Document nj4vJkkrgqMwvmqzJbNMjvx2

BEASLEY. DORIS, widow of BUIOYEE BEASLEY...OT3WAS.H..................Z?.Q9A........................J>etrp*t........ . *en ' tow eu. IMMta c*r EMBLOYtt Own?..Coming. E*fc?R9?.**. Company.... .J5300 W. . 8 .Mile....Oak. Park___ . . Jobs Mansville Company 832 FiSTldl*Building, Detroit ** MSUKANCE COMPANY-foot agort)............. -.................................................................................................. Mb m Ml la mtmm ImbI Tha appCcaat mpei Ifull) Am: ' I. That thi* dams <iatt( to a panoaal ia|ary phich occottod on or ahoot..............$7?.$"?P.*.. . A ?.??-. at..... various places _ in Wayne County_ ........... ........................ MawiMniiMli' 1 . OK to a doabiatataf from octspoHoaol disaas* which .aecanad oa or ahoat >4t-.24t7j0,. .324t71. .. Z That tie injury or dinblemtot eawi ot.PMWJT........WY??P...........MICHIGJJ.............. oad hi th* following '. on cm m. .-BfFWWTR.OTfiY-ffWiy. JTSWW. .tft .Jatpf. .and. .fiJberglaaa/.. M &J.L-) * Mkr.mi I totWept . *4-24-70/................................................... ^............................................. .f300................. *'****..............................vi m nm ) Mbt MMin "4* ...................................raMir MMii* 1 death, pneumoconiosis, asbestosis. bronchitis, carcinoma ............... ....................... ` W Cato of ncoeory....................................... ........................ Cato of mtom,to work................................................... 3f..,, * ^ ^^ 4. U tooth mohad, gha Koto of tooth :.. .3-?4r7.i........... talarionthip of applicant to daraasad .V.ifP.............. Saf. 5. Nww of pantmi depaadeat apoa mjarad employ** m tot* *f mjery Wife.. .Doris................................... ^9.. .J* ~ 'h h- Ho* rntnp usatius bap paid or is campmtsali** baiag p3id tor the mjory? Yes____ M. XX .* > ' **.? '% 7. If ndjntmsnt of attorney or medical fen cr funeral nyiM it soeght, ptww ttoto which and amoant........s^w.. J^f^tor* appGcast request* that ht ha granted saeh rrfief at ha it entitled to Motor the Waihawn't Compensation Law of Michigen and that the Bureau set this matter for hearing so that the partiu hereto may hare a detorminotioe of thair right* *d*r the Worimeo'i Compensation Law. A?.Dated at .. .Detroit..................................... this . ^wam aod address of Plaintifft Attorney (H any) Dice. _Sweeney & Sullivan Dlt.San w. Thomas .Detroit Sank & Trust Building Detroit. Michigan 48226 VO 2 5909.......... ......................................... Addict* .120SW Heyden... .Detroit f* topoto regarding compensation matters may apply to the Bureau 02209 0(o09 SPhcetmn mast bo (nailed to the Bureau of Wartmen's Compensation, Lons, to one copy. VITAL I aJAWiIj 4313 1 CERTIFICATE OF DEATH r n*n **t m.or Al OAtl ci CtAJrt *< &2[PJL mccas II Beasley . Male , Kerch 24, 1971 Mrtlf * * IvmMI 1 All (Mil Ol iMlrt -Ctit. CCC'NIT Cl CCAlrt tie ^ | i *f*m Mt. | *! 1 OVlt tc r/, n1 !* Mil t , 1'ov. 1, 1916 V.'nyr.c (.Tir. VII Lr/jf. U<~rC'.VITj 11; O' CiAih Del-re it musi cn iwi'i nOilllAl Ck 0^11 icsI#<JLT fit VI NO 12094 Heyden fl MQI W !**, C| |l|l *> yali, I SIaK Cl ft'fcIM m **ci< *m m CilUt* Cf WHAI COUHli* maHiIO. KW< MAlt(0, ;C'*viyc injuu m '*i, chi mim London.Ontario U.S.A. wqowto. ptvQJCID ii uirricu I ,, Ibris Cents 16la; LC'.' **f 4u`Wl* 3^*"* // fa' `Ii __ f'r%rnyn // sfili-V'.. ! - ... ICUJAl C<CUfAfiON *C**t IM o* OU M4 tUIMC mOK O* im. w ii> mo i H :t. Cven Cornin'; fibcr ula33 CSVNfV CUY, village cr TCWN^HIP * VJ*'** Detroit &Hd Ol tUUMSS ot iNUUSTtr in_Astoctoc' tferher Mftl C * * ?| ANv I 'u. 12094itf(f;;it ot hi -i - na -o I ::cycn A. I hereby certify that the forccoirr io 'a rue copy of tho record or. file in tr. Dotroit Departnont of Health; attested by the raiccd ceal of tho City "of Dotre .i!!L " 0 m7t Divioion Head, V.ttcl Utatioticr. 02 209 0fe02