Document peKZwxqRwwZdYZ6Kbw84K69gX

FILE NAME: Contract Unit Workers Comp Claims (WCC) DATE: 1959 DOC#: WCC012 DOCUMENT DESCRIPTION: Workers Comp File - Dean, William Contains all documents found in the Claimant's file, with one blank page between each separate document V # . < 1* * '1 f 4 I *# '4 <y 00^ 6 90 05522373 c 5931605 O STATE OF NEW YORK WORKMEN'S COMPENSATION BO ftfch . 50 PARK PIA CE, NEW YORK 7 , N . Y . D ii,C t d . t e ilU im D satj D is .C t d . 1 2 /6 /5 9 \ w <65 CASK NO. OATS O F ACCJDCNT WC1 Drot>d*ay . . C . B p ftc.Fu n d s Con Cotoni 20C K.V2nd a t .f l.X .C aojodt 4 C o rk C o rp . 7101 Toon*11 AT. / C 1 ff o B * v g ii,ff .J C h ari 3Wood 4 Co* d i Malo >t. * * s t oraiiao * sb asto Con at r .Co. 0 60 -607 k29 tii d t.tf K 5 T 3 i n CAm tlKft CASK NO. 6 1 - 0 7 W ood a ld o A r a . CLAIMANT ^Opd gl* f f Y _____ ;_________ NOTICE OF PRELIMINARY HEARING V s n fc a o r s t a r f t & s C < i. u~ T"-- a d d r e s s 2 7 * 1 6 V O t li T t t . L - I e l U ^ M .r ______ PLACE: 50 PARK PLACE, NEW YORK, N. Y. T r v i r n ln s .C e EMPLOYER a d d ress 8 0 Jo h n 3 t t f.Y c * Hartford cc.Ine.Ca.__________ 1 .2 3 W i n l e ` t . f f . X e C . M ag n a s i toa s t C , -----------------3 9 -5 0 C w a a t S t U le C !.!* DATE: TIME: F s b .0 ,1 % 1 130 * * . 2$ -P A R T : Date of This Notice K .4 8 . In s u la t io n C o . c a r r ie r 2 C-5 - Abt r f ! A B r o e l t l j n B | 0 * y 1 /2 6 /6 1 AWE A rm stro n g C o n tr C o ADDRESS 1 3 0 if o . L i g e S t . '" l o u e s s t a r > * ' L u b a ra * n s M n t .In s .C o 3^2 Madison Am H.T.C H a t t h s ~ d a 1 ;> g e h " C a t e i* la * . Puad 1 9 9 CEuxeb s t . f f . X X M ine C as.& iu rst/ Co > 7 - 0 3 **th f t . 3IIC . |M.1 . 151 h U li u a t .f f .X X . C a rrier it contending, through report filed with th Board and copy tent to the claim ant, either that it it not required to make paym ent! in this ca te , or that iti obligation it l tt than the amount being claim ed. In order to le t a date for Trial Hear ing on any ittuet that remain untettled, a Prelim inary Hearing w ill be held at the time and place above ttated. \ Both claim ant and carrier are to be pretent, prepared to furnith in full detail all of the following information! t . Nature of the ditputed ittu et and of the evidence that w ill be produced at Trial Hearing. 2 . Namet and addrettet or other identification of all w itnettet on whote tettimony the partiet will rely for proofs, Includ ing both phyticiant and lay w itn ettet, and brief statement of evidence each it expected to give. 3. A day and hour when all w itnettet and the partiet can atiand for Trial Hearing. 4 . The time each party will require to present tettim ony and to cross-examine witnettet of the opposing party. At the Preliminary Hearing the Referee will make findings on all ittu e t not in dispute, or at to which dispute it withdrawn, and w ill then fix a day and hour for Trial Hearing and estimate the time to be allowed for taking all tettimony. ON THE DATE SET FOR TRIAL HEARIN G, THE CASE W ILL BE DECIDED ON THE EVIDEN CE PRESENTED. THERE WILL BE NO FURTHER ADJOURNM ENT EXCEPT FOR G O O D AND SUFFICIEN T CA U SE STATED UNDER OATH BY THE PARTY W HO HAS FURTHER EVIDENCE TO PRODUCE. C-210 C-210 C-210 Chairman C-210 C-210 eJK&e, < , JAN 1 i wut 0 06003650 D th , C5522373 05981605 M a .c w . STATE OF NEW YORK /j RKMEN'S COMPENSATION BOARD 50 PARK PLACE, NEW YORK 7 , N. Y. i; w 9 CASK NO. OATS O F ACCIDCNT 3V2 Hadloon fit* 5*C Hatha* Belloaeh Co* 37-03 3Vth a t . L .I X . 3 tata Ian* Fond 199 Ctauroh St.tl.Ij;* M ta a Can* A S u re ty Cc 151 William S t . fla* XorfcH.X CAA AI KN CAAC NO. 61-0 7 WoodIda Ava CLAIMANT. -MpdId, X Vantaor* AaBaa&a Co. lUtf? NAMI ADDRESS . ? 7 , l 6 W 0 t h * V O . ---------- Trara lo ra I a.Co.(H artford) 60 Jo te S t . H . r x . EMPLOYER H a r t e o f f ;Q o t t l i a tiA A B i r h i B f A f q Voi Broad*? H .I X . ADDRSS Qpaa.Fuoiia Coo Cow* 200 fa at V2od 3t.H .Y *C . Hoadt Cork Corp. CARRIER. 7101 Top s a il Ar a . Horth Bargan >*.J . date to s Codatm e t loa Co. ADDRESS. 603^607 y . 2 9 t a s t . ~ tT. r x . ----------------- C b arlas S . Wood A Co. S3 Halo 3 t. Waat GroocaV*J* Hagnaala Aabaatoa Saaulatlflo Co* ' 3gj.5Q.jC.raeact Ht U IC.IU Ir---- NOTICE OF PRELIMINARY HEARING PLACE; 50 PARK P U C E, NEW YORK, N. Y. DATCt TIME. 1 1 ,3 0 --PART. D o t. of This Notice 1/6/61 AMI H 7 a y r ^ m a t i c a t o ; ------------ 205 Buffalo A*a. BXlyn,fl.I* Armstrong Cootr.Corp. 120 So.L in a S t . Leoea s t a r la C arrier is contending, through report filed with the Board and copy sent to the claim ant, either that it is not required to make paym ents in this case, or that its obligation is less than the amount being claim ed. In order to set a date for Trial Hear* ing on any issues that remain unsettled, a Prelim inary Hearing w ill be held at the time and place above stated. Both cioimant and carrier are to be present, prepared to furnish in full detail ail of the following inform ation; 1. Nature of the disputed issues and of the evidence that w ill be produced at Trial Hearing. 2 . Names and addresses or other identification of all witnesses on whose testimony the parties will rely for proofs, includ ing both physicians and lay w itnesses, and brief state ment of evidence each is expected to give. 3 . A day and hour when a ll witnesses and the parties can attend for Trial Hearing. 4 . The time each party w ill require to present testimony and to cross-examine witnesses of the opposing party. At the Preliminary Hearing the Referee w ill make findings on a ll issues not in dispute, or as to which dispute is withdrawn, and w ill then fix a day and hour for Trial Hearing and estimate the time to be allowed for taking all testimony. ON THE DATE SET FOR TRIAL HEARIN G, THE CASE WILL BE DECIDED ON THE EVIDEN CE PRESENTED. THERE W ILL BE N O FURTHER ADJOURNM ENT EXCEPT FOR G O O D AND SUFFICIEN T CA U SE STATED UNDER OATH BY THE PARTY W HO HAS FURTHER EVIDENCE TO PRODUCE. C-210 C-210 ( L /^ C U s U T \ Chairman C-210 C-210 a&ttfcs EMPLOYER (^ ) STATI OF NEW YORK ) WORKMEN'S COMPENSATION BOMD 3 50 PARK PLACE, NEW YORK 7 , N . Y , 05522373 D i s . c t a . 06008650 Dth. William Dean 05981605 D ia.C td . 2/7/55 j l l ^ liJbQ -9 ^ W. . CASK NO. 3C W W W CARRIER COOK CARRIER CASE NO. CLAIM AN T- AnnpF Mar/ miter namci 61-07 Woodal4e Avenue Wood slA fH .X * NOTICE OF PRELIMINARY HEARING PLACE: 50 PARK P U C E , NEW YORK, N. Y. em p lo y er Yentaore Abeato a Co______ DATE: D 1 ^ I9 6 0 ADDRESS 2 7 r l 8 j 0 t h . A t g t _ i f 1 x , TIME: 11 *30 A.M. --PART: 30 Dai of This Notic Luabermena Mnt.lJBs.Co. rACPipg 3*2 Medi eoa Ave. H.Y.C.____ Spaa.Funda Cooa Conn* 11/30/60 AMR ADDRESS. 200 15b at *+2nd St.H .X .C . A. Markhoff,Fa<i* bOl Broadvay N.X..____ Armstrong Cork Co. 295 F ifth Avenue H ..C . Mund & Cork Corp. BaiIch Co. 7 1 m f o n n e l l A v e .____________ Bo.Bergen.N.X* L .I .C .tB.X. C arrier is contending, through report filed with the Board and copy sent to the claim ant, either that it is not required to make payments in this case, or that its obligation is less than the amount being claimed. In order to set a date for Trial Hear* ing on any issues that remain unsettled, a Prelim inary Hearing w ill be held at the time and place above stated. Both claim ant and carrier are to be present, prepared to furnish in full detail all of the following inform ation: 1. Nature of the disputed issues and of the evidence that w ill be produced at Trial Hearing. 2. Names and addresses or other identification of all witnesses on whose testimony the parties will rely for proofs, includ ing both physicians and lay w itnesses, and brief statement of evidence each is expected to give. 3 . A day and hour when a ll witnesses and the parties can attend for Trial Hearing. 4 . The time each party will require to present testimony and to cross-examine witnesses of the opposing party. At the Preliminary Hearing the Referee will make findings on all issues not in dispute, or as to which dispute is withdrawn, and w ill then fix a day and hour for Trial Hearing and estimate the time to be allowed for taking all testimony. ON THE DATE SET FOR TRIAL HEARING, THE CASE WILL BE DECIDED ON THE EVIDEN CE PRESENTED. THERE W ILL BE NO FURTHER ADJOURNM ENT EXCEPT FO R G O O D AND SUFFICIEN T CA U SE STATED UNDER OATH BY THE PARTY W HO HAS FURTHER EVIDENCE TO PRODUCE. C-210 C-210 C-210 Chairman C-210 C-210 CARRIER 2 f J STSATATETEOOFFNNEWEWYYOORRKK WORKMEN'S COMPENSATION BOQ , 50 PARK PLACE, NEW YORK 7 , N. Y . 06008650 Oth. 05522373 Oi*.Ct<S. M ilita * 0#D Og9frtfiQ5 O ti.C td ._______12/6/59 Dth. W. C. a . CASK NO. D A T I Or ACCIDENT Kthe B a lio h Co. 3 7 -0 $ 3 ^ th 3 t . L . I . C . , I . . _69------------- CARRIER CODE Mary Dean CLAIMANT-- 6 1 - 0 7 ------------------CARRIER CASE NO. ----------- -u -r --' NOTICE OF PRELIMINARY HEARING W o o a * l ,8 Y , ad d ress V n iita o y e A a b e tb e a e o a--- ______ _ " PLACE. 50 PARK PLACE, NEW YORK, N. Y, 2 7 l6 V c t h Aveo tte L .X TraveTera Ib *9i p /iriH Y Fn p p J o h n f it Harkhoff .G o ttlie b JKHarkina Bsq a. a d d r e s s V o i --H r o w w y " 8 r * v E ............... . 3pc.Fundi Cobs Coesa. _ 200 V ast **2 S t.H .a C . CARRIER Han t & Cork Corp . --------------------, ,, D c 7101 Tonnelle Ave. Borth Bergen, 3 . J ADDRESS fi . . - l a s ufart l on-Co .------------------ 205 B uffalo Ave. B k ly n , .*. Asbesto a Construction Co. - 6 0 3 =6 0 7 .'29t i r s t . s . r x . ----------------Chea* 3. Wood & Co. " 88 TCala S t V * a t or a g i ,1t T i------- DATEl Dee.1**,1960 ^ n ? o A.M. ~PART| 30 Data of This Notice 11/30/60 AWE Magnesia Asbestos In su latio n C< 39-50 Crescent S t . LeX*C.9B*Xe Araatrong Cootr a tin g Corp. 120 Ko.Lloe S t . L a n c ia ta *,Pa e C a rrier ii contending, through report filed with the Board and copy tent to the claim ant, either that it it not required to make paym ent! in this ca te , or that itt obligation it ie tt than the amount being claimed, in order to tet a date for Trial Hear ing on any ittuet that remain untetfled, a Prelim inary Hearing w ill be held at the time and place above stated. Both claim ant and carrier are to be present, prepared to furnish in full detail all of the following inform ation. 1. Nature of the disputed issues and of the evidence that w ill be produced at Trial Hearing. 2 . Names and addresses or other identification of all witnesses on whose testimony the parties will rely for proofs, includ ing both physicians and lay witnesses, and brief statement of evidence each is expected to give. 3. A day and hour when alt witnesses and the parties can attend for Trial Hearing. 4 . The time each party w ill require to present testimony and to cross-examine witnesses of the opposing party. At the Preliminary Hearing the Referee will make findings on all issues not in dispute, or at to which dispute is withdrawn, and will then fix a day and hour for Trial Hearing and estimate the time to be allowed for taking all testimony. ON THE DATE SET FOR TRIAL HEARIN G, THE CASE WILL BE DECIDED ON THE EVIDEN CE PRESENTED. THERE WILL BE NO FURTHER ADJOURNM ENT EXCEPT FO R G O O D AND SUFFICIEN T CAUSE STATED UNDER OATH BY THE PARTY W HO HAS FURTHER EVIDENCE TO PRODUCE. C-210 C-210 C-210 C hairm an C-210 C-210 Q Lcv'mtjn4- ,, ,, - __ / j l i C i n * . ___ D is i s . "Xf/ft/ C br'/H ___ . G r z ..... c U 't C o/ ~ v t .-______ S fitte A /tU J ............ -Q ^ < -- ./ //?* / 0 J l/lO / o BALTIMORE NEW YOU*. CLARKSBURG TULSA sr louis CHICAGO LOS ANGELES ATLANTA PITTSBURGH SAN FRANCISCO NEW ORLEANS MIAMI PHILADELPHIA A L E X A X D K K & A N E X A N 3DIWiR INCORPORATED INSURANCE AVERAGE ADJUSTERS CONSULTING ACTUARIES 2225 NORTH CHARLES STREET, BALTIMORE 18, MD. March 28, 1962 TELEPHONE TUXEDO 9-434 BELL SYSTEM TELETYPE BA ,ti CABLE ADDRESS "ALEXBLUE" Mr. William L. Hughes, Manager Insurance Department Armstrong Cork Company Lancaster, Pennsylvania. Travelers Policy No. RUB 7595412 ARMSTRONG CONTRACTING AND SUPPLY COMPANY Dear Sir:- Please note disposition made of the following claim; S.-V55 Date of Accident: October 4, 1959 Claimant : William Dean Location : New York Claim No.: Disposition: B-923Q463 $48.50 - Expense Remarks : Indicate Whether: W o r k m e n ' s C o m p . _____________ H__ Auto Liability B.I.________ P.D.________ General Liability B.I. P.D. Very truly yours, ALEXANDER & ALEXANDER, INC. LOSS DEPARTMENT. V BALTIMORE NEW YORK CLARKSBURG TULSA ST LOUIS CHICAGO LOS ANGELES ATLANTA PITTSBURGH SAN FRANCISCO NEW ORLEANS MIAMI PHILADELPHIA <S'-> A T aK X a n d k k & A ij h x a x u d h c ir INCORPORATED INSURANCE AVERAGE ADJUSTERS CONSULTING ACTUARIES 222 5 NORTH CHARLES STREET, BALTIMORE 18, MD. February 26th, 1962 TELEPHONE TUXEDO 9-A304 BELL SYSTEM TELETYPE BA 582 CABLE ADDRESS "ALEXBLUE" Mr. Wallace B. Hofferth Assistant General Manager Insurance Department Armstrong Cork Company Lancaster, Pennsylvania Dear Mr. Hofferth: re: William Dean - New York D/A February 7th, 1955 Died - December 6, 1959 File B 9230463 ______ We have now received a reply from the Travelers Insurance Company with respect to our inquiry as to the status of this old case. They advise us under date of February 21, 1962, as follows: ''This file was closed by the Workmen's Compensation Board at a hearing on I a recent date and this case is being closed with no payment. The Travelers were relieved of any liability in this claim." case Accordingly, we are closing our file on the Sincerely ALEXANDER & ALEXANDER, INC. 1ENERAL ADJUSTER R BALTIMORE NEW YORK CLARKSBURG TULSA ST LOUIS CHICAGO LOS ANGELES ATLANTA PITTSBURGH SAN FRANCISCO NEW ORLEANS MIAMI PHILADELPHIA A L E X A M ) K K & a\ L K X A M ) E R INCORPORATED INSURANCE AVERAGE ADJUSTERS CONSULTING ACTUARIES 2225 NORTH CHARLES STREET, BALTIMORE 18, MD. February 7th, 1962 W p ir ' TELEPHONE TUXEDO 9-A304 BELL SYSTEM TELETYPE BA 582 CABLE ADDRESS "ALEXBLUE" Mr. Wallace B. Hofferth Assistant General Manager Insurance Department Armstrong Cork Company Lancaster, Pennsylvania Dear Mr. Hofferth: re: William Dean - New York D/A February 7th, 1955 Died - December 6, 1959 We acknowledge your letter of February 2nd, 1962 asking that we secure an up-to-date status report on this claim. We are asking the Travelers Insurance Company to furnish us with the information requested by you and just as soon as it is forthcoming, it will be passed on to you. Sincerely k February 2, 1962 Nr. 0 . H. Finlay Alexander Si Alexander, 2225 North Charles St. Baltimore l8, Hi. Inc. Dear Mr. Finlay 8ubject: W ill law Dean - New York D/A - 2/7/55 Died - 12/6/59 We would like to have an up-to-date status report on this claim. We have reason to believe the claim m m b e r is 9230^63 because it appeared for the first time in the second retrospective adjustment for 1959 with a reserve of over $20,000. Please ask for statements concerning the adequacy of the reserve and the method used to apportion the loss among prior employers. Very truly yours, Wallace B. Hofferth Assistant General Manager Insurance Department MUT Nay 1* 1961 Hr* Q. & Finlay Alexander A Alexander, Xno. 2225 Forth Charlaa St. Baltimore 18, Nd. Dear Nr. Flnlayt Subjeotj Williaa Daaa - lav York Xi/k- 2/1/55 Died - 12/6/59 r * ,/ z? 1 *3 0 ^3 In reply to your April 27th lattar va anoloaa a Therao-fax of a nano writtan by Vallaea B. Hofferth* Tha nano originally van not written for outside oonsuaption, however, lta oontant in addition to tha data of tha accident ao thoroughly presents all tha foots in our possession va knew you would bo happy to gat tha whole stoxy. Sorry I left your February 14th lattar go unanswered - ay apologias. ary truly yours, NL t Enclosure R. C. Sohiedt, Jr. Xnsuranee Department BALTIMORE NLW YORK CLARKSBURG TULSA ST LOUIS CHICAGO LOS ANGELES ATLANTA PITTSBURGH SAN FRANCISCO NEW ORLEANS MIAMI PHILADELPHIA A lexa n d er & A lexa n d er INCORPORATED INSURANCE AVERAGE ADJUSTERS CONSULTING ACTUARIES 2225 NORTH CHARLES STREET, BALTIMORE 18, MD. April 27th, 1961 Mr. R. C. Schiedt, Jr. Insurance Department Armstrong Cork Company Lancaster, Pennsylvania R'l '< 'M Dear Mr. Schiedt; re: William Dean D/A February 7th. 1955 Reference is made to our letter of February 14, 1961 in connection with claim involving the above employee. We are wondering if you have determined the correct date of the accident, so that we may set up this case in the proper file. Tour comments will be appreciated. Sincerely TELEPHONE TUXEDO 9-4304 8ELL SYSTCM TELETYPE BA SB2 CABLE ADDRESS "ALCXBLUE" BALTIMORE NEW YORK CLARKSBURG TULSA ST LOUIS CHICAGO l o s An g e l e s ATLANTA PITTSBURGH SAN FRANCISCO NEW ORLEANS MIAMI PHILADELPHIA A l k X xV X d k r & A i L K X A X U d m t INCORPORATED INSURANCE AVERAGE ADJUSTERS CONSULTING ACTUARIES 222 5 NORTH CHARLES STREET, BALTIMORE 16, MD. February 14th, 1961 TELEPHONE TUXEDO 9-A304 BELL SYSTEM TELETYPE BA 582 CA8LE ADDRESS "ALEX8LUE" Mr. R. C. Schiedt, Jr. Insurance Department Armstrong Cork Company Lancaster, Pennsylvania Dear Mr. Schiedt: Subject - William Dean ____________ D/A 2/7/55 We have your letter of February 10th, 1961 en closing letter from the State of New York Insurance Fund In connection with the above case. We note you give the date of the accident as February 7th, 1955 whereas the Compensation Claim Examiner indicates date of injury as December 6, 1959, the date you show Mr. Dean died. Will you please let us know the correct date of the injury? Also, please advise whether we have been furnished with a previous report of the matter, as we are unable to locate a previous record, if not, we would appreciate your sending us copy of the report for the completion of ouf file. In the meantime, it would appear to be entirely in order to furnish the Compensation Claim Examiner of The State Insurance Fund, the information which they request. Sincerely ALEXANDER & ALEXANDER, INC. R i t_ * . X . - l I February 10, 19&1 Nr Chrlatopber Hoff Alexander k Alexander, Ine 222$ Vorth Charles St Baltimore 18, Nd Dear Christ / Subject ,/Villiam Dean V a - 2/7/55 7, ^ ' ' Vhfit should ve do about the attached request fron the New Tork State Insuranoe FuadT Our file indieates William Dean's death, December 6, 1959 vas oaused by asbestosis The first hearing by the lev fork Workmen's Compensation Board vas held September 28, I960 and a seeond hearing vas scheduled for February 8, 1961 To date Travelers has not requested a vage statement Sincerely yours, NL Enclosure R. C. Schiedt, Jr* Insuranoe Department / e T h e S t a t e In s u r a n c e F u n d w c h u * cm run h i w y o 7, n , y . WOrtfc 4-7)00 W ILLIAM e FOLGCR extcuTfvr c .* icto ji 0 " To Address Armstrong Conerooting Corp. 12C No. Lime Street Leicester, (a. IN ( H r F U A ii l i f i l TO C lA im C O a HTMINT . D.P.A The claimant referred to below was injured while in the employ of Matthew Belich Corp* Under the provisions of the Workmen's Compensation Law it is necessary for us to ascertain the claimant's earnings From : jun t 1959 To : December 1959 Will you, therefore, complete the enclosed payroll statement, in duplicate, indicating thereon the claimant's earnings while in your employ, and mail it to our office in the enclosed return envelope. Thank you for your cooperation in this matter. Case No. : < 5566 416*04 S . S. No. : Claimant: William Dean Injured: 12/6/59 Date : 2/2/61 ____D 6o s wo_r5.h ............................................. flmoAotx Compensation Claims Examiner c*i  T he. S t a t e In s u r a n c e F u n d m CHUtCM tTtCCT NfW TOM 7, N. V. WOrtfc 4-7100 WILLIAM B fOLGEH lU C W Tivf OIMCIO To : Armstrong Contracting Corp* 120 No. Lime Street Addres : Lancaster, fa* im unr n u u w u to CLAIM* DITAITMINT .P.. The claimant referred to below was injured while in the employ of Matthew Ballch Corp* Under the provisions bf the Workmen's Compensation Law it is necessary for us to ascertain the claimant's earnings From : jun#, 1959 To : December. 1939 Will you, therefore, complete the enclosed payroll statement, in duplici e, indicating thereon the claimant's earnings while in your employ, and mail it to our office in the enclosed return envelope. Thank you for your cooperation In this matter. Case No.: S.S. No.: Claimant: Injured: 416-04 Wiilia* Dean 12/6/59 Date ; 2/2/61 D. Eoaworth IHryjoff Compensation Claims Examiner 1 WAGE STATEMENT SUBSEQUENT TO DATE OF ACCIDENT THE STATE INSURANCE FUND 199 CHURCH ST R E E T , NEW YO RK 7, N. Y. WOrth 4-7100 r Armstrong Contracting Corp Date___February 2 1961 ~1 Case No_ 5566 416-04 120 No. Lime Street Lancaster Pa. Injured Employee- William Dean........ L J In order to properly handle the above captioned case at the Workmen's Compensation Board, we would appreciate your completing the table and questiona below, in duplicate, indicating the employee's earnings (rnm 6/1959 to 12/1959 and immediately returning them to this office in the enclosed envelope. THE STATE INSURANCE FUND ,, D. Bosworth .Claim s Department W eek Number W eek Number W EEK ENDING Month Day Year l 2 3 4 5 6 7 8 9 10 11 12 13 14 IS D art Worked Groar Salarr Including Ail Overtime W EEK ENDING Month Day Year Days W orked 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Total Grot* Salarr Including Ail Overtime 1. O ccupation ___________________________________________________ __________ 2. Soc. Sec. N o .-------------- ---- ---------------------- 3. Was this employee given free rent, lodging, board, tips, bonus or other allowance in addition to above e a rn in g s?____________________ If yes, state weekly value th e re o f----------------------------------------------------------------------------------------------------------------- ----- ------------------- D escribe------------------------------------------------------------------------------ ----------------------------------------------------- --- --------------------- S ig n e d ____________________________________________ Title -------- ... ------------------------------------------------------------------------------ Date of this report ---------- ------ _ --------------------- Name of Employer ______ _ _____________________ _____ ___ __________ ____ Note: Give reasons, if known, for lost time, if any. (For example: lack of work, personal illness, weather conditions, accident, seasonal work, etc.) C-63 NEW YORK. 6-4-58 30M (7B-736) WAGE STATEMENT SUBSEQUENT TO DATE OF ACCIDENT THE STATE INSURANCE FUND 199 CHURCH ST R E E T , NEW YO RK 7, N. Y. WOrtii 4-7100 r Armstrong Contracting Corp D ate..... F a b r u a r y 2 1 9 6 1 C u e No.. 3 5 6 6 4 1 6 * 0 4 . . 120 No. Lim Strsat Lancatr, Pa. Injured Employee... W i l l i a m P a S A L J In order to properly handle the above captioned caae at the Workmen'. Compenaation Board, we would appreciate your completing the table and questiona below, in duplicate, indicating the employee'* earning* f r o n L 6 / 1 9 5 9 tQ . 1 2 / 1 9 5 9 _____MXXfttt, anl immediately returning them to thia office in the enclosed envelope. THE STATE INSURANCE FUND By-------- -P __ __ __ _______ ___ _____ Claim* Department W eek N um ber W EEK ENDING Month Day Year l 2 3 4 5 6 7 8 9 10 11 12 13 14 IS Days W orked n G ross Salary Including All l l Overtint* 16 W EEK ENDING M eath Day Year Days W orked 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Total Gross Salary Including All Overtime 1. O ccupation __________________________________________ .________ _________2. Soc. Sec. No. -- ------ ------------------------------ 3. W u this employee given free rent, lodging, board, tips, bonus or other allowance in addition to above earnings? ___ ___ __ __________ If yea, state weekly value thereof______________________________________________________________________________ ___ __________ _____ D escribe------------------------------------------------------------------------------ ------------------------------------------------ ---- -------------------------- Signed -----------------------------------------------------------Title ------- . ---------------------------------------------------------------------------- Date of this report . --------------------------------------- Name of Employer . _. ----- --- -------------------- -------- ----------------------- -- Note: Give reasons, if known, for lost time, if any. (For example: lack of work, personal illness, weather conditions, accident, seasonal work, etc.) W ) NEW YORK. 64-58 JOM (7B 736) ^ g ^ s a 4 *01 droiivijr 2*X*d* 3p m *h b 4 i C i Commi* 0^ 00% a & S th * STATE O F NEW YORK iRKMEN'S COMPENSATION BO 50 PARK P U C E , NEW YORK 7 , N . Y JO C R .V l r t 3 t B .X C 0 * u r t t * C o rk C rp * 7101 TootMtlM AM* 2o*Bvf*i,if*J* 05523373 D i*C t<. Ommb C591605 D ia.C td . 12 /6 /5 9 C h a r i a 4*W cd A C m* d M a la t * Am a t 0 r M g 9 A a b * to t C w a t r .C o . X* w. C A M NO. DATS O S ACCIDENT 6 0 - 6 0 7 te .2 9 th a * .J H C CAftftiKJt C A M NO. 6 1 -0 7 t o r t a li A ll, CLAIMANT address em plo yer B T _____________________ I t a t w f a fe n to i Cm* 27-16 VOth A, IT O M I * I m *C m * 80 Jak *X*XCa R c r t T a r a c .la t C o , 123 v u u t . f f . r x * ADDRESS K t f P M s l A b t MM C * 3 9 *5 0 C*MMat 3 t * L . l e C * 91 * Z * t 4 * . In ul tic Co* CARRIER. 2 0 5 flu f f a l o Am B r a a k l j M 2 * 2 a -- A x iit r a a i CoM trX o * ADDRESS i a & a p u -- a t # l w w t i f / i r ~ LUMb*n#Dl ttat.Xaa.Co* 3^2 M I m AIM* m. i x . t t i l t n b a n C d * --------------------- li ST 3 7 -0 8 3*H h 3b * NOTICE OF PRELIMINARY HEARING PLACE; 50 PARK P U C E , NEW YORK, N. Y. DATE. TIME. f* b a ,1 9 6 1 130 P * 4 * -P A R T: 2 9 Dot* of Thi* Notic* 1 / 2 1 / 6 1 AMA * t t M I s * PM&6 1 9 9 C t e t A s t * i X X * AmRmm C a * A 5 u r t y C m * 151 * 0 1 1 t X *X X C arrier is contending, through rport filed with the Board and copy sent to the claimant, either that it is not required to make paym ents in this case, or that its obligation is le u than the amount being claimed. In order to set a date for Trial Hear ing on any issues that remain unsettled, a Preliminary Heoring w ill be held at the time and place above stated. \ Bath claim ant and carrier are to be present, prepared to furnish in full datail all of tha following information! 1. Nature of the disputed issues and of the evidence that will ba produced at Trial Hearing. 2. Names and addresses or other identification of all witnesses on whose testimony the parties will rely for proofs, includ ing both physicians and lay witnesses, and brif statement of evidence each is expected to give. 3. A day and hour when all witnesses and tha parties can attend for Trial Hearing. 4 . Tha time each party will require to present testimony and to cross-examine witnesses of the opposing party. At the Preliminary Hearing the Referee will make findings on all issues not in dispute, or as to which dispute is withdrawn, and will then fix a day and hour for Trial Hearing and estimate the time to be allowed for taking all testimony. O N THE DATE SET FOR TRIAL HEARING, THE CA SE WILL BE DECIDED O N THE EVIDEN CE PRESENTED. THERE WILL BE N O FURTHER ADJOURNMENT EXCEPT FO R G O O D AN D SUFFICIEN T CA U SE STATED UNDER OATH BY THE PARTY W HO HAS FURTHER EVIDENCE TO PRODUCE. ^ O IA . / ^ 6 t u jr \ Chairm an r-2 io C-210 V~K *)AN X 1 m STATEO f MW YOttC RKMEN'S COMPENSATION BO, 060C3650 &ttu 50 PARK PLACE, NEW YORK 7, N . Y. 05522373 Di*cta. irmi-- i>-- O556i6o5 M scta 1 2 /v W w. 6 * . C A M NO. DATE O F ACCIDENT ___________ _____ i * j i M i t h n i f i t i jW i U tirn m m . B .X X , Mathn B iliiir ii Co* 37-06 3Vth at. lXXe,J Ctoto 2a* Mad 179 CXaucdt fcJ.rx. io ta C* A aavoty Cs< 151 v t t U M at* !o * XerkyHJi c la im a n t EMPLOYER CANNIER C A M NO. C l-0 7 V o ta ste A s V-- ir t d s .I TM T 1*1 _ _____C o . U i6 , Ir fis to lo s i 2as*Co*. o sa) 60 Jo ta S t . f f .I X . NOTICE OF PRHJMINARY HEARING PLACE* 5 0 PARK P U C E , NEW YORK, N. Y. .1 9 ,1 * 1 DATE* ADDRESS to st t a a st*a*rx* l a i t A Carte Cora* CARRIE! ADDRESS. Astsstos CoBstvaotloa Co* 0 0 3 - 6 0 7 v * 2 9 t a > s t . T u r x ^----------------- Clarita 8* lead A Co* 68 Mils St* Vast Ososa!/ lofMsi Aioot~ 8aa(Liitiarcor~ 39*50 Csmssat 1ft L.IC*tlT*-- TIME* Date of This Notice 1/6/61 M 205 B u ffilo It o . *k ly 9IX f * ' Cssp* 120 alim at i>asssfc**Fs* C arrier is contending, through report filed with th Soard and copy snt to th claimant, either that it is not required to male* paym ents in this ca s*, or that its obligation is less than th* amount being claimed. In order to set a date for Trial Hear ing on any issues that remain unsettled, a Preliminary Hearing w ill be held at th* time and place above stated. Both claim ant and carrier are to be present, prepared to furnish in full detail ad of the following informations 1. Nature of the disputed issues and of the evidence that will be produced at Trial Hearing. 2. Names and addresses or ether identification of all witnesses on whose testimony the parties will rely for proofs, includ ing both physicians and lay w itnesses, and brief statement of evidence each is expected to give. 3 . A day and hour when ail witnesses and the parties can attend for Trial Hearing. 4 . The time each party will require to present testimony and to cross-examine witnesses of the opposing party. A t the Preliminary Hearing the Referee will make findings on all issues not in dispute, or as to which dispute is withdrawn, and wit) then fix a day and hour for Trial Hearing and estimate the time to be allowed for taking ail testimony. O N THE DATE SET FOR TRIAL HEARING, THE CA SE WILL BE DECIDED O N THE EVIDEN CE PRESENTED. THERE W ill. BE N O FURTHER ADJOURNMENT EXCEPT FO R G O O D AN D SUFFICIEN T C A U SE STATED UNDER OATH BY THE PARTY W HO HAS FURTHER EVlD B'tCE TO PRODUCE. C-210 C-210 C-210 C-210 C-210 '(/ . C . ' tI e! M Deeembar 30, I960 Workman1a Compensation Board fatal Accident Claim Cnit 50 Park Placa law Tort 7, law Tork Oemtlemeai Sttbjaoti Caaa lo* 0600650 William Daaa Zn rapi/ to jomr Deeembar 27 lattar, Trawalara Inaranea Coapany, Hartford, Connecticut waa ovr carriar durlnf 1999* ?ry truly youra, ARWSTHOHO COITBACTXRQ AID 8PPL C0FP0RA7I0I T. C. Atkinaoa Cestrollar NLY -.8A.O7 ( J .80) S e. SENIOR CHAIRMAN TA TE OF NEW YORK W O RKM EN 'S CO M PEN SA TIO N BOARD 50 P a u k P l a c e . N ew Y o r k 7. N . Y . December 27 I960 Case No, Dec'd: Employer! 06008650-Death William Dean Ventmore Asbestos Co. Armstrong Contracting Corp, 120 North Lime Street Lancaster, Penna, Gentlemen: This Board is currently investigating a claim for the death of William Dean who was in your employ during the year of 1959. Will you kindly submit the name and address of your insurance carrier who covered you at that time. A hearing is being contemplated in the near future and both your name and your carrier's name will be plaoed on notice. Very truly yours, SOL MESSIAS DIRECTOR OF CLAIMS FACU-5/ib FATAL 1 EMPLOYER STATE O F NEW YORK Z " " '} Q'O, R K M E N ' S C O M P E N S A T IO N B O A ^ O 3 50 PARK PLACE, NEW YORK 7 , N. Y. 05522373 x>i*.ctd. 06006650 Dth. WillI n Don C 1 3 6 0 w ill 05981605 W e G t d . 2/7/55 w-$j ca" no- CARRIKR C O D I CLA IM A N T ac C A U R IS* C A M NO. NOTICE OF PRELIMINARY HEARING ADDRESS 6 1 - 0 7 V ? o o d H Am avm M ood s lIf H .X * P U C E : 50 PARK P U C E , NEW YORK, N. Y. -- EMPLOYER. TtBtBQPf AfMtirtQg Cr a ADDRESS. 2 7 - 1 6 H o t h Ay r . L I X . r * . Y . CARRIER. ADDRESS la h iiM a i K atelas.C o . f t 2 Hi d li g p A Y t. fft7*C %>Jftad * Cono C o n * 200 flit **2od StX*IC A. Karkhoff Saq. toU r a a f a a r MtIC* Hoad A C o rk C o rp . 7101 TrmnwtT Avm- DATE: I> 1 ^ 1 9 6 0 TIME: 1 1 * 3 0 A J -PA R T: SO Dot of Thi* Notte 1 1 / 3 0 / 6 0 A IA in s t r o a g C o rk C o . 295 F ir n Aroma I.X .C * B a iic h C o . C arrier is contending, through report filed with the Board and copy tent to the claimant, either that it is not required to make payments in this case, or that its obligation is lest than the amount being claimed. In order to set a date for Trial Hear ing on any issues that remain unsettled, a Preliminary Hearing w ill be held at the time and place above stated. Both claimant and carrier are to be present, prepared to furnish in full detail all of the following information: 1. Nature of the disputed issues and of the evidence that will be produced at Trial Hearing. 2. Names and addresses or other identification of all witnesses on whose testimony the parties will rely for proofs, includ ing both physicians and lay w itnesses, and brief statement of evidence each is expected to give. 3. A day and hour when all witnesses and the parties can attend for Trial Hearing. 4 . The time each party will require to present testimony and to cross-examine witnesses of the opposing party. At the Preliminary Hearing the Referee will make findings on all issues not in dispute, or as to which dispute is withdrawn, and will then fix a day and hour for Trial Hearing and estimate the time to be allowed for taking all testimony. O N THE DATE SET FOR TRIAL HEARING, THE CA SE WILL BE DECIDED O N THE EVID EN CE PRESENTED. THERE WILL BE N O FURTHER ADJOURNMENT EXCEPT FO R G O O D AN D SUFFICIEN T CA U SE STATED UNDER OATH BY THE PARTY W HO HAS FURTHER EVIDENCE TO PRODUCE. C-210 C-210 C-210 Chairm an C-210 C-210 2 CARRIER STATE O F NEW YORK ORKMEN'S COMPENSATION BaX&D 5 0 PARK PLACE, NEW YORK 7 , N. Y . ? 06008650 O H u 05522373 & U .C M . V lU lM i 0a -05981605 B lieCtA.------ 12/6/59 Dth. W. C. S . C A M NO. D A T or ACCID ENT " u th ji* B lio h . 37-0 Bte U C * | X X 48 CARRIER COOK * f r & * CLAIMANT f t 0 7 >ood16,*7 CARRIER CASE NO. A . NOTICE OF PRELIMINARY HEARING P U C E . 50 PARK PtACE, NEW YORK, N. Y. 27-36 Hoth APium t*XC|X*T* T r m l i r i Ib .C. EMPLOYER ^ l r g . U . ------------------------ DATEi 8 M . l ^ f 1 9 6 0 M a * * h o n , ,G t t li b 1A H y id ji * B q a ADDRESS> V o i B r o a d l y g . Z e .--------------------------d p * .r t iB d s C it C o m . ^nMEi m y ^ ~ PARTi D ot. of This N olle. ui.i 2 0 0 V a s t * 2 B d 9 t . l l . r R C . CARWER--Haalt * Corti Co rps 7101 fo o M llt Avo. Horth BrgatI . J . ADDRESS. ------- tv r 205 Bofflo M n. B U y a ! !. Asb tot Cooftruetio Co. 603-607 w.mKnit. .rx.-- has. S . Uoo 6 Co. o 8 'K lfi'9 t . K 6 t O rftB ff t V ./ . 1 1 /3 0 /6 0 J* K M sfM sls Aatoatos Ia l*tlo o C, 39--50 Cvfictoft S t . Is e X X .,* .* . In u tN B g C so tS M tliis Corp. 120 K o.L las Bt* L*oc*W f ,Pi . C o rri.r i* conl.nding, through report filed with th . Board and copy sent to th . claimant, either that it is not required to make payments in this case, or that its obligation is toss than th . amount being claimed, in order to st a d o t. for Trial Hear ing on any issuos that remain unsottlod, a Preliminary Hearing w ill b . held at th . time and place above stated. Both claimant and carrier a r . to be present, prepared to furnish in full detail all of the following information! 1. Nature of th . disputed issues and of the evidence that will be produced at Trial Hearing. 2. Names and addresses or other identification of all witnesses on whose testimony the parties will rely for proofs, includ ing both physicians and lay w itnesses, and brief statement of evidence each is expected to give. 3. A day and hour when all witnesses and the parties can attend for Trial Hearing. 4 . The time each party will require to present testimony and to cross-examine witnesses of the opposing party. At the Preliminary Hearing the Referee will make findings on all issues not in dispute, or as to which dispute is withdrawn, and will then fix a day and hour for Trial Hearing and estimate the time to be allowed for taking all testimony. O N THE DATE SET FOR TRIAL HEARING, THE CA SE WILL BE DECIDED O N THE EVID EN CE PRESENTED. THERE WILL BE N O FURTHER ADJOURNMENT EXCEPT FO R G O O D AN D SUFFICIEN T CA U SE STATED UNDER OATH BY THE PARTY W HO HAS FURTHER EVIDENCE TO PRODUCE. C-210 C-210 Chairm an C-210 C-210 JLI l Armstrong Contracting and Supply Corporation Workmen's Compensation Claim William Dean___________________________________ September 27, I960 The attached Notice of Hearing vas received in this office late in the afternoon of September 26 The hearing vas scheduled for 11:00 AM on September 28 at the Workmen's Compensation Board, 50 Park Place, New York City* From the in formation available on the notice, it vas almost impossible to determine vhether the hearing concerned determination of disability under the Workmen's Compensation Lav or under the State Disability Benefits Lav. The date of the accident ehovn vaS February 7, 1955 but our records failed to shov any accident to a William Dean. Payroll reported the employment of a William D. Dean working out of the Atlanta Office in 1947. It seemed improbable that this employee vas the one in question. Payroll also reported a W. Dean employed in Nev Toxic State between June 15 and October 2, 1959* In viev of the date of accident, it seemed improbable that this individual could be the one in question. Being unable to identify this accident in any respect, I called the Workmen's Compensation Board and requested infor mation on it. After identifying myself at least six times, I finally talked to the individual responsible for this particular case. I vas advised that William Dean died on December 6. 1959 and the date of February 7. 1955 vas the date officially designated by the Board as the date for commencement of^disability. The deceased died of Aqfefitosls. It vas at the hearing helTTn*15eptember^ 1959 that the referee directed that Armstrong Cork Company and two others be brought into any further proceedings on the case. Why ve>4> did not receive a copy of this directive I do not know. The individual I conferred with at the Board vas able to furnish me with the social security number of the deceased, and ve were thus able to identify him as being employed by AC&S from June 15 to October 2, 1959. The social security number of the deceased is 097-03-2801. Since the hearing to be held on September 28 involved apportionment to prior employers, it vas essential that AC&S be represented* Payroll furnished us with the dates of employment, gross earnings, and total hours worked by contract number for William Dean. These contracts were then Identified as to customer, job, and type of work performed. In each instance, the deceased worked as an asbestos worker. One of the contracts, 231955 vas excluded from The Travelers' Workmen's Compensation Policy since this insurance was provided by the customer. The customer, however, placed the insurance with The Travelers so The Travelers is ooncemed with all four contracts. The employment record of William Dean is attached* Since The Travelers vas not listed as receiving a eopy of the Notice of Hearing, I called the Nev York Office of The Travelers to inquire bf they had received any official notification. The gentleman I talked to vas a Mr. H. Eckberg of the Workmen's Compensation Claims Section, and although he personally did not have access to their file on this claim, he knew that the individual responsible intended to appear at the hearing in our behalf. This being the case, he said it was unnecessary to send a eopy of the Notice of Hearing or the individual's employment record at this time. MLT  * ' , -*>. .'`,^5 1< -y-' , *c TATer NKWYOAK -"* -.- , * =-.1. .>>-.' "rr?s-?-- - [} Bf-SSRKM1E:N,S COMPENSATION B O A R D ^ A * * * ' * * O P A R K P LA C E . NEW YO R K 7 . N. Y . ^ ^* V * I M P O R T A N T 2 2 % % ^ W U * * P f - M/. : .-' '.y ,,.. O J 9 8 1 6 C ? ^ * r . - V 7 / 5 5 H C ^ a M k H , W s .,ir W . . . C A M NO. pT.'.;, ~ [5-iW` . S - '. C - - . / C A I M U M T O D -y--. a E'* -. "* r *|^L ' ^ C LA IM A N T sW- a ;' IPIM T I tSeistrTi-*..*???** E ADDRESS ;, * n w m k DATS o r ACCIDENT f . 3 7 C B rTi ' CAftRft A C A a tM ** -5S- |Mr Pii! -H. *- , . ; t ' ' T " * ' - ` : u '" ' & **?& *" Y*.** - ? 11M M f^T *'-'*'*' **' '*'***!^rSr9B!WISW*Tr fv^.W'-a e ; NOTICE OF HEARING r :*<?oift m : ? K A C v S P P ^ P tA C f, W Y YO RK, N .Y . p jS ^ .i ' -y - d' 8? if '"' f e t ^ em p lo yer V i n t a o r n A t f c t g f c M Y *^5<*v 'T ADDRESS A T ^ . I mnE tfirn > e % V / : o j W g v'.T U A E t^ .IM O Q A ^ f W A R T | f. ; ' | 0 i'',%' : ' --: -.>^r*vyx.r-. jO,. < ail* a* bfe*l fcrwnTs-^a -u .- ii; : T . ^ j * ' ^. f M H H W n N M I^ r tC # e 3N* Ito liNI AWu**X*Ce *k~ ;-li^-V-t^Ij-T .,* : v :* v 4 't. If ` U ' *4sC< ' ,0 p^ >r'?P ta ***> '1 g{ ?U WRg- iif-tiC*' '-A v;.-' fu." y ^ *r ' M ` 1 <Mffliiqflf.5- - - ^vir..ta'A^srf. g fifvs.-lrti-.-* *i-.i 1.1.1? A -*ff a*4 .i'j;;"'!'-'? `t-/ AND ,C A R R IE R . 5 H 0 U U i.^ r PRESENT A t | . /" t;w * !T"- r - ; . T ^ s s w ^ f T A K f a- _ << HEARING AND PRODUCE NECESSARY E V ID E N C E ! INDICATED BEIO W , OTHERW ISE, THE REFEREE M A T ^ ' '^ K J 'ijy f 'r i" -~ - ... >2 ^ 1-> OTTfCP^^n^-'-O ^ iOSE ASE ON WIDE^ jNjFII "V fy ^v. y :0ni ig r; j.;.13 QlTig .(H'-t; `efshiSS !;t ft> H.:ib^-'*V&ift* ^ : '#."t.'1 - ' i f '*' ? L ;^3t;.'' -' . .fi i iif1i'w .wii .eSr nv*i ili-j3 ^ * i i N * '<** ^* n * - "- S ^ W I W M 6 r i r C # '- ' 'f - i..C.*:^ .- ; ; .HNoolUi OO nnllyy IHteemm IInnddiiccaatteedd fbryy wqnJiXr L'UMJeow* ;!" TM apply la this hearing. * %S- . ,IV. : . y , X fU t ilC O e > Wt ,!v M 'W*' .< '-Ji 1 , IJ 1 '? '; ",'! '. ,,v PURPOSE OF HEARING ^ / . wd w r^-.y:, 3'- v *y 5*51- --1<1. -RiRS^oiA' TO ONt TO HAVE CLAIMANT EXAMINED BY STATE PHYSICIAN [ ] Period and x |e |B |ff dlfabiltty ,V , -''W*", DleaW IUy, ST i "{:iy rfe?^jje8fev . . ,, , , ***"*- .a -, ;.**?a- :' f ^ Accident -- Notice to em ployer. . Q C a vid l relatlonshlg ^ accident to |n |uryt Fad al dltflgurem ent. ^ Rate of compejuaHon, fl l earning***, y y *> j j R nal Adjuitm ent. -, .*"' i- .* 1 . . . . . * *_ - --C Operation or Treatment --*' -*f ' . ' -c Further co n iid eratio n .' ---^ r >*-'wM-*!# i PiaifilUTT CTIW 4- -J* ^V- -*-> S E?*i BY CLAIMANT l EVIDENCE TO BE PRODUCED -V^.' n a t e f f d|!Mil regQft frempwn phylflon, ' 4^ ;vi- I I Record of earning Ine accident* BY EMPLOYER OR C A M IC I* " >' ^ 'v n>"' ' .; ' -"ili ., , , m i . ^ o v O M i o j i A a i a T 3 w a s , v . : ' i - ;4 T i> '.W i h r - s E J s S i 4 S , K ? r " f * rt * 4 : :, . - ' - v ^ f ' ] X-Raye. ' . ' - " - ^ '.' I I Hotpltol recordti,, ; . . .. - . ?*> ' , ........... ...... ... C -l 1 I Notice of Inured perton'* return to w ork) jf> ', ' | { C*2 (Employer1flrif report of injury). ~" *? ^