Document g27pdL2mq6YOeE7qyDyJ8xXYQ

ATTENDING PHYSICIAN'S CERTIFICATE NOTICE: This certificate is to be completed by physician actually attending and treating the claimant. It is not to be completed by any Company Examiner who is not acting as claimant's private physician. 1. Full name of patient. Ben L. Hester 2. Where did you first attend him? At his home, or your office, or where? At hie home 3. On what date were you first consulted on account of injury or sickness described on the other side hereof? 4. During what period and how many times did you visit him at his home on account of this injury or sickness? 5. On what date did you last give him actual and necessary treatment and what was the total number of treatments on account of this injury or sickness? 6. State the precise nature of this injury or sickness and give your diagnosis as finally made. Maroh 8th, 1933 6Irom-,^^ffk ,, Septa IB Confined to bet A Up A about Number of visits to home .. _____ . ___ ______ ___ 19.33 Last treatment____ Sept* 18______________ _______ ____19 _ I*Total number of treatments attendance SlUC# MUTCh 193 ch- Bronohltle, attacks of pleuriey eh Brights with hypertension Pulmonary Tuberculosis 7. State in detail the symptoms observed by you during your attendance. Cough - loss of weight - diminished expan sion - Tubular breathing over upper half of ehest -Roles over entire chest - Blood Pres ew* Weakness. . 8. State in detail the exact condition at the present time and give your prognosis. Condition poor - improvement very slow Weakness prognosis poor 9. If the disease is tuberculosis, state by what tests the diag nosis has been confirmed. Tubular breathing shortness of breath rales oough 10. How long will he be necessarily confined to house, w'holly on account of this injury or sickness? 11. If not confined to house, how does he spend his time or purpose to do so? patient la confined to bed part of time From __________________________19... ... To..________________ _____________ 19. and up and about Dart of time 12. Is he wholly unable to engage in any work, occupation or business suitable to one of his experience, training or qualifications? 13. If totally disabled at the present time, will such disability be permanent? 14. If total disability will not be permanent, approximate a date work of any kind may be resumed. IS. Can his ailment be successfully treated while continuing at work, either for full or part time? If not, state why. ... Yes ____ _________ In my opinion yes* NO \ been such? Yss -8-10 yrs^ Date signed....... Sftj/t# 12......................... .........19...,?? *........... .................................................................................... Year graduated..................1.9.19.................................. ........... .. Signature of Physician 3)r. W. W. Wild Rd,,,*no. eet Resident physician for A Rubber Difii Lon City.. Horth Charleston___ state 3. C*..... Metropolitan Life Insurance Company DISABILITY CLAIM DIVISION Permanent Disability Section Form 0347 Apr, 1930 PRINTED IN U.S.A. STATEMENT OF CLAIM FOR TOTAL AND PERMANENT DISABILITY BENEFITS TO BE COMPLETED BY EMPLOYEE 1. What is your full name? 2. Where do you live ? 3. Please give your personal description as follows: Ben L, Hester Street. X4 JT,JCllIS...... City N Age__ 84....... Sex...?*SXO.Married ltOIX State. S * C_*__ ___ ________Color.White... 4. Nature of present sickness or injury? Chest Shoulders Weakness In knees 5. On what date were you first totally disabled by this sickness or injury so that you were wholly unable to work? 6. Have you since that time engaged in any occupation or busi ness? If so, state particulars. 7. On what date were you first treated by a physician? 8. Name all physicians who treated you since beginning of this disability. 9. Have you been confined to house by this sickness or injury? If so, how long? March 4th, 1935 No . March 6th, 1935 W. W. Wild .MarOh 4From... ............ ..............., 19.........to.. April L......... -....... 19-31 10. If not confined to house, why are you unable to work? 11. Are you now wholly unable to engage in any work, occupation or business? 12. If your disability is due to accident, answer the following ques tions: (a) Were you at work when accident happened? (b) When and where did accident happen? (c) Describe accident; tell how it happened. lo. Are you receiving benefits for this disability from any other Insurance Company, Society or Lodge, etc. ? -- If so, give particulars. HO 14. Are you insured under any other policies issued by this Com pany? If so, give numbers. Wq Chest9 Shoulders, Weakness In Knees Yes CompanyAmt. per weekNo. of weeks payable........ Date........_SP^*.--13ft-.,1933.............. .........................................Signature of Employee......... TO BE COMPLETED BY EMPLOYER Group No.. 2045-0 .Serial...... 4Q_.........................................Date of Issue.. 1. Name of employee. Bo L, 2. On what date was he employed? 1-5-23 Harter ei.OOO.OO .Amount of Insurance. 3. Was he a full or part time employee at beginning of this dis ability? 4. In what occupation? Full Time Wearer 5. On what date was he last at work? 6. Was he laid off prior to beginning of this disability? If so, on what date? 7. What was his weekly pay at beginning of disability? 8. Was disability due to accident in course of employment? March 4 1935 No |25.00 NO 9. Has it been reported to the State Board or Commission or any Insurance Company as a Workmen's Compensation Claim? If not, state reasons why. mm 10. Are there any circumstances which would cause you to question NO the validity of the claim? If so, please give particulars. ----- 01NKHAL ASBTTrTOS h HTBB7H DITIBION Date.. aaptMtoar..12#. 1935 .Signed.......... ................... o..ILaybflstoa-tle3ihattan^inX36* b>. W.KJfuckenfuee.... ATTENDING PHYSICIAN'S CERTIFICATE REQUIRED ON OTHER SIDE