Document n9v4amZ2oQ3E8jyDG3bXq10jw

FILE NAME: Garlock (GAR) DATE: 1958-1960 DOC#: GAR027 DOCUMENT DESCRIPTION: W orkm en's Compensation Case Report 'a UAKT 4 l i f t H * *4.i M^HAUTO U I,W ki*(H M. 8UFfAlO 2 HO FtmHU S t NEW YORK M N C < tn St. XESTE* 14 i h U .. St. W. W O R K M E N 'S C O M P E N S A T IO N B O A R D YATC o r NCW roan NOTICE OF AWARD IN DEATH CASES IN WHICH TRE ARE NO PERSONS ENTITLED TO COMPENSATION SYRACUSE I IM Ww m St. 1 W.C.B. CASE NO. 2 CARRIER'S CASE NO. *0 COOE NO. 3. DATE OF ACC 10ENT 7590*291* 4. Grace Baylord NAME OF OECEASEO 91 11-2-58 t: B a t e or bcjth ------------ 11-2-58 (. DATE Of HEAPING 7 DATE OF RESERVED DECISION 8. OATE OF THIS NOTICE G a rlo c k Packing c o . Palm yra, R.Y. 14-28-60 / 5-1*-60 n y CARRIER B aployera Mutual H a b . 1 0 - C l b b i S t r ..................... R ochester, N.Y. ADMINISTRATIVE FINANCE OFFICER WORKMEN'S CChPENSAT ION BOARD 80 CENTRE STREET -NEW YORK I3 .N .Y . c e : S . A. C orrao ces E . D, ig o a ............. a`lhisiridiaii'dua YOU ARE HEREBY NOTIFIED t h a t w-*an*TWarw*wy on d a te s t a t e d above a D eciaion and Award a t aade and d u ly f il e d th ia day aa follow a: IRE EMPLOYER AMJ/OR HIS INSURANCE CARRIER IS DIRECTED TO PAY AT ONCE TO: Robert B yen i Name ' f the auai of t i 1 *0 0 .0 0 for R. D. #1, P alm y ra. N.Y. Addreaa expenses; THE CHAIRMAN. WORKMEN'S COMPENSATION BOARD. "VOCATIONAL REHABILITATION FUND" * the sun o f 1, * 0 0 . 0 0 j n accordance with Sec. IS, aubd. 9 o f the Workmen'a Compen sation Lawj r-- ---- -- ' ^.THE CHAIRMAN, WORKMEN'S COMPENSATION BOARD. ` FUND FOR REOPENED CASES" the sue o f * 1 * 0 0 . 0 0 in accordance with Sec. 25A of the Workmen's Compensation Law. * Forward checks payable to CHAIRMAN. WORKMEN'S COMPENSATION BOARD, to the Attention: FINANCE UNIT, 80 Contra S treet, New York 13, N.Y. y eloaad. Finding of no dependents. Memo attached. D E C IS lO fn t _ i < i w t * w * \C -d i (M -55) C -68 C-68 Q C h air* an C .6 8 r .ft ( MKMORAHDGM Ret 75905294 Batate of Oreee Baylord ea. Oarlock Packing Sap* Hu CO. Finding of no dependenta. Allow'MfOO.OO funeral exponaea payable to hotort fiyera* eon of the deeeaeed, wbo paid the funeral bill. Carrier to pay the uaual ausa required under Sooties 15-9 and Section 2$-A to the Special Funda. Caae la eloaed. D fK /T t 4 /2 6 /6 0 Dv h a L D i , J L i - L f 4M4HX 4 1*4 N u * WMW4MTOH n W M rM It. onAIO S f ie trmk** ft. NCW TO* t 0 H A fU m 4ts m IM AUto ft. rrtACtm : ftwi* OA* W $m WwAUr* * STATE OF KEW TORE . WORKMEN'S COMPENSATION BOARD s, NOTICE OF DECISION IN DEATH CASI W. C. B. Caae No. Carrier Case No. Neme of Decedent 79909294 91 ------------------BRACT t t v i n a n ______________ o w " " *s. *<* im c E P PALIYM, N. Y. Bmploy;er: AM.0CK PACK!M CO. PALBYMAt N. V. . BOBCAT BYCIU A* #t CAST PALMYRA, A. Y. You arc hereby notified that at a hearing held before the Workmen' Compensation Board 01 l A i f c f * ............... ........ a decision and award of compensation was made In the above caee as follow* Km AMrmm KiImUAi DatttfStft PMOWIMS Katape*We* ACCI PCMT BOTI T AMD CAUSAL RB. (ITI ON HTA t u SHED r M CAVI ALLY M U TE SCAT 4. CONTIMUTD. f t id the employer and insurance carrier are hereby directed in accordance with the provisions of the 'orkwen's Compensation Law, to par such award to the following persons: To .......................................................................................;..... ........................................... (Iba.) (A*4m .) al r a il and fonerai expenaea $.................... t o ........................................................................................... - ............... (Iw ) ( U n a ) Ampio?er and carrier are directed to pay at oso* | .................... fo r .................... .weeks at f .................... from data e l death................................................ .to ...................................................1#.... direct to the ......... ..... - ................................ :....................... and thereafter (9 .....................................bi-weekly). Balance of the award it ordered paid into the Aggregate Trust Pond as provided under Section SI of th* law. Prtant value of the award as orderad paid into the Aggregate Trust Pond as o f ..................... ...................................... it $........................................... . Present value does not lntlud* funeral benefit*. Cheek to be drawn to th* order of "State Insurance Fund-- Aggregate Trust Fund Account" The Aggregate Trust Fund is to main bi-weekly payments at th# rata of 9........................... beginning with -- ................................ to the................................................ -- ................. Death benefits to surviving widow shall be Increased to 40% of decedent's sw a g s weakly wag* base 8D0D termination of death benefits to sUldran. The above eopy of tbs decision and award is sent yon pursnant to law. TAKE NOTICE that to* above award or decision was duly filed in tb* office of th* Workmen'* Companaatien Board on th* tCYCNTM.......day oCT0KR..........................& ------ Datad............................4 8 w ? * f8 lP ...... * By.................................. alt....... Cbsin&AB C 6 7 i C-23 (5-57) ALBANY 4 1f4V Nardi raadway O BINGHAMTON 21 Woehlngfert to BUFFAIO 2 NEW YORK 13 310to.*#to. 0Omr.to. o ROCHESTER U ISJ Mow, Si. w. SYRACUSE 5 !* OWke fcO*t WeekklgtO* U. WORKMEN'S COMPENSATION BOARD STATE OF NEW YORK N O T IC E O F D E C IS IO N t.W C.P Cut NO 75709691 4. of MtAFfNO 12-10-5 2.Carrk*Casc NO.and CootNo Ai0 22777 j 91 6.Datcof RtAc-'VtoCvCt`'j* 3.OATSor/c*.IC*fNfO .MJURV ?T? 6 . Oat* o f TH>a N o n e t 12-15-58 my Cw*<VA*T flgjflB P iT lc r d B a ta ta R* F , D . I I ....... f lB 7 T * r .J I ,7 ..................... - c l o y . Oarlock backing Co, Bal*jNrar * . T . .........-y/-- TO THE CLAIMANT: Any cuinfx rsatiou due will bo sent to you by ' 'heck i.y he employer or his iiisurance carrier. 2. Keep a careful record of the payments received In c rie r that you may have evidence of pay ment o r non-payment In ra*e of dispute. 3. Do not pay tn.*ney to anyone reprt'enlir.g you. The fee, If any, for auch representation is determined by the Board <r Referee and will be deducted from your award and paid by the employer or his insurance carrier to your represent-,five or attorney. 4. In icorJcrion'r compensation cases, no compen sation aha*] be allowed for the first seven d*ys of disability. However, if tire injury results in disability of more than thirty-five days, com pensation shall be allowed from the first day of disability. C O IT TO: A fter herring on daw stated :-bc.b the fuUuvri::,! -eci-t-t: ai.J Aw.vd wns :..ad ' and duly filed this 1..;. ..Jt !:_ ' B Workmen's Compensation Law . (7) Volunteer Firemen's Benefit Law* AWARD: TCE 5MX*YER I--'t.o...r...u.i.s..a.U...D..'y _ --cks . ovw a /rorj p..e..r.i.o..d....1...t.o....... INSCI \N CB_CARRIER ARK DIRECTED TO PAY A7 ONCE ' at per ;W--1* ; --TM----'1<e.t 11 " ~ " " -T,OT: 1 a - 9 - 5 8 1 1 - 2 - 5 8 3 6 .0 0 ^ 5 6 . 0 0 ' r:-MV/NT less payments mede covering this period. u ben on award payable by separata chock by carrier to CLAIMANTS REPRESENTATIVE OR ATTORNTY loo to tO C TO R for attardane* a t haartr.* DECISION: Case was ^ a j j m * n t . .d l d . o i i . 1 1 - 2 - 5 8 .. If c a s t was "eontiMied" and mtirmtng payment waa dlracUit, H ahall bo mad* *t tho abov* rato fa r tho jxrriod stated and shall h- eontinuad thrait** until tho employer 1* carrier has (nodical or payroll e v id e n t of a change of condition an d givo natica thereof to the Chi-ivnan, Workmen's Comn*nsetian B ojrd, unire* s tb rw i$ f provided in the dec&ou, A fa rth e r bearing will bo h*M in a Meonrmiod'* caro to di-terraln- the extent W farth -r tfaibiJity, ii any. * In Volunteer flrvtuen's Benefit cases, the liable political subdivision Is deem ed |e bo ilio *XMPIX?YXR'* a / 12m volunteer ftraroan. . ' a cCim. irmsn fAsc*-*-'* C -2 3 C -23 C -23 C -2 3 C -2 3 . Ji * *s / \ EMPLOYERS ( UAL LIABILITY INSURANCE COMPANY OF Y ' 1NSIN EMPLOYERS MUTUAL FIRE INSURANCE COMPANY^' HOME OFFICE: WAUSAU, WISCONSIN The Garlock Packing Company Palmyra, New York A ttentions Personnel Department M drm JUpfy fo M rm w m m if (U u i n il m irt ilN iitii t , i n r m w i l l uiiiTia i . i m November 1?, 1958 Gentlemen: There i s not much question but what the Compensation Board w ill erect a death case on the above claim . We would lik e to make a prelim inary check on any known dependents o f Mrs. Baylord. In the i n i t i a l report which our a d ju ste r secured from h er, we fin d she i s widowed, and apparently has children.over th e age o f 21. Unless she was p a r tia lly o r wholly supporting aged parents, th ere probably w ill be no dependency estab lish ed . We would appreciate anything from your personnel f i l e s which you may have in regard to the dependendy fa c to r, we fa rth e r suggest you forward us a photocopy of the W-A fo ra from your f i l e s . Yours very tru ly , CWBollman - EC 1 Claim Manager  c-t 1** (ru WORKMEN'S COMPENSATION BOARD Sfote f Nw f a i t * ATTSMDIN PHYSICIAN'S UPORT ; 70 AfflWWO HWMOAH M it m Ah f f a ffa ff h MA wMff M f f a i M ff rf rmim f f a a i . h w fla n *i I r W i M l ffff afd* dHff II ffr* fia M la -- m , a d m f if f a a kffa m ha r a h d XI imfi m h a M a a a ih| aaa m M mm m M i M h hia h d iAnMAI MtOCT m h l a a a f f W M m a d i a d M h d m f a f f . i affr*. If t a M h' a f f la i I a ffi* * ffan, h a wpw* a d aafc P fiHAL t in Mt a dfffA aUd d -- 1a d h fcaA a i AAff CDf afftAWffWdI|AaNCI0C) AOUI*MM Nh ,mWOaKMffB*ttttoCnOtoMnf*fM. ATKMtO*K> a M Ma I ff* MA* l>dffii M arfffa ' M a ^ to ff* Iff d ffa h Q AtMOUt M U M M A H ] IM A Y J ffO B JJQ MOOOM tffOCT g ] FWAl m * t .. paa Jf f f f a f ,a,h p f| ff Vtm .jl >44rw.W)Mn Amiamt r Nw^r ObsmtM .... G arlock P acking Co. 1. MJUtfD retto* * a 7. hOtiAHCf eA taa Hi m ' C raee B aylord tr ^Kf**- V ; -tO* G a r lo e k P a c k in g Compiiy M P L om ts m rruA t uabiuty nratnuMcs o eoiffAinror^BoowiK A ffla. I Afa R. R . #1 P alm y ra, ^ e v York S2 11 1 * ' K; P a l s y r a , New Y o rk ^V .ioaaiB S srM S T o c u s s m 4, ite? yomc . HOOTTM Qfnr) *** J- (P .u lh o n ip a o n M e ti'l Hoap. - -X a n a n d a ig u a ,* New Y o rk H M *|U#'ffJ*i.a' i Ldad.at lAa IwMfay imwtiI M ga ai Ufaaff. ALf**A-j.ALaa,aff djr a a,r-d. -a/f.f a--H-a.* --.---dAw* a MVMKAO-TO Va SV V H N R SBa ^B^Nv JPB^aV >nvM OTmmi (www* v i^ w i m |^ vtv (^m v w hb^ vw shbhbi pbv <bb>n^B>/I A.'!* " i ! o"*'- P a tie n t1 condition detc lo rated rap id ly . Emergency hoaplt& lliatlon 11-2-58._____ . v^ri1 P a tie n t deceased ruddenly 11-2-58 a i 6i $0 PH See #16____________________________ j D*i*q ' - MOHy r rfd} -.y g fl . tfw .li (aah I Sa fmmm hf i____x c a _ '* * fc*nr Ib Yjpod- J B f l- ;- ^ ; . , j d a . -d im ih . IA Man I < term inated' II'*"1' ! .1. / M WhM ) tr* (b*M yeWeBlt-- jOHm'pmHtm bm kitmft M J M m -i~ i6 ~s 7 . . _ . Tbfl - - HiwUrfT- W ix ft ;r r ------ ao - - - (Z) ia l tivat w h it.-- 1 1 - 2 - S 8 mh. jfomm-- IlII**?--I5____tfi . NMMtff. Cfcrt-- -*-*_ *< - * m M i I mvfc I pmMmmk. I k* Ub w m m IM ,,n e ra r.. Ifl^fU ^ r * w tf - . nftYftr. IcoMfun rrms \u\% o u k t u cm th u un e a u o> wtinotf w o w w hich avi tw u mpomATioKil U - H -5 7 v < jti&'l'pwnfeji!p\wm WwBwKvwy.i "T "1 uni i, ttr ila *1* N I t ` > )tM ** -a 1q1?nO-|waHU M m M MmI U m M fsdfjf dl (Nrti rfM rM n . W Wm ftmqn( n f. 'Il . ;R * L h *a` a h a , ha tl) f fa d a ff Aff rf a d f n l a d (SI !-6.*iJl'JH I III a hr W hfft_ >n t-ol.: (.' -I- K-h *a> a ^ Uaay a I l i a nini I raaAdff h|ar a l a d . y-i-- - -K - -- <.:- s-< ...a .- ' . V a AaLu. M. h f f a ffla la ia a U. Wa i a a ad a r Ayd d I a i M l|'* M M-h d"a*'<a a ffA dina I M MA ff* L * U ffnr a d aadhd f f a Id a p a a d f f ' . ;-- ' 1* .! -'-------- ------------- V t, a a d a f f a d i M. M a f f a d M a i M aadiai a n a *vf " Py fin d in g ! P ulm nnarr abollB m from thrcm bua o f r ig h t -- ------------ A t r i i m d iia t o t a e i f ro m c o r r a ilm o n a la s e c o n d a r y t o a e r a r e p n m o n a r v f i b r o s i OUi-M f fNM fMrf 4Me<Bf m if a isii tfraa b NM vtfM w in t r* M w4 ( m H H* M I avkMvMM, MicwHii M f,W mito wHt IMI tiiwli <t i tf H* i r wfatii f in tl4 #1!fo W>rfc**VCi f mvHn Uw <MW w w H m *ft tia iit Uw I sM '.tiLV *.- tw '.-mv-' v Hm >-- i tffcyrttiB My ltm>< . . i -m.. . . d ; / v -4 * .* ? H . tfttMw .j * .biflif. ati fa tWthrt 1 Mw, twfc. .ti;'-- - ,-i - s* -' i* ;*!> ; * '! * NOU f*'- *-- \ ** ` *** wi..cCxJ.'M ff rf f . -y T '.. ." ' * -. ./ r r 1. " !"* 1 " I ' ! < ' ; ' n ! I" --'.___ ^ * < S ipn.tO W tm A in J . B r a a l ^ , M .n . I. : > a IW f f a ffw ri a A f f i d a f f r f f a j ' - * 1-- - n .,>.1 "21 ft E .a t C harlotte Ar e .. _______ Kovembftr I. 1958 _____ Palayr, New Torte______ C -4 C -4 C -4 C -4 11-14-50 Hoap, Copy - Varifax of o rig . to Mr. Piero. SJW C -4 o n (s-ss) . WORKMEN'S COMPENSATION BOARD STATE O f NEW YORK EMPLOYER'S RE1 OF INJURED EM PLOYEE'S CHANCE IN EMPLOYMENT STATUS RESULTING FROM INJURY This report is to be filed directly with the Chairmen, Workmen's Compensation Board at address shown on reverse tide as soon as the employment statm of an injured employee, as reported on Form C-2JS, Form C-2, or on a previous Form C -ll, is changed. Change hi employment stains include return to work, discontinaance of work, increase or decrease of regular horns of work and increese or redaction of wages. Copy also should be sent to your faaarsnoo carrier. W.C.B. C*m No. C u r tM 'i Cam No. so d Cod No. D tt of Accident N tm * 1 r A ddr**j 1* C a p i r r 2. laiaru c CnrUf THS GAHLOCK PACKING CCMPANT & p lo y e r s IfutuAl L i a b i l i t y 10 O lbbs S tr e e t PALMTEA, NEW TORE In s u ra n c e Coaipeny o f W isc o n sin R o c h e s t e r 4 Heir Y ork 3 _ l* | ro d P*r*oa KBS. GRACE BATLGHD #5-638 It. D. I l , PAQCTRA, JIE'-'YClHK 4. Date of most recent Employer's Report filed: (Check "x" form and give date filed.) fo rk e d 8-1*130 s h i f t C-2.5______________________ 5 C-2 J l - 2 7 - 5 7 __________ C ? C d l J = l l = i ___________ 5. Date Disability Began:__6=8=55-------------------------- Hour of Day:__fliQQ________AM______________ P.M 6. Nature of Tnjrry jmlwAiarr fib ro s is of lunpa with shortness o f breath.________ 7. Date of first return to work following injury:----------------------8. (a) Change of employment status resulting from above injury: Employment 5 Utu* Hour per Dey D ijrt pfcr Week C in io ii Prier to Ujury Cksafed to (b) Date of this change'in employment status (c) Remarks:----------------- . Occayattoa 9. Loss of time resulting froin above injury since first return to work: 11. Has injured died ? T 14 so, state date of death: 11--2--58-------- ----------------------------- 1--------Name and address of nearest relative known:--BflhffTTt !< By c m ,Cfion) IL--P. #1 FfllulVIS-- Date of this HrrvemtvT- ^ 19 ^ -------------------- Firm Name THS...GAfiLQCK CTil^'P-CTl.M Ol 1303-3117 C-11 Signed by..................................................................... .......... D. F. PHASER, TICE H C SIt^T ______ -- rm. C-11 C-11 C-11 GORDON D. CURRIE, M.D. 797 Elmwood Avenue Rochester, 20, New York August 18, 1958 Employers Mutuals of Wausau 10 Gibes Street Rochester 4, New York Attention: Mr. C. W. Bollman Gentlemen: Re: Grace Baylord t s : Garlock racking Co. #A40-22779 This is a report of the examination made on the above-named claimant on July 29 1958 At your request to my office. As you are aware, this claimant has a history of working on a machine which makes asbestos yarn. *or over 20 years she has been employed by Garlock Packing Company in this capacity. A diagnosis of asbestosis has been established on this patient, and, as I understand it from your letter, this diagnosis is not disputed. Following the establishment of asbestosis, the claimant re turned to work at Garlock Packing Company but was put in a department which was apparently free from dust. In June of this year, she developed an up^er respiratory tract infection and ws under the care of Dr. William Braell of Palmyra, New York. Associated with this, she became very short of breath and had cough. Following the respiratory infection, she continued to suffer from extreme dyspnea, wheezing, and an inability tc perform any exercise without the most marked respriatory difficulty. t FsAeSntT HdIifSfTiOcRuYl:ty,TheaCnldanimoaonptehraastiohnasd.noAsecroimopulsetiellrneevsiseewsoofthseysrttmheasnwathsecnarrer-ied out and was essentially negative in all respects. The family history was non-contributory. OCCUPATIONAL HISTORY: As mentioned above, she has worked for Garlock Packing Company for over 20 years. PHYSIC,i EXAMINATION: Temoeratvre 98 Pulse 120 Respirations 36 Blood pressure 140/90 Height 5'4^" Weight 1471 pounds The claimant is an obviously sick white woman in respiratory distress. Her respirations are rapid and wheezing in character; on the slightest exertion she becomes extremely dyspneic. Skin: flight cyanosis of the nail beds. Head: Normocephalic. No sinus tenderness. z7- .<r/ e/ U C- Re: Grace Baylord Page #2 August 1958 PHYSICAL EXAMINATION (continued): Eyes: Pupils equal, react to light and accommodation. EOM normal. Fundoscopic examination negative. Ears, nose, throat: Negative. Mouth: Edentulous Neck: upple. Trachea in the midline. Thyroid not enlarr-'* Some cervical vein engorgement in the recumbent position. Ahorax* ^hows some slight increase in the AP diameter. Breasts! Negative Lungs: There was dullness at both bases on percussion! On auscul tation there were bronchovesicular breath sounds at the anices further devn both lung fields, the breath so nds became bron chial in character; at the base of both lungs, extending half way up, coarse rales were audible bilaterally. Heart: Appeared not to be enlarged. The rate was rapid. Sounds of good quality. There were no murmurs. Adboraen: Soft. The liver and spleen were not felt. No masses, tenderness or rigidity. Pelvic & rectal examinations: Not performed. Spine: Negative. Extremities: Showed th presence of finger clubbing bilaterally. There was no pitting edema. Neurological examination: Negative. were LABATOHY DATA: Urine showed a trace of albumin, no sugar; microscopic examination showed no white cells or red cells. Sedimentation rate elevated, 40mr;. per hour. Hematocrit slightly elevated, 46. Fluoroscopy and x-rav of the chest were obtained at the off-'c of Dr. Ide and associates. Their report follows: "chest examination. Fluoroscopy and film examination of the chest reveals prominence of both hilar regions, fullness of the soft tissues in the right upner medias tinum and diffuse linear and fine nodular change throughout the lung parenchyma bilaterally extending from the above downward. In the bases there is sme softer superimposed patchy density ilaterally and some oblite ration of the pleural costophrenic angles. The heart is mildly enlarged in its transverse diameter. No specific chamber enlargement is noted. Conclusion: There is radiographic evidence of a fairly diffuse and rather extensive nodular fibrosis throughout the lun~s. There is some superimposed subacute to chronic inflammatory change in the bases. The heart is mildly enlarged and there are some mild congestive changes in the hilar regions. I suspect that there is a right upper mediastinal lymph node producing the enlargement Be: Grace Baylord 3 r' s t 18, 1958 ? LABORATORY DATA (continued): x-ray of the chest(continued): "of the sahdow here, with the clinical history of exposure, I would accept this as a penunoconiesiaif fairly specific type." (Signed) Charles . Sherwood, M.D. The x-rays from Mount Morris Tuberculosis hospital were received and were reviewed. lectrocardioferam showed a rate of 120, a PR integral normal, QRS comnleses were all noiroal. All the waves were essen tially within normal limits. The tracing showed only a sinus tachycardia. OiINIGN: It is my opinion that this 52 year old claimant is suffering from severe pulmonary asbestosis with marked l&wering of her pulmonary reserve as a consequence of her disease. Secondary to the pulmonary difficulty, I believe that s^e is beginning to show evidence of cor pulmonale and, indeed, is rrobably in a early cardiac failure at this time. The claimant is at this time totally disabled and it would be my opinion that the would probably remain so, unless some benefit could be achieved by means of theuse of digitalis and di'iretics. With the use of these drugs, the element of cardiac failure may be removed and some of the congestive changes noted in the x-ry may disappear. If, however, after treatment of her cardiac faildre, the claimant still remains as dyspneic as she is at '-resent, then her disability will probably be permanent. 30 far as t*e pulmonary disease is concerned, all one can do is administer bronchodilators and expectorants. The relief obtained from these drugs, however, is purely symptomatic and down not prevent progress of the chronic pulmonary disease. . Yours very truly, (siened) GORDON D. CTJR?JZ, Y.D. J"2 0 5 A.63 CDC:ee Grig, to ..CB 3cc envl. cc Dr.Braell end. G erolck Packing Company Palmyra, lew Tort Mias Graca Bayiord B. I. D. #1 Palmyra, Vew York Ea: Gerlock Packing Co. X40-22779 J u ly 2 , 1958 Dear Madam: At Br. E r a e ll' a a u g g a stio n , wa a r f plaaaad t o advia th a t we hat aada arrangements fo r you to ha m in ed hy on o f our consultant*a hare in B o c h e ste r . Wa r e g r e t , however, th a t a hay haan unable to make an appointm ent u n t i l :> -a fo u r weeks away. W ill you rfsakindly report t o th e o f f i c e o f Ur. Gordon O u rrie, 797 Slmwood A venue, E och eater, Jew York, a t 3 :1 5 P.K . J u ly 29. This la on a Tuesday. We w i l l teim burae you fo r your t r a v e l expen on t h ia t r i p , ahould t h is date d o n flic t w ith any other p la n s, kindly ad vise promptly in order th a t a new appointment can be made. Youra voyp t r u ly , CWEollman - SCI Claim Manager V -ysr V '- L . q. >L v-- / /_ t. /* * c.- / *** WORKMEN'S COMPENSATION BOARD I W * f Nw Tirk ATTENDING PHTSICUN t tIPOET 0 ATTTMMNO H ffllC U M fc fw k M* Ajt fw A l U to ( W vIHila 4t fc..n ft. . ft, t--l * in . tri ', ,, . --* tm n m - I'n i'in " * * ' u - * l MM. fol* W J. I I to r, mhm * M M l , M M ftn f'M , f.p<Kt. M M o l l ( 23 in y t *1 M l . h . , M M m . A4 m m m m tm rni It tftfaaatM flMAl W OVT fkti ton* mt In I W cafard!# I W l 12*g fa **y prwiM i ctportv H traotawat k w i f i i i ^ a H ii y, ur, a# rtpatf t W i w i H FINAL wrW* Ikn*dftlligtftfa Aafrftfaffatfaafpaytafca**r(2f)*>AH*fairtMcSflUyMfHaC*f(Cf)AJTCVHJEAftIf,tMtfAINn,W,OtttMANVECMnOOMYCffWt.SUOM *OAXO I A t #*c* I Abtrk 1 fakfc A* ** ~X~ U * * I * # * Q 4*HOU< ftniM tH A M Q ' 5-0AY UfOftT Q PtOGKSS * O t f | HNAl ffTOfa 1. W .C .l Cat M f btr (If I n 1 2. Carrltr Cast Nafanr m i C tfa (H k ttr c l 3. Oat fa AccWtn# r Ifatry m i Tint 4. AAArtw WWr AfadtM rr fafaty O a t m l C^nrlooh f to M n ^ Oo. A. IHJUttO tetsoM * * . cMnoru -flraaa BaylnrtL G a r lo tk P ackin g Oonpany | ** R.H.-/1.-rlnjr3,.-BM..XarA___ L52 ,, P a la j n , It#* York r MSUIANCI C A M irt a MOStttAl W*r) . AmmI 22Bp. "t u t . L i a . I n s . Oo. 10 aibba 3tr e t ----------------------B o a b ftA tftr._ ._Mttt York *H patt*t diM tkmt h fw / m tm ti ton p*t4*rmiy tu/pntd Ar#*fac Arty 0* * Vfatrt**r H m .wn, '.at t t fMftOYtf A * tHy, 1 ***, rtttty* ar b iih t agtir.# whi<k rbf?*t / W * far Vefarfaer W*m**'i tnt'-M #d Mtr "X" ktr*; (i*H4 AiapftWA 6*A*. rvfc/t^* t#v>fa'i* / any cfangc fa tmiltim Atct fatf p#yei`) -P ttlto war y f l b pa l a-<la*-V>- jm Aytpota.^^ W-^, beat * --I-n*rt*A*g-- () Il W t taw ay Alt*Witty *r faytk<}t f a t r l f --- II 9*. b **<k Akobtftly *r d*f*rf r*N t i Ik ^r*t*#kl U|vry *r __ y _ (k) May l*|try Pourk 1 yroMMni Mafal or Iw M ^i<ligr*NMRf t tk*r ^mai*M ... . ___- ____ If a. tfr w itk * _________, Bulaowty lpix^>at-------------------------------------------- k of *!!<11*1 ----- -- ------ --1 - - . . . ... .... . .... . . _______ .... ___ ___ -ir- ,.. fa) Wfcta 4* y * (1) Ant trwt yeH *eit. (V) Hot pmVit* k*** A tA a rfij Am **'<? -5/16/53- . . m. . . _____ _ (7) lott tMt 7 M . aT. _ ^ / l 2 / 5 8 - _______________ ____ ... If a, git rf*tti . . . . ................ . . . . . A <m*. i4*vh 4 *4* I - ltiplif . . r --,-- - . . . . __ _ Hi a it ... . . . .. . H fc jt.. .. ____ _______ . (c) H fvtvn aperaHaa, fcMfrfnt, or raWWHa'faa k*akwM M hM >------ -------------------------- Il a, ifai* **iwt <J t**ck <r*atflr>ti___ ____ 11. Da* yai ttifnk palUnt m or wftl k* abit (> fa) m v tit kk m*I wrfct. u n d t m l A o d -- 4M A* my *!* .VY-- ......................... (t) li *atl*t ^*lagf |\ p - 1 fa) S**{tfywork A*ny... - . . . --------_______________ . ....................... --- - - [ c OMFUTt ITEMS .I Q WtW ON THIS UNI CTt Of t v i e m I I I O I I WHICH >*T t THU mPO>M*Tin-1 l l / l > i / e , 7 ~ | 12, I* ptitiMft 4*m ttff i fa r r M*V ......... ............... ........ - ------- - - ------ ------------------------ . . . IX.ktx'faatr*m MftMtofU(*ry tfu*y>!jpfHofkv4yWweWtdi fa) W tr* X*r*n fakm t____ ____ . <k) W#i patUal noNmliw) . . ....... ............ If *. far km Wgt . lei If t k ia b faf a AtM Mi glti (t) Afy<ikwt Afa of ***< fa r t k f a . . . . . . . --___ -- __ -- -- . . . Cf) Ofa* AbafettHy X y M .. (3) fat#*' *ccrpati*fa hi#4* r y t_ .___ ______ _____ A Wm patimt prmtawAy m*t #m** fa amafc* yltyfat*) ___ _ fanWmi---------------------------------- --------------------------fb) >i*i far katfatii fa) Ofa y *t aktal* k itfr / (fa mtditmt Aat* fa* gr*cWlg faiytlcfaftt------- t l fnr fctr* aAdMaafa lafanmtt* at trba: -- - .......... - . .fa) A a, gh* m m m i f a k a i fa t If fa, aw ik * it* n i fa not*. Itafa H a l fatAa4lg* A pUI*a givoa 1fit fatffaf ai*A1col rgr1 0m fan a*A fra fa fk fait fam / fcavh i f , h f r m * 1 lt $ m i kMf, A >iAk with fall fcawfaAg I fk * fra rlftl* fa i t t . 114 fa fk Wrhna*ft C *n * * tfa la w m i Sk . I I fa fa t Y *l *ft*r N n a n 'i lAf la w . I fk a f I mm a fk y > k ia a Aly UtaA fa f r a e flta A ltla la f k * Sfafa a f Mw TrL )i->^'^1 & 0 &KMENS COMPENSATION BOARD S ta te * f tta w T a ri ATTIHDINft PHYSICIAN S KEP0 R1 10 A T T M X M O W m e t A H M a r t a a a f a b la n a A m M b a a i a * U a h a a n a h a r y a a fa ri w A r I n r i a . r i la a t i fa . ' -- . M i l i a a > '1 b a a a f a a aa aa a y A A M a 1 A a y i H a t A r a n 1a l a 11I, a a i a a f a a y a r i Ar p a r a a M n a l a a f tX A a y a a r U ta A a r t a , a a r i i i i l , a i t i a i . A a l la la n i a a ia A flH A l M PO A T a a M i l a a a n a b a a i | M w a f Am t o , a f a y y ia l i n ta p a r* . M a i a li i i l la am plaM a tfala 41 I i la VINAL ria a A rn i tflaal af a a * fa it n a * M 0 ) CHAMAK W O KM Tt C0MMMWI10N AOMf al a aAUa af A . A nta la a tf* A M aat I aai Va afcaatf aapy a*k CO Ita MUAAMCI CAMUS. * baana, ar An IMAOTB. 1 M a r H * la ab a* fap a a a v a * Q AfaKOM ta U M M M T Q W O M K tT g j fA O O M B M P O tr Q flN A i. M PO (T la W aCft. Cm H -- h it 0 f tetar) ; 1 Cm iW Cm H m U m CW * " (If fatata) t . O w M lA a A A a ( rl |ta y a W tk * .A . A A A re* W M A W Iam * r fafary O w tw rrW 1 IH JU rtsso N * A iM fio n i 7 , NSUtANCC C A JO U S - " ; th aw r . C ra c B iy lo rd t - ) - i'-' O o rlo c Jc T tc W n c C om pany n c p b o m s M U TD A L U A X Q alT T U ttU K A N C X * CO M PA N Y 0 7 W ISCO N SIN : i - O a rla e k P a c k in g C o. AAMm .. j te a t E .D . # 1 PA LK TH A , IM T O S I 52 t P l* y rt# Itw T o rk M o n a s s n iz i T a o o oe s t x . k it ro iu c A, HOSMTAL V ~ r) i 1t A[H y aJlttya r i a la l a a I b r i f a |a r y a a a ria a rf a l U a y^ *a1f^a1 r a t a y a a^a f y a a i f a t a t a l i * A y a a a V a l l i t i i r r i n a t a , a b a * a a CMWa l f tO r tX Aa taita^^^* T^a^taV Bl8 t a ^v a ^^^*1 . t. - *mwfif*D8 WB^f ^8y *kw0W f *^tt* ^J* J^ **pWT) Pulmonary fib r o tltd u e to pnoumocomlomlt from b o tto . Incra sitig dytpnea and H u ' i I tippar ratp lratory- In fa ctlo n .____________________ I (a)J>Am m v ar fa^lfcy.M yfcyd-- Idrfwtt -- = V m k M % r Aefc# m A al 6m pMMl hfwy * Am m . M kqr tafvnr iw A la pi ra w M facht ar fcparf A il| n a M i ar a*ar paraaaaai iU litff y" ' Pulmonary Im pairm ent * ! ,7 * * . ; |IOa M atw ra a l i r j! ........ - ra t ^_____ i r 1 * _ _ _ _ _ _ _ _ _ _ _ _ _ i_ _ _ _ _ _ _ _ _ _ _ _ tf i ' _______________________ i j (a) W laa * i yaa (1) f a i Iraai y a ttm it ! 5 /1 6 /5 7 -,^ |T fg | fari la r i yaAial_ 6 ^ 1 2 / ! ': ta fa iW a mfaiowri ^W ^B^H^^^^MBB a^^^^M^Mta ^^^MSBaT^ri -A ratAva Aaaaa__ !______________ t a r a l a JUL mU * If #M * a aM a a l mhA A iiM irti^ U Dm j i n A k l |M tU a a a s a r fil W M a la (0 faaaM Wh paM wldiicf--- US____ Mlparva*l ri-r* - I Aa aajr alk ar M arkt-. jc O M H lT I IT 1M S l i - l l O R g K T lI OM T H U U N I PA T1 O P W n flO U l M fO tT W H IC H > A W T H IS IM P O tM A nO H i | n / l U / W I V I t SMa^la Arihafa m ^ a rii U aadiari ar j ^ l ** O a a afa a a a la ra a a i a r ia r i a f l a f a y a a i ri'A f y aA y a iA a f M y fa a a la a ii- M wi aA aaaf-- M I f afafai la f a r a A ha a aa , ff a a i ( I l f a y r a f a a h A a la a f a a a r i a f ra l aaa f 0 ) D a la f h a t a l y >'>' .i * * ' 4ft 't f * M ^ 1 ' : . . . 11 . Kr . aia fa r t e a la a A fa af lariaryi. ' M la M a a a a y M A ary a r ariA aaaa y rn a r i a l fra M A a| fafaay a r Aha . V; `It*|' ^f_ fwa--MMMy t a P t a M W l^t^^*Jt --a t a P t aJM t a t a trai,t--a V ^ P t a a P I t a t a M taMOT t a 11a l i U fa yriU.ri>p.i.a..ria,.afA;--anaAa^r ,A*.min.a(iia a..l aaafaa.r yhyriAaaf_ . aa a M ; afa t a aaaa aaA aMraai af yaaaaiaa fr) .VMlymtdkI lfa,,Mr.fcaa,aAiaaj.ya nirityior.aaaariai________________________________ arVpi* . :,a4-;.i I W t Hf li* Ai A hn * l f h l r i ffew h <WhI m m m m A M w i irf < rt M l M fr* h ft* Wvf *f a y btw tolM,,M wrmtH-- M M M , I m 4 HA M t li rwtiAn H ir W riw i *f im* 114 f m Wift o w 'i Ci m i m iHi U w N I m . U r ftfU Vst--tu r M W I m i U w , I M t IM I 1 fl yfcyrfiUw M y h u I H prwW-- > < rin h I h l W i f Ntw.TwL e- * rv w 4. > aa^cha W ^s*4 /.".' ai' '< V' *'*'*4* j^> <*l *fi*i * -i b*^ir{ ffa'fiuf .y 4* *;.' * #ty*p^p> IV* * ** ' v**tavu' W.C.i.lHfaaAa, f-fa . Ir* T *' : IS 4a- K t - ! <V >- r ^ " (8 lTA) . 111U J . . E r a l l . XaJa IFta ** telai p A r r * 4*;" `M H*.'' ^V |< U . : ^ W ( W f M t a U A M iW W *wW taQ '* AXi. awA-riA 20S201_________wr<***^'216 . Ohrlott# Ata. 4M aA - PilAyrA, aw Tork C -4 C -4 C -4 C -4 t 2658 H6p. Copy - T a rifa x of o rig , to Mr. P ia re . 8JM C -4 u m ilio W . WORKMEN'S COMPENSATION BOARD ... fhrt* * lUw Yo* ATTENDING PHYSICIAN'S REPORT afe* rwlwHir 10 ATTHO ftfrStCUMi Ifw to M I m M 4 to AM feto* * toan Aw ym Art tor M M t to W i N t f to Atto I f to p Aar Aril iraalMat, m m N y topar at tok o to to 22 to p r ton torto| Aaiafili!vfcUa41kavn,ito fcatmaat k k fto a tto ftNAL UfOtT a Ato lam a fe to AM i to A t ito * to if p a to n p k If I m pari mI wmk A PINAL. mm to* Aia !, A* mm m to Ito fe *W Atoto to A mpart toatof toh 0 ) O U IW U K WOfe/WM* COMMNUTIOM tO O D I * Aw to to fetote to Uto to d d .it -- rod --4 Ato fe *W pr fe CO * fe SUAAMCl C A M * h y r to* IMPIOTO, fetor n r to to w I f f to H i p i 4M40UA u M M tr t*0A 1 B^oomi ANALtOOtr ! . W X X e ttowtor , i l . Cantor Ca Naato.fetf Cato. 1 kart tA rtlM a r H a lf m i Um i ^#khtIf^b^AMmMi VwApamia **s ^ Rito-- ) * 'A M * . . .. J. INUHD PARSON * A AMPIOnt Maw , ... 0 r c t B ty lo rd , nn ' j % O a rlo c k P a c k ln * C om an? v . . . . . - . J ____ O a r lo c k P a c k ln * Cam pan?__ A4Ir t a 1 Ay R P f c a PA lM JP A a ir .Y t ____U ____________ ____ r ' ; '. i .1 ; - - P a lm y ra . S .T . " 7. mtUSANCt C A B O LO TSM M irroAl# UABZUTT DttUIUMCB company o r m scom or ' ' . ' ' h o d k i i u r a o c K is m A m it Tome . HOimAL . . i/ i Olaaf) M . .... - it * ! L .* # pato* - ._ S top? i tor Vafcafaar fe a to i i o ra n r few 11. Pwuat wirfHti. fetoto lifiito Af t Atto* : i *v-`` * i <**P ,R i I . - h a > ,l p r Q T A d -b itll. A tlA n t l i i to m f toa* to t i l l a ir lr a d lT d y ip n t lf i J T A n .O T . ftU d .jA X ttitio n i^ r r r.tP'iTwwiry fStenti.duA,ta p n a im n n n n .ftili fro m M b m Mw M f I ratlbf > ftfb w l rtd ad t. (k) kUy rt|atf tatalt b> i ___P t w t < p t r i M .t r t f p n l w n w r y f h t t n t t n n . a b a to .,T T i - ' , f ' ___ D n d a ta rm ln a d . . _. - M Lal -- to feto ator to ato Im W i Mi , - ............. - ____________ ? - .*>- S f K f i o _______________________________ Data ata a r t - -- - t a a d l L a li. ta <at ------- U . --^ O n d e te m ln td #V\ 4m aaa mIImm omW H b .rtrtrt aartrta---------- HQ----- H ) H arth wart Ir t H Ilil. aafi T o t a l b t p r a t a n t ______________________________ I C O M P U TI ITO M I . H I OR 1M T1I O b TH U UM B ATI OP H tm O B I W O B T W HICH A T I TH U IHPOIMATIOW i | 1 1 -1 4 -5 7 v I I b a r t 'rt partaaft atm i b kaw aartrtart m rt|w r * Oataba a a tw M l MMW I H y aart artfra tl .a rti at kartf h w t.iJ i- H W o* C raft I M . M M rttrttt k ft *!, tftw (if Arpmrtaart rtart d M M r t rtlrtirt g a ftiM i. 0 ) Ort * ia lM f kt#at, ' I ., , . ,, - .... -- ......... Q) TTT- M b Am M f kbrttf *r U h m fr ttir t I btnferw_ U M fam U . Ww fa M fifb a fr w k r i t u n I I u rtlrta I W WajMtbdiIIMtfMdatM bM Im pmaadhtfkfdrttat.. .Ibtwb* iMff. tf'Y 'l . tf-M Am HI. 4M *kiKnm m MladdraaIfrtwAtl . a rt.a M * M ili i I al i Ijo y ) lW *-yi . tarata!! I ib b M at Ma M a f i a a t i f l t l t a ftra a b M a a a th a l f r i ara tab n t traa la M a k art a t m f kaatrtadaa, ta fa n a titi katlaf, a r t a r ta w ttk fa ll bu w lalga a t Ma arar ttlaat a t ta a . 114 a t M a W i iU ii' l C a a iiB ttila la v a r t la a . ( I a t Ma t i l u l i ir Matt IIV.i a' n-.M'1*..} - fft ,U w, ;.MI*a' lata M af'tI aw a p if'ia"la'li'1rt"alv -bafla*a/aa'rt ta fra a tk a aiartlrtaa la M a tta ta at Naw.Yark. t * : M*'* l - ,,*i i* U to t * t * K P * fl? ' *^1 flirti w j . b*!' I, % v * ^ * * * t * * ' * -** - WXA tof r* 4` **>,n v* ,i>*i* to .>>r 1 M i.iubi41.i"."!. .'..' ' 111U b s \ S ra e llt HP__________ (WHMMI rtaarttwa rtrtrtt f^t rwa.). InT~ ~r ~ - trrttbZir*tkPt rtMMn* a t_ A _ 205201 n ' / : 4r M 'r U 216 1 . C h arlo tti A ttnat ___ =5fe5B_ C -4 C -4 yh -* -? C -4 PblBfTb. Itaw Tork C -4 C -4 f l / r b *}l< *-. P / 't f-t > i" r ' * Physical Examination of Employees D ate Name March 17* 1950. Grace La Plant Saylord Proposed Job Twister-Oper #2 . j.---Age 43 Weight 139 .......... * Textile Dept -- Permanent - Rehired -- Height- -- 5 ft-3 -1 n--------------- ----- - - -- - --V> -- - - PreviousOccupation Previously worked at G P . Co., Textile Dept., Left ^ 1 9 4 0 . Medical History Usual children's diseases. 1931 One child. . .. S urgical H istory______ Condition of: --------- :-- ---------------------------- Brain and Nervous System Good Heart Normal ' Lungs C lear ---------- Gastro.Inte<fina1 ` Good M. D. ,, ^ u Kidney No sugar No album in Prod. Mgr. Nose Throat C lear Good Personnel M et. Ear* Clear tro 3 M i h o m Py* Rt 20/20 Lt 20/20 Blood Pressure. 130/82 H ernia No Other Defects Has upper plate As corrected by glasses (D(D O *O nor O vn O 00 a H* O 11 =r A d** C 2 . X 33 5 a Physical R ating A B C M ental R ating A BC 1 1 1 111 V2 2 2 2/ 2 333 3 11-2-52 Checked after absence from Oct. 6, 1952, due to hone accident, injured rt shoulder. OK to return to work today. Dr. Nesbitt. 3-25-53 Checked after absence frcn 5-13-53 due to grippe; OK to return to work ------- today 6 AH._____________ _ Dr. Nesbitt. C9 O O O c** SS 3 cao a 1 r ii , AT < 3 -------- M - . O 3 Ov Z M CA ffl 0 > 3 ir o PC O M3 M O - --: 01 3 1H M O vO H- H I O CO-n 3 H O' o r 10 7 : K ____3a.a-. ^I 1 2 -3 0 -5 3 Checked n i t e r ab sence fro n 8--21--53 due t o nervous breakdown. OK*d to r e t u ^ g to work Jan 4 t h by S r . D lk ler and Dr. H e s b ltt. Dr. H asbltt. au 5 2-14-55 Checked a f t e r absence fr o * 2 -7 -5 5 du to In fe c te d r t 3rd f in g e r . Coup. C a i s s e - ? g 0 P Co. Ok'd by Dr. H e sb ltt t o retu rn t o work today 8 AM. Dr. H eabitt. /O -t' ' o *1 OKO. IMI / 'm e d Ic a l . Nam ffHAOt SIZES .'ULTLiST BAXLOHD OATS rmuu*v om mjjmm ' " | ^ate " -t ~*miUPIY"OR 1UMM '..5=1=38___ C old - 1 M w r is t ^ 8 Heada he and 1a ran uu :S-U-39 * * * * * * * ______ :_________ \ | 8-15-51 Ufav in 1ft m n n-u ll-g-39__ Xar&che - Headache - Laxative .1-11-UO Lameness \ | S -i7 - ;i R etreated l e f t ear tvm ^ 10-15-52 ..Per .Uep.iiep. 10-15-52 won-occ 6-11-41 7-11-41 P h ysical Examination L a xative - Headacje 11-3-52 n - 6 - 4 i La left fnnt-- Hawdicha-- Laratlir n - i 9 - 4 : Headache 8 11-6-S2 12-15-4; Cut left index finxer at home 3-21.-53 Checked after absence fromlO-16-52 cue to home accident, ii'.juredT^ s shoulder OK'd to return to work today DrN iwr.Dep.Rep, 11-4-52 Returned to work from nun-occ dis." 1 1 -3 - 3 2 Per.0eD.ueo. 3-23-53 ijon-oce din 3-11-42 Col4~Laxatlve began 3-13-53 3-17-50 Physical Examination 3-25-53 CfcecKed after absence from 3-13-5. 6-5-50 9-28-50 12-6--50 Physical Eramination fTart*13 lameness left hip, laxative UU Cough and constioated W 4-1-53 9-1-53 OK'd to work returned 6 Ak tgday Per.Uep.Kep. 3-30-53 kon-occ dis CflQCfl J*5" ntr P`5 - . - - - 1-17-51 Cold 121 Nervous etc. Per. Dap. Rep. c_i_ca ' 12-30-5: Checked after absence 'frcm 8-21-5 e-2 4 - 5 5 Lameness -- nervous breakdown OK'd Dr. Dikler 1 0 -1 7 - 5 5 Callous rt 3rd finger. r~"-----and TVM return to work 1--u-54 1 0 -2 6 - 5 5 n rt 3rd,left index,cough,lame DrN 9-27-54 Cold 1 -6 - 5 6 Dry skin both hands, i 11-15-5 + Cold and general lameness rt.shoul ler*10-24-5< Per.Dep.hep.10-23-56 1=4-55 Several abestose cftroaiboth hands. ' 1-21-55 Checked ash corns both hands-general lameness Orw. _ . 9 Q -- 2-L-55 T n fe n t.io n r a s m i r e r . D - N 2-4-55 *edressed right 3 finger. ;---2-4-55- TpjjLlBltttl tlflJldS^ f l f l DiII 2-14-55 Heturneddto work todays edrssssd rt. 1 3 ringer,gneral lameness Dru |1-------- 2-21-55 Trimmed abbestos corns both hands redressed right rd finger. DrtJ 0 n o er R_75_55 TtHn p d a s h . corns rt 3rd fin. Drl * -15-5 ~ A s b e s to s corns both hands DrN 1 1 -2 0 - 5 6 Checked after absence 10-8-56 duet r.on-occ dis.nervous condition,OK. t . 10 return to work 11-19-56.under car DrQikler. ' 1i_cn_qA Tr)H H*>1 T*p . -------- !IonM>cc dis ended 11-19-56,6AK 1 0 /3 0 / 5 7 11/14/57 Dry skin, slao cou^i. Absent from work for 3 days due tc <B and shortness of breath. Under care of Dr. Brae11. uA'd by nun tl return to-crk n/i/. A ? -- Tp oft 5-25-55 Asbestos corns rt handDrN 6-17-55 Coin left index finger.rN | 7-26-i 5 Trimned abs.corns both hands-D~N L __ _ Mt --------- ^ 11/27/57 ...V | -- Probable asbestosis of lungs. { C-4 by Dr. Braell dated 11/14/57. ? Negative C-2 dated 1 1 / 2 7 / 5 7 . J L . . a S ~ l'5 ) MEDICAL RECORD Nam* GRACE DATE BAILORD tNjuvrr on fUMro A M nu DATE iKJUfrr cm iuios 12/18/57 Talted with Dr fi. re: frequent // 3 *ST -- / //- .*f <7: absences due to chest congestion. Dr i*.// dtsuE*-*/ //" 5 ' 7 > B. tlaked with Hany Beach, Bay 4 v iustin and . Van Holder about same matter. Also. -Employee reassured. Z '-a c '2X (l)/tn L jrt, C/iJi-- 2oa, Hfjr.syS'J ~ fit /? ' ' t . ( -avs-s *' " -- 4o 3 he^u +Jl* ^ v--. J t j f - f."re\ Me *< roa- . 4 * .< _ vfe--c^1 ^ 1. r.s/U__ ^ .. . rr I 4 IV<9 tlv fh CiDcdwry JH^AVAff 5? W oil.^g' ' St. p u rrrrrr i1o0 ; ?t>ffom' n*t. r'.MT 13 r-^.Hr.sirr 1.' *'nn $1 \v t W CV CMC No _ 7W*_ 4 C a j i o * H cak in c 3-10-5 WORKMEN"? COMPEMSAtlON BOARD 5TATr Oi Uf-W YORK NOTICE o r DECISION ANDv s. * C'/ ft :* a u t'j - AfcO 22775 . . . I 1 | t t t. TMt rs- t - Ot . . . L ? i f r ---- 3-1!-5 ry 1 i ' 1| 11 . r. r. ft. ,? * 1 I .*,T. f*M*Lr y Oarlock fookln? ci ?lj7xa* h .T. TO Till. Cl AIM/ : 1 Any con y n >:i-*n C * v V. !..* Vt; . l. X cher 1; | \ t.`.n cnj 1 r.r !/:- iit*. i i C. K'n t*a ..n in!!iv i tin |-*jy . vu* *;. in a 1<r tb; t : 1 *. ha*,j t . `.n n*cnt v ir-tivi .\ *i :J}\ ; r;;*C`*f *''J 3* Do r*-j4;a it I.*. t .'Ti Tr. pj . ' ..tin;; ; ij Th? Iat. V ; ri| f* * i drtr rniii*4 ! .rd r * j:i.! v iM l.?i di.;taM*.i *1*i i V'.-j : ir.-.rd ;-a 1y: i.v 1*>A vtnphy^r o h.-* :ns-:r;* r * ' t V \ D'if repn* .rntr*.4** t -1.t1*0.. J. /n y orkvii <*: * i t n - N , j' mi j en* riU`nsi nil 1 i .**:df I.V* *.t .1 .rt d'*v ol disnbilit . 1! Ij *.'xt !!.J M\ rr. *ill* tj d is.tb iH y *t *!: ll'M; fr. jxtivalru \.:\\ v*1 I.*'-*' Ct cl divibitift COPY 'll) Altet hearing ondatestaledabove tfvUU* ,%m;* t**dAward %. :ttd* i.*'1.'mV S Workmen's Compensation L*a\v V r.'v"w:. AWARDj_ T lffi^M IT -U Y E rf AND.-OU TV.rl INMMJVNCF. CAHPUT. / M T*!!j-C"i ! ^ r ^ S S k llitj- ' ovcr foiloH 'oi _woek*J j.--------- -----------------f-r-o--m--------- * I at rrte ! * r e r t t M V j 1rt' ` of I ! riAiMANr tiledtv .C wider tV: 3* m f-1 ` V J AY AT ONCH i h s i |.`aj*t*:r*ils m ade rc tri* ' n; i omoi'J os on aw&rdpayableb> i*p..**** check V> J to CLAIMANTS IlUPRESLN 1`ATIVfc OK A T n `l.S T i } { to POCTOrt for att*-*u..iirc* ; i He.*tini* 1I DECISION: Casewas.**9*94 on tb* featlt of thaaa findings* .Paeapatlcnal eoaditlot n^tiof. and_.**! ralatlon for aabaatonla. af tba lvnpa, DlaaMllfcy do# net 9*999fi. .? .day H a ltin g paglad .......................... ...................... If c-.se w it "conlinui'd" *i;0 coti'Jnuins piiymen* w * d u t t ! it *Ji .11 irtU* ;.t ft- ;. o-e rile O r the l*rr;o.! f l i t r! and sliall bo continufd hermit** until {!:. ttn y '.o r ci <t r:ci has si. u . sj uV. viAncc of r chans*, of e* nditii>n and fiv es notice thereof t-> tit Cha'tmiit:, WcH.men * C*ntunsui*on ix>**rd, usnc*-.. *Ju : v u*e provided in tJv. d t'" *,n. A fu rth er hearing w;ll h* hold in a *r*jmmu*d` t iiutninc th r extent i t furihrt luaHlity, If any. * In Volunteer Firem en's Ben rit r i H i , the hal le subdivision Is deemed to h t*M* 'T A il'l O Y Eli" of the v H o rtc fi fireman. O.si- C -23 C -23 C -2 3 C -2 3 C -23 S-2 (5-53) WORKMEN'S COMPENSATION BOARD STATE OP NEW TORS EMPLOYER'S REPORT OF INJURY Seni this notic directly to Chairman, Workmen' Compensation Board at address shown on rarer aide w ith in tan (10) day after accident occur. Copy al*o ahould be aent to your insurance carrier. -------W.C.1TUSEWE----- :-- -- giuim o a no.Aim-- .... .... COTEHO. -- TTAiTUyALUBEHT-\ NAME 1. ZlfP LO T O ___TH E fA B l/m T P SC TTW ffrV.Tl iV T _____________ _ T iT S m > t . 1 1KSUXANCX c a g lia i u s p l o y iu m u tu a l u a b iu t v insuh anu s co m pany op w ieooN sitj trc v Al)bjtSS T A P r _____ ___ _ LK PLO TtTS S. S. ACCI. NO. n ftfl _ m _ l.e A n a BTJUIZD FZKSOM M R 9w JiM X B ' T L B M n . R. D. #1 PAUCMa.S&JPRK EMPLOYER ACCIDENT 4. Nature of business: (State principal product manufactured cfPtiSfc fo ^ e P W ii rendered)- Moohanlea l Paehiagg -------- ----------------------------------------- 5. Place where accident occurrrreedd:i--------- Mo a c ci d en t 6. Date ^ - 37~ ?79-- l.P ay of Week--/ -Hour of Day- -A.M- _P.M y () n*t> di-fti'iijfy tv-pn- Bnns Hour of Day_ -A.M- _P.M (b) Wa injured paid in full for thia day?. & Name of foreman------- g a r r y Daaeh---Ring 9. When did you or foreman first know of injuryy?:'._____ ^lweod Memyfvten - Textile 10. Names and addresses of witnesses:________________________ INJURED PERSON $ * * jNATURE OF r INJURY ' OR * OCCUPA- ` TIONAL * DISEASE FATAL CASES 11. (a) Marital status: Wlf- (b) Sex-- Fanale 12. Age:----- 13. Dicl'ybu have on file employment certificate" or permit?- 14. Occupation: (a) Job title for which employed- 1 t a r t e r A Wrapper______ (b) Occupation when injured i. 15. (a) How long employed by you?- R e tti1ad ,7 y f ggjb) Piece or time worker ?_ Tlate (e) Hours per day:------------ - -(d) Days per week l_ 16. Earnings in your employ: (a) Rate per: Hour $ 1^60 Day Week $. onth $_ (b) Total earnings paid during year prior to date of accident: (include bonuses paid, value of board lodging, etc.) $____________________________Average per week: $____________________ ___ (c) Bonuses or premiums paid and included in item 16(b) above: $____________ (d) Estimated valu- ... ..o f board,..lodging, or,other advantages jnaddition to wages:-(included in item 16(b) above " r (e) Calendar weeks in past-52 in same kind of work as at time of injury: 17. State nature of injury.and part or parts of body affected: (as "Injury to Chest," etc.)__________ -- ----- Cowp la ia t >f -- w i ho r t W ; ? br e ath ' '-- ------ ;-- *------------------------------ 18. Did you provide medical care?---------- :-- :----- K *o, when?-- Oon gu i t H own ph y s ic ia n 5-16 19. Name and address of physician:----- Wa, J . Br u el l i MsP.s Palgyr a . To r i t------------------- 20. Name and address of hospital:_________________ :__-__ ____________________________________ 21. Probable length of disability:___ Mo m _____ -- ------------------------------------------------------------------ 22. (a) Has employee returned to work?- _ (b ) If so, give date:- (c) At what occupation?- -(d) At what weekly wage?- N O T E : Form C - l l most be filed each tim e there is any change in the employment status as reported i Item 22 above. 23. Has injured died?______________(a) If so, give date of death:_______________________________ (b) Name and address of nearest relative:___;_______________________ _______________________ 24. (a) W hat was employee doing when accident occurred? (Describe briefly as "loading truck," "opei ating press," "shoveling dirt," "painting with spray gun," "walking downstairs," etc.)________ -----------------Mo a ooi-dan b - Oaployoo work ed l a Te x t i l e D ept, a s Mach in e opeTP.-.ur-- (b) W her^ii\ccf< ien t^o ccu r? (Specify whether in street, factory yard, on loading platform, in fa< CAUSE OF ; tory, etc.)_L-- -Mo Acci d ent ------- --------------- r~---------------------------------------------------- -- ACCIDENT 25/ How was accident or occupational disease sustained? (Describe fully, stating whether injured perso OR ... ' ^ slipped,.fell, w4s .truck,. <{tc.,.and what factors led .up to or contributed to accident. Use addition: OCCUPA TIONAL DISEASE - If? * . sheets, if necessary.) .D q flo y po al l e geo bop eh er t a e ee of b r e a t h vh l eh ehe b e l i e ves -o l a^ duc t o yor k i n g - tw Tex t i l e De p t , e v e r n -po rl cd o f y s r i r 26. (a) W hat specific machme, tool, appliance, gas, liquid, or o< er substance or object was most close! connected with this accident or occupational disease? ' .'"(r(b^ If mechanical pparatus Vehicle,)]srhat jpart^f it?^(State^if gears,'pulley, motor, etc.)-- :------- I , t ' I i | .1 ' r * * . . 27. W ere mechanical guards or .other safeguards- (such as goggles) provided?------------- ___ in use at time of accident?..... ........ , ..(b) W as machine fool, or object defective? in what way? _(a) Were th< _____ If Eater in this box h accident a i re ported on Form C-2,1 Eater "X" fai thu boschi accident v u preiotaly reported oc Form C-2S T O X HAlfX: nomo a rt. OARLOCK m o p y n OONPAWI- OStcil VA7B o r THIS u r o t T t ...% e r * w p 3 7 , - 1 9 5 7 . 7D-2 te- C-2 D. F. FRASER, VICE rRE~IDEOT C-2 C-2 Stato of Now folk ATTENDING PHYSICIAN'S P.EFOJIT ,TO ATTtMOlHO PHYSIOANt wort* oo fib fora abovld bo Wod wbbln 4 t boon ciHt you f n , ( W y boolmon* U worinon't m -p innrtiiin cm or a voJ,.r1_ , ' I U koSi o , ogoln wlilin 15 or* ohw Urd f r o d a i , ond a* Prognm Rport>l lotarrab of 22 doy* or b u during naili.vlng h.hn-i A. on i Mw tmra.pnl*bo tfdmndoovoiltaHd FflINNAML RPO*T oo A b (ora a n * bo ( W ngordloa o( Aa Ung cd ony grwrt nport*. H trw tm .nl b noanUmd .in ,;. 4s |bevo, Si# - M. Marmi ft dgnnd and f t. o original 0 oocb goal owy triti rao)poIrkl .dIltNwStUlyItAwN!Ci i(1C)ACCTHIAEIJ.MtfAkM*, W^O, RaKMHEiN. 'StMCnOOMYPEEN.SATION SOA*9 ot lb . oco <4 Ibo dbtrkt In * i t * ^ 0 ** b * f r r to cbtv typo I ropw* fifi AO-HOUt WBJMJKAJCr *** ItCFOST Is o ay trrc o ri PROGRESS t&OKl F1KA1. RfPOJTT 1. W.CJo Cora NooMw (H knowfi) X Cotrftf Cow Nvttbtr to d C ttlt (if kotwn) '* ` 9. O vttof Aecdd*ittr|n|wryoodT(M ' 4. AddrtU Y/btrt Accident , injury Occurred ' .................... 5. INJURED ttJOON * Ntera Grace B-aylord .................. * R. F . D. ffl v P e lm v rfi, f'e v G arlo cIrl-^p rl-T ^ir Add, mu Y ork Cn-- ? - a ., fa CAAflOYK 7. INSURANCE CAKJU Garlock Packinr Concenv EMPLOYERS MUTUAL LIABILITY INSURANCE COMPANY O f BTSCONSIH PalnriTa. I'ev; York io a B B S STREET - ROCHESTER <, KEF YORK . fa HOSffTAl (H tny) * /f poftenf' fclolml Met ftfury --tortoti wM* p*rfearMR0 Wprttd drawunfc dvfy oc Vlw H *r fireman, Mew EMPLOYE* Mo erf/, fm, tillmpm of dfrfric# tfofau# vWcfi /( fa madrn 1mt VWoofoor f irmmm' $mmmH mmd mnt+r berci f . Frotoof todttittt (W W * dlmgmmmi, ofafectfrt Ahfingi, w t / cf>i'i oot p fajwft end o / M tn f t t# -- drffto roe* Jnf raptrfj probable a sbesto s is o f lu n g s. XOray f5.rdir.es o f n& sonar? iubi-o^jN Complaint i s c f dyspnea on ex e rtio n . () U tktro now f i r rfrabtlfy * pbyfeel ****** y * * If to, fa radi dfaoblllf/ f dofaet ftraH I M* pm tf.f faijwfy -- d ra t ? . <h) K07 Infvnr raw/H fat pamefitfrt fociof or b ttd dicfifitramtftt o r tifiar --run * d!,* __ T e3__ ff 00, d--aribes.___ _ ______rytoonarv S ibrosis There i s p ro b a b ility o f progression '_______________ 10. Notvro of --mtmmmh__ _ErOIlChO dll&torS a____________ _____________________________________ () Wkoft d i d / r a (1) lini troot p ^ t t _ 5 / ^ / 5 ^ -- <b) Ho /4tot boto dodteratd from Irooin otH?__ -Tift _ -- finimenti................ -- -- ` - * M--pfraft - W fa fotitro tptnrfltn, bttpllet, or fablIHoffoi trw tw o t --- _ not (2) faul froot -- ---- ------ -- - -- - ---- m , afro A *.-- -------------------- -- |( ocf, otKofoi uro** o - -- - - - - O fR ot...... ........... -- a t p r g s f f y r h ff Mf etoi* oofvro of oweli (r--tiowoti-------------------------- 11. yem thtolc*potlont 01 or wW bo obU to (0) roto** U t rural ororbf__h S J b g n ... Q>) dm ony otbor worV?----------------------------------- W fa polio* w orths?__ ygs _ (d) spodfy work AoitaKow, H - * r a v o i d . . d u s t e y n o y n r e ---------------------------------------------------- * f C O K n n c ITLK1S 12- n O g t s i t c f ; o n TH U UKE PATE OF YtCYIQU tC tO C T W HICH CAYC THIS IKFOEbCAnOK: | | U S ia . In point*( own w.rdr Iww oecrdwi or InlnT d u st a t work" "S h riT -t n f h r p n l . h . TV rpnt.v yoarw * - o y n a m r o . l a .a r.-i ii.iiis !J. t b a r ii. notvr. ond o a .n l o lnt.ry ood *f<Hy oil gorf. o( body i-- t - d . F n p n T .o r n - v ( f i s t R , i - i r h a h ' l r , n t . l n 1 n { r <<- p r i , r . d n 5 -- -distar? rf Tuns._________________________________________________ <"> w .r . Xwoy, talon?______ 2 S ________ (b) Wo* galMf monadoa*?________ CC________ H , (or lw long?______________________________ W H doi* I I * d i o , < (1> Aggrontaota doto of onuf mf nlotad ympliimii T lT y p n m T fO _____________ !_____________________ d;->"HlY lagoni_______________________________________ (}) Pofi.nl'* owryodonot V-*---- V f e r k g d f o r 2?, T " ^ ^ " _________ _____te x t i le D e-t. exposed to asbestos d u st._________________ ________________________ (d) b f i , ooy ilatary m w lrfcota f rm.nl d gnoontdlng ln{y or dl . . . ? 1 0 K to, d **al\i*i. ^ ^*** Pplnl** wo* oaidail orrb|ry darcHb^ oboon ibo c o a p a .n l frododng on. of w*dtrino ^wnlnnd . m n i l rrwrrbirYrl 1 1 T.rr I l Wo. p o ti. piarla If ond *r H cor. r f onotiiw gbyA bo? .* gtiyalcbitt ~ ' TIO ' " ' lr-1 If M, g l o o a . ond oddroa of giwodtng ............................. ' __________________ _ (0 Old yoo obtah Idtloiyond aodloof dola from prncoding piydrfo.t If n, onodr Cta<*>m*rrt * reels*. U. ftrt ran ^ittefrai Uftmcrtra - -This re p o rt i s subr.itted _fit reopest of T atf rn t_________ -- -- piTrv-ngrTr.nhynttl.. _______________ _ J * t*l* fbet- t t * f iiilg y j ttici rp U to M |( v t fa fb a f i f e f o t s f n(*(el r p t r f e r a Fvll c<4 fro f e f k b tf o f t y IrierratU ou ed bMxf<, rad e d vlffa f*U Liicv.'ft^ o f fbe- previfier. o f fate. 114 c f f li t Work* C o m p a a io tira te w o td fate. S i t f tfac ktlel*rr r f r o n t t farntfit Lew. 1 tl e f # f k t f I om pb /elelo o dmiy i i t t t t t d t o p r t e f i e t t d l c l t t f t H a S te lo t f K tw , t t f L W.C.*.dn,c-do-- 2Q52D1_____ :____ :_' /S4rnort) V'nUnr ,T. Bro.^Ti.,I'.n.____________ (W tiH tn iiffMl*!mf fhft!t>m n) w.cx Arrtboriioi.. N.mb.r_X_________:___________ ` ~ ' Add_ 216 E a s t C h a r lo tte A re m e_____________ bu T1A 1./C7_____________________________ _______ Palmyra, KVw York WORKMEN'S COMPENSATION BOARD U ltimi New farti I O ATONDtNO l n a u 'i km fcaitWHt il ATTCNDIN PHYSICIANS H fO K I PHYStCIAH I m H aa A il fan Haeitt be Hett tabla 41 bean aliar yaa t a * raattar Il e w t * e #s mm+mmUm mm t m m , e t 6* tibia 11 aitar I n i Im l a N t , aa4 m F re e r* iepar* I ialerrab I 22 ttay ar Ai raaa RNA1 HPOKT * Ab lent m m W HW nptrlliii I 4* MU* f r ynwtow lapwta. tf IrttaMta ! m p liN l l 1* FINAL 41 haan, 4U. fil fftMi W m * repart 4ba*fy M (1) CHA1SMAN. WOCKMB^ COMWNU.TIOti taOttJD I Ha Ha I In ttbtrttt ta r ttpaatt aapjr wMi (2) Ha IN8 JSANCS CAMH. hwv, m Ha CMPLOYBL ypa a# rapar g j 4 M K X 1 KBPOCT MlN A IT 1A0AY PI HAI 1. W XA . Caaa H i t a ir 0f ta vwe) L Carrtar Cm NaaHar w 4 Catta Qf tatara) L Date a l Aatttteta er ta|eryea4TI* 4. Attttrw Wbara Atattata ar lafvry Occarraj J. INiUMD PttSON a 4. IMPIOTO 7. tNSUKANCC CAMUa . HOSPITAL (1 aay) ! Na* Grace B>aylord !' Garlock Packing Company KICPIrOTm MUTUAL LIABILITY INSURANCE COMPANY OF WISCONSIN . . Q A r T o o k k P e o k i o g Coth^ a t iv A44r * B. F. D. # 1 : _Palmyra. Hew York_______ ____ __ Apat . . 52 . S; Palmyra. New Tork uoB B Ssm rr * ochisth a ht row: 1 * N ptaftta Mat* Ha aff? law Hat Jafery aararrW wttf atfapa r l i M t ppataM petaerU t f tkh U *Mtteta mfpaett taw a a li tttay a n II VaJaatoer ft Vataataar f l ria a a W i I raa l i i H a*4 * alar IMPIOTO *3T berat f . Franta awtthteai (U d ita Mapaarf i t f i t a a AettUpi, ntfettNt ______ probable asb esto sls o f lungs. XOray findings of pulmonary fib ro s is ._____________ Complaint la o f dyspnea on e x ertio n .______________ j____________________________ W h IUm m v any A-Wth, m ytyl.rl LJ~ " 7 " " V n . la ar* Aiiketi rr I M a lank al *a panat h|aiy ar * a i t____ ZS_ (b) May l*|wy raawh ta pamaaata fatal ar baatt U f m * l er Her aacnaaata tttaitat T68 Pulmonary gibrosig There 18 p ro b ab ility o f progression ' | m 4 n _ _ f i t Natara at < , Broncho d ila to rs 4L (a) Wbea 4M yea 0 ) ta * treat pattaaft 5 /1 fi/5 7 /(b) Hat pattata U w 4htanrte4 Ira * trttanrtat T>f> M I tatara 11 Date )fw Hlab pattata at ar M he able ta (0 i W la pallata arttaft-- f f i f i ---- -- I I Me aay albar arti- avo<d dust erpoeure_______ |cowan traitu-itonumi onthis uwi daw op rawout rowwhich qati ran iwomAnowi| ' U. iMta la paHaar* m aM> la axMaat ar M|ny iaim< " S h o r t o f b r e a t h . T aant.y y e a r e - W M iff t o sbff.atj dust e t work" '___ _____ U. OaaHfca aataa m j a a * H -y _ J * f -- J i_ly i--l-J. P n e u m o c o n io sis, p r o b a b le e ti o l o f ty i s a s h a t __ disease of lung.________________ _______________________________ (a) Wata Kray tahaat_____ y e a an . ff rat #ar feaw baff le M<Umh a m m .fhia.0) l||iadaa4m, alavalal irUMl l y ^ r i Twn years Ago Worked for 22 tts In ^ T extile1De~t. exposed to asbestos dus?.* H la Sara aay laty at atMiaaa ytaM al yn taliSin lataiy ar S a a a t . JOO. U . Wat pattata pravimIj War Ha aara al w a tt* fAfAwa_ _PQ ---- -- _ In n i! -pnA ftb^U ty uUtfAM mi 44r * al (b) tara Ver --ad-- _. _. .. . ... .............. ........ ...... _ _. .- _ W W j a a abita bittary * 4 aattltta ttata fraa pveraHip flyJii--t ------ . ,M ' If et, tatacb tttaaawta al IA latat kan aMtMaai lakM iaa ar imi ili T ^ l r e p o r t I s s u b m i t t e d a t r e o u e s t o f t h e r e t i e n t ------------- t a yf.aViTlaVi oniapM M T <.y I f h a y p i l l o w a f y W V 'r^ < a T `________________________ I fata fta t tba flattiyi a ta pptalaat (v n la Mm larapata f attkat rtpaH er tan a l fra ta Mm k ttt I i f ta it a i l t t , tarfarnata *4 babai, a4 Metta H I tali haawlattfa ta tba pravtilaat a l Saa. 114 e l fW Wrrtaaa'i C ie fiw iH a a Law a4 Sac. SS af ta# Vtteatri ffraMta't laeai t Law. I alata that I m a phyabiaa ttafy M in it i ta prwaMca a r l l t l t i le tb aSteta ta tiaw. Tarb. W.Cb battap r - u 0050m <r i y ' ' ___ ; - (Signed) .W iniam ..J_rslX>-H-.IL__________ XWrttH/f ttpaafwe al AtHmm H y lttaiij IJ5-J1I0 9-11 . WrCA A a ttu rtU f n .a h .i T "216 East C harlotte Ayenue___________ U/1L/S7 PblsnyYA^ New York / l I C ' f 7/i> '7 > <- / *. C -4 (' r / T7-'. < C -4 C -4 4 C-ll (3-S3) WORKMEN'S COMPENSATION BOARD STATE OF HEW YORK O " '*-.TT:>JBrJEMPIjOYER'SREPC . OF INJURED EM- PLOYEE'S CHANGE IN EMPLOYMENT . . . v. c- .. .. STATUS RESULTING FROM INJURY This.rtport is to be filed direcdy with the Chairman, W oHaan'i Compensation Board at address hows on rarer aide aa soon a* the amploymani statm of an injured employee, a t reported oa Form C-2-5, Form C-2, or on a prarioai Form C -ll, it changed. Chi na in employment status includes return to work, discontinuance of work, increase or dacreasa of refdar horns of work and ineraaaa or raduction ef wagas. Copy alto should he eaot to yoor irm n a o e carrier. ^ ............ W.CJ5. Cam No. i Cmtr'i Cam N. ab4 Cede No. Dete of Accident ! Hus# Addreee 1 bq4rr THE GAHLOCK FACEZBG COMPART padora, m i rem X. hivraac Comer frp lo y trt Mutual L ia b ility Inourenee Coptny o f Wisconsin JO Olbba fltroot ,*~r Tlochoatr 4 Haw`York 3. ftojamt Fatma RES. GRACE BAYLORS #8-838 R . D . #1 P A D jm , RWTCRK A. Date of most recent Employer' Report filed: (Check `V* form and give date filed.) Tories 8 - 4 |3 0 s h i f t O C-Z5__________ :---------------- J O C -2 _U -27-57----- ^ C -ll-------=------- i ------------ 5. Date Diaability Began--- 6m9* 58------------- :-------- --Hour of Day----- _-------;-------- AM------- :-----:-------- P.M 6. Nature of Injury:__n r prirnmary-ftA* t 1m m wt+h ><---- - - a h _______________ 7. Date of firit return to work following injury:----------------------8. (a) Change of employment status resulting from above injuty: Employment St*tu* Hove potDy 0*7 sir Wm V Eoralnye Trior to hijvy Cka&fed to (b) Date of this change in employment status U. (c) Remarks:--------.----- , ,, ------- ---- Occuwtt 9. Loss of time resulting front above injury since first return to work: Fnn (M *- Day, Ywr) T (M *,9> r,Y r) Ktuoe a 10. Is injured still under the care of a physician?---- Zas--------- If so, give name of physician - ___________Dr. RpaaH y i'nlnym, Haw York ------------------------------ 11. Has injured died?-------------- --If so, state date of death:------------------------------------------ Name and address of neatest relative known- . - -.. ---- --------- --- ----- ------- ------------ Date of this Report J un e l l t 1956 ----- Finn Name THE G-iRLOCI I-ACUTS.SOKPAHT------------ * -'S C-11 C-11 Signed by_______________________________________ D. 7 . FRASER, TICS TKESimTT oa*,i m t C-11 C-11 C-11