Document nm32LOaqVpVQxGngga2E80v42
* /
X)iTP- Ad
Greiachar, Paul J.
NAME
Unknown
D/l
AGE
//
SEX
Ar.bc^-o^is
INJURY SUSTAINED
L.un^s
PART OF BODY INJURED
U/S MECHANICAL CONDITION ADD ' L INFORMATION:
Head Office
COMPANY, PLANT, DIVISION
OCCUPATION
. O/E
P.D.
20G-7ii78
C LA 1 M NUMtlt-N
62 OAK 8108
I.A.C. CLAIM NUMBER
AGENCY
AGENCY PART
TYPE OF ACCIDENT
U/S PEHSONAL FACTOR
l
** i
V ,
-/
Q, rn ^ c_ f~] r* ^
CODE 12-6;
NAME MED
1. >T,
MO SP
,_4/
c-
_ _LL_
X-RAY
$S
S________________________
TI'MP;
DAV
WK
OTH E R
EXP LA NAT 1 ON CK NO
P.D. FnO m
THRU
AMT ,
4 -> J `K>
/
20G -- 11 [ {8
CLAIM NIJMBI
TO TAL
wcsr r .
1000..
c < v A,;
,1 1 ( i r-fi /
(>>
5t6 j
1
1
i
o' >
--
//.r: 1 -
/'
C ] ',
i
7'0
J 1 1
1
i
;
t
l '<+
+* r
\
\
*
r' -l. .S#P
_ V1' u< i rW-uni*. i- ^ -
*;~7Z^r^ClpOO-OT-: 'iOTO^'YL'''2''"-"'tf'
: y-rnfji's*