(Cuy)
6. Ai.!a^4^?.Fe^le:..I:!'il3 Div'^.d'w'd^wed:...>:arrie4.....l^uriiy ^?OrC7-0405
i.'O Do mot write in this column
TJiuieMJitT Jt.t H<r" F>><
bait ( Daaih
rymni bat
7. Number and rclationthip of dependent!:........9.S.?.. " .:.!.4:.L9..............
t. Wu deceased a partner, member of firm or owner of business?... .:*
OCCUPATIONAL DISEASE (TIME) _ ,,_____ 9. Where was disease contracted:.......
. .................. .........................
V
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Ap.tr lUimit)
10. Date quit work:......"CO
of death:...!.0-1 '-cS.. .Date
.... \
11. What was deceased's occupation?
/s/;$; Trr.et Di.aat
12. Explain fully the kind of work deceased was doing when disability began: i............ ^
'/..........` ,
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13. How long had deceased been doing this work?........... 14. Experience of deceased employe in this type of work tl&rioY.
A.
AttUll VVi|
i
15. When did the last period of employment with this employer'beffin?
Vr
16. Name the employers for whom deceased lidd worked'during the three years preceding the beginning of the disability, and give their addresses and businea^:.
CPp.KSll*A| L><|ro o( U>gff
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17. Decedent's earnings wert reported on payroll reports of Risk No
Under Manual No................
...
By signing below. I do hereby certify that I have authority to execute tliis Employer's Report and that
the answers to the que.tions given in aid report are correct to the best of nv information and belief: that
the deceased herein named was, on the date shown herein, an employe of the undersigned and at the time of (did )
tRtering into the employment from which the disease is claimed to have resulted (did not) represent himself
as not having previously suffered from such disease.
Date report sent to claimant
t:;- r;:r.s? c.r.~EV
ca.
Date received from claimant..
Y /A.2^TM sup^n.
Y/iOfficii! Iile'et err .'.!{mnt mi A.. Irkr>ir<ii!/ /
Data mailed to Bureau___ ___
iNint { tmpiertr i
i |n*uriu CffificAlf'
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