Document mpeJ1B14yXwbELbnLKXDemDkJ
nent of Libor end InCusL OF WORKERS' COMPENSAliuN
a
luuumcni APPROVING
SETTLEMEK
i V
a DISMISSAL
DISCONTINUANCE
?r~'3rtS
District Office:
.\
FIOCftAl. CMFt.OYlA'S IDENTIFICATION NUMBER
ACC
3a
NAM(
_crr _ u. ^mii (^g^vLig . *S7~
Us
I
, . , . = |aooj*esi
4*.
s8 SSStsaar^o_ c ,,
*SrJi_A-S OMsCfc CAWtte-.
vs
AOO.CU l.^cm*i^caaacnfr^ ) Srr
NAMC '
O h* 2
<* Ari.1 l- ,5g Brr^wVs-Tv.
>IK
2
Za
AoontSS iiiiueie Cowiivi/^a.-j-ws re*jT\ 3o/
c9
O & AAP9VCEAARtPIN*G
ts
j ilrWHt^' <3 I^AMilM I fhwl
NAMC (lrt0ftC*t If Nl CovrM Of If MMHturM|
ss IaEAxJ/.-^Q
i!
OAT* OF ACCIOENT: QCC^ P <)(,,,( fO
OCCUVATjpj^AC^CXfOSuMC^ j _ ocscKiac <#wty>
'/fcj2rOw'(C^T
1
Weekly Www
>33;^
Rt(t) gfr*?
iFRE-OPENEO PETITION. INDICATE FOR LAST AWARD: DATE \1 fi* ft# permanents V-TO/O T temp s
]
This mertsr hiring com* on before the Court on this.
------- <^of_^------------
. i* ga.-
2 ORDER FOR JUDGMENT:
It appearing tbit the Petitioner suffered eompenubie injury on the iboee mentioned date while in the employ of respondent: it
is Ordered and Adjudged that petitioner be awarded compensation benefits, payable as indicated on Page 2. OROER APPROVING SETTLEMENT:
The parties having settled the matter and a finding by the Court having been made that the terms of the settlement are fair and just; it is Ordered that this settlement be approved and the petitioner be paid as indicated on Page 2.
OROER FOR DISMISSAL
This matter having come on for hearing upon the respondent's motion for Dismissal which was made and duly served and there
being good cause shown, the claim petition herein h hereby dismissed for
. CD 1. Lack of Prosecution
2.
ORDER FOR DISCONTINUANCE This matter having come on before the court and the court having received evidence that this muter should be discontinued and
for good cause shown. It is ORDERED AND ADJUDGED that this matter be discontinued for the following reasons:
It is FURTHER ORDERED that the payment indicated on Psga 2 be mada a part of tha Order for Discontinuance for petitioner's disability. (Percentages and members involved.)
WC HEREBY CONSENT TO THE ENTRY ANO FORM OF THIS OROER ANO ACKNOWLEDGE RECEIPT OP A COPY. (Sign U WPliteBIsl
--. STENO PEC______ _____________
BY .
(PETITIONER'S ATTORNEY) PETITIONER inhere SBpWteaiW (RESPONDENTS ATTORNEY) vc-iaetsecs
____ ________Cmlz'sL32.
"HEARING OFFICIALSlCNSFTuRer a
/MPAAT1 E)
(JliME'lJifftArilNGOFFIciA^1 (PfJltfr Ofi TYPEl
Judge of Compensation
O Referee
RESPONDENTS ATTORNEY
GAF15101
iw ^ir ovtmant of Libor and Industry
(
DIVISION OF WORKERS' COMPENSATION
UJf JUDGMENT
TIMPOAAAYV: ______ n--ks*r% ... - _
$ - ..... ........ .......- (ss S
--
part Mane* du S - ^ _
:
FfftMANfNT:
,. a **Va *_...., Jf gra
^gr-Q ^
Mtptej! Bi>U {Docton and/or Inititutitml/
$JJ <u&mAucJ
e^r~z~s
fy^Juu^J yb" Au~, `22^`T'- "iT^ .
'<^*7 h f^^--
MEDICAL PEE ALLOWED (CasaM ane/e> TM.mom*l>
TV
TtiC^T-
l\p ^nv'/'V a-s.^fc'.l
TOTAL AMT. ALLOWCO 1-5X5
z-r
AAVASLC BY PCTITIOMCA
~i<r
PRAKSVPAOSNLOI CNbyT
iv.rt>
,v.\0
ATTORNEVISI PEE
MM2M S
STENOGRAPHIC SERVICE
lAcCt ft 5 C. A
Static smesuMD sswu^
TOTAL
T70
TOTAL
~lsf
RPCATVITAIOIUNIAST
310
PPACVTIATSIOLMCCABY
PAYASLC SY ACSAOMOCNT
ALO
PAVABLC SY
awqwocrt
we MKftCBV eOMSCMT TO TMC BPMM^ rORM OP THIS OAOCA AMO ACKNOWLCOOC
A COPV:
IHEARINGOPPICI.
uJdL^
A Judgt of Compensation
Rafaraa
6-2.S-&
{PETlTIONtfl'S ATTORNCYl PETITIONER (Wkm AppitabU) wc-iaa.1 (R-a-771
RNEVI
RESPONDENT'S ATTORNEY
GAF15102