Document evJgeBarXa0aqemRv4zmwrgZE

T tw IQ-Tf 'l ;/^r-' v- - v`. . . l! Cs*(>lTh or penm'svlvamia ' -ocppwc.t or L*ao<< no tjaw*fpv ' 9J`C`0' OCCOX'IOKAL 1NJL.amO CISCASC COMPGXSATIOM niMiMURG 17 US EMPLOYEE'S CLAIM PETITION FOR COMPENSATE UNDER THE PENNSYLVANIA WORKMEN'S COMPENSATION ACT OF 191$, AS REENACTED AND AMENDED ' ' ' * .` (TYPE OR PRINT CLEARLY) . . SOCIAL. ICCLBITY.NO. . e .T. s3SSel-: . . .. .... .182-05-0186 IAO OR NUMVCIt - 1 ~^fn 1 -* ' ^r <"' ' fcW-' -r' . \ OATS OR 6IRTH . 10/1/07 . ,TQ WI' r ..^ 1'. aUATY . Mir: - STAY* _ Sir coot TtLEAHONt * "".'. : * 19008 356-1468 *^ :., .: ii -- Ti. VsT'ivi^J^r-'- < Trj'ctr--- Vr fT .V.' **<-! |R PLAINTIFFS 1 ; || ,; EXHIBIT | Iffi ' ' 'r ' ' . 1 > . : v .' ........-^rtVjSS&Sf )p.Tpun. i.t-7 ' INtUNAMCC CARNIIR ;inghouse =-- -Tetaa^Turbine Divis ion , '-.p---. -- * -t'Tii *m-Y*yU' vano numis- * STRUT AMD NUMUR . . >' : :. v. \ j . V S'-\ i. v.^ .tgRe.a'Tbrr"v-.fN`*' r-~'-TS''".-MYvrr.,-.' ;.>c\*S" TAT'`.'V' .''.V. ': . -v-. ^=x9iir^ CITY. OR TOWN : -V--Pa?:-: .f *tAth: . ; -- v:---- -"--O^ V'/ '.>.' iiAtoot * O.,-- J>_':t-r>i??-V; OSiL HONORABLE BrrEREEt : s . . - - s.- V ' .V ;. ?" v -: :. , .,.. ._ >;C32>' sbocenaoed claimanc n-jpeulnlly allegcsthc following fact'^'K rareof^**p*<$**'*Manufacturing steam turbines " '' ' , Tl.aaRgSgeSrr_-^ insulated, trUmTrbbiilnieeSs V>:1 , - --% -V-^i n~e*f J.^-rDCSCRIR* YOUR WORK INCLUDINQ Tin.t, !F A*fV:rt.^ ' \ i--V : v ' '' V exact date unknown .'V* VV.v' * . . V . , V- V; w ify-iajury occurred otr <-apIover*s premises S> . ; - .-.... ..If not, state exact location, including county or state:' igjjjf ..v v .--'~v . .' ' " ': ,xj: injury .or disease ocwni^aAt following nMn . * inhalation *ingestion of;.. insulating^ aaterlaTa^-'--"^':~ ,- . -:~ V-: ' ," ..-.' i'-'g&M .Tib*-', 1 - !:'.Vs . .. * - -- .v*-* * :* -4-. * ..'..*.*..;>:.v-f^s - ---------- ------- -------------- ------------------------------------------ ----------------------------------------" occmK mn.Lt thk syeHTt wHtCH msuctce m, roufm>Uffv or oiscaik C* V: tihronicfObstructive pul^c?iiary disease heagt:; ofay lajary-br disease is ^ V'^arp'i a<|' an'voXvdngtvtV aaligPflnt tiMiT. left ^S- ~ OESCPIPC FULLY. INCUUDma PARTS OP BOOT APPCCTCO eld:ii fwr- OCCUPATrONAL.OISEASE aader Section 108, compI et 'the fellowing odditiond Iniormolion: .. '. ^y_.' I kecame(tota21y> (partially) disaUed as a result of tie above occupational -disease : .' :-'>.^ 'r`>r\\. ffl^on pywa^T' 0>>9T-gL: DtJ I^QtAA)" }.L/L^r.Z&i$ -^SciTL ' Vd-- t '___________:'" * e.1^- '! ' j -_V _ _a_______' *' ' '' V '_____ .. exposure arts; June30. T973,'todielMzard of die above occupational disease was T >m ----"-yC'-v'r ^J5 ................. ' employed by .. 4J . . ^~*T >. ,. _______ "-v " " l > *. 4: - ,19. ., while 7s>c; Prior to June 30, 1973, I was exposed to die hazard of the above occupational disease while employed by: 7,-.^,:," . ... -.. <>:.'/' - : -:' ' ' . - '' ' "* - . oAxes of employment . RARE ACL gMOLOVgUS .. .. #_ . . .. FROM ". . : ` TO vV UjpM'iAA/sk/)o'<p-j fevrfre ,Pa, a/a? ~ 1 ii/72 -^28006483 *--!*tv rvtaaimRf or otW si do v mV f*r6duced 3/93 ^;v /j. r/us treated by the fallowing doctors sad/or hcspitsls: ^ ,/?jpksyry /&+++* 'ib-P. $(,/ &. .{ i .... ^,,:<.v.(:J \.*,v .->--} f. / 6lh tuucrao AQ0MC3SES. IF MONK. SO STATS. /L**AL*)*-*Sj ____ J&-. __ .. . . 9. a. I ad..i/.f. rcooest sit escplover furnish the shore medics! and bospies! services/ y:. S* 'S>\ ;- O y . y'V;?..- --Mi 1 O '* - .' . J | 30* J' od:yyfl / 'faaiA awrjee sseerrrriicceess.. -. ' Ifae_for sCor port oT these, services u. c*.'// aJursjir .m^y^rdstss, from KACr DdL \M><U<#r* '~ -- 1L. Ii i?'. X. ^ A. ed mi-mock, at my previous occupation sod at myforaer wages, which weret - /*t /< - ed upon uqr em plo' yer'on . * . j **< >%/ *"**%3 '- ' . ' .">' '* i^hdLs o*-y In the following msnnervv'^ -. ./sr2f-- STVrCTO WHOM AND MOW MO TICK WA iVKN M[sets to be important: 6/^4^^L ***? . VV^MBl I ask I ' f the Peoflsjrl -honorable Referee Issue so award of exuspenssuoa to ne. io accordaoce .with tbe pirpvi-? I'sCxNapcanation Act. iASE ESTER MY APPEARANCE FOR PETITIONER Mr///+*' 7> ao &j ATTOWMKrY<9 s~ vs3^g^ . - .` 'J^Aclu /** /4//0. * ' ' - -wfctf:m-;?.:^SstJ ICE This s*iion should be filed original and five exact copies either typed nr printed, It is only necessary to . meke'edneavfrte the errginol petition. y. _ ; ; .. . . .,, 2B006484 ) ' :V Produced 3/93