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NAME OF INSURED . DEPENDENT'S NAME.
NO-.______
Ford Motor Company. -ilil
|n.AHT a LOCATIONl
SOC.S6C.NO.
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Out of Binh _
0a Of Birtti -
Dace of Death.
Pot. 18GCC 27500/0?
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NAME 06 SPOUSE.
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. BiaMate o< Spouse.
****** Ol vou-----------165 .-y- WMtiM--------------------------------------
. Date of Marriage j__
Giy. st. Zip----------- ,.toa, - 7--4^324------------------------------------
. Enrolled Pari B Medicare (If tpou>t over age 651
Q Yes Q No
Dpt. No.. 1.74^1, Date of hire -Q^Upb-
. Job aafiction . If r*hired, date .
't -Sf -i
If retired, give date and , type of retirement
. Date of fesi reinstatement'
QOji.
QSp Early
O E5ty Q Normal
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l-;( 1 I I ____________________
L^rffefrCi.Jc//; j of UcAill
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DEATH CUKT:"iCATIS AT .-TRACT
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REMfP deductions % . , _
Survivor benefit elected --
_
Eligible for Company Paid____
to comimit 23 months
)l to continue to age 62 ,
Eligible to continue for fife --_
fom m<sr (fCHOI sta -
Date Repor ted! 8y Whom ____ Address_______ Phone No______
Plan Code ____
rt+rt^------------------------ --
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DTKR 0000361
Produced Subject Protective Order by Ford Motor Company
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% Apr, X7t 19^1 !. Lenawee
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J Emma L. Bixby Hospital
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Ala
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Ford Kotor Co
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Lenawee
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165 N. McKenziee
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Sylyja Green_____i__. __1__6_5___H_.___h_c_K__enzle
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Adrian Kich 49221
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Chestnut St a, Adrian,Michigan 49221
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,MFeb. 21,1979|m4Braun Bros. Funeral Home |;tt 1$01 a. A.aumee, Adrian. A i
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DTKR 0000362 Produced Subject Protective Order by Ford Motor Company
I, Patricia J. Johnston, Clerk of the County of Lenawee, do hereby certify that the above is an exact copy of the record which is on file in the office of the Lenawee County Clerk, State of Michigan, Adrian. Michigan.
ItJ TESTIMONY THEREOF. I have hereunto set my hand and
ft*ffil the seal of said County Clerk this
day
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NAME AND ADDRESS OF COMPART
MOF.ROrMm. NO.TOm. occupation
reason fan leaving
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if even H1RCB BY r<HtO OB SUBSIDIARIES SIV NAME Of PLANT UNO OATES
I HtBCtY AUTHORIZE INVEST rCATIO* Of ALL statement* CONTAINED IN THIS AffLlCA-
TM*. I ecufIff THAT SUCH 5TAfEUENTS ARC TRUE AMO UNDE&TAMO THAT MTUCFAC*
SEHTRllOK WAY Bf tAU* fCMtJtCfAlAfl'ON.
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DTKR 0000364
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Produced Subject Protective J
Order by Ford Motor Company
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APPLICATION
. (PRINT ALL ENTRIES)
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drafts ^ottoi/L- at-
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ro urom **T *i#r Y CHAHLT 9Htrn AS EQ. *T CWEART
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D0" p4tMT Af
O TELEPHONE NO.
U,6>Cr-2 Vs'C*
l FEMALE
BIRTH DATE
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TATCA
ro_______ {/-yy-W- odiim
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DAirt or u.$. Mm. service
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MOST RECENT GRADE CXASSlWCAtftON
CIRCLE THC HIGH
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COLLCBC
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EST tQUCATlO*
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cr TCS. GIVE OATE. PLACE, ANO REASON:
iftvc YOU EVER BEEN DISCHARGED YES m A**CO TO RCSlL**
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if YES. StAtE CONDITIONS: mT
chicle ahy
AOOl TlOMAL
education "*
you have Hah
APPRENTICE APPRENTICE OTHER 1C ,S . US)
Training
GRADUATE
MESS, TRAOt OH VOCATIOAAE
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0 rflU HAYE ANY RELATIVES vorkinG for foro to ION COMPANYf
iave you Even been .ERfOUSlT ILL OR WACO'
its
YES n
MO 63"
ir YES, LIVE KAMC, MORN LOCATION. AhQ RELATIONSHIP;
NO IP YES. STATE CIRCUMSTANCES AMOOATCS INVOLVED:
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L'________
1AHC YOU NAD A PREVIOUS
OWAVQiiCMAOLTOERXACMOINMAPTAINOYN* *
.11 YOU NAVE ANY PHYSICAL fftCd'
YE5
VES
NO IF YES. 5TATE WHERE AND WHEN:
B"
IF YES, EXPLAIN: er
______
.VS NAME, AOORCSS. PMCNf 0. Of PERSON WE SHOULD CONTACT TN EMERGENCY:
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DTKR 0000355
Produced Subject Protective Order by Ford Motor Company
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Attending Physician's Report
{
,o the attending Physician:
The bearer, an active or former employe. reports that his absence from work is due to illness. We would
fleetly appreciate your cooperation in furnishing the information requested below. This is important in protecting his
length of service with the Company and will assist in placing the employe on work suitable to his physical condition.
Failire to complete this fon* will delay action on the sick leave.
______ _ .
.. ,, .
ANTHONY PACES, M.D. (
7700 E. Michigan Ave.
_________________Saline, Michigan 48176
IflMi CftvstcJani
. . Saline Plant Plant location Mailing address_______________
1. Patient _
Ifirti,
l>0_____ (y-r- e t* .7
Miial, tail)
2. Nature of present disability (diaprosisj).
S.S. No..
/V ' /-Jjy'iS. Hourly QJ-'lJataried 0
3. Diagnosis based on: (Please check) Patient's history 0. Clinical findings only 0 . X-ray Laborataryfindings 0, or Additional findings:_________________________________________________ -
4. On what date did patient first consult you due to present illness or injury?.
i zjiT. h f
5. If surgery has been performed, date and nature of operation.
__ ___^ A*.-frTtltrn 4-Ccr>^________________
I
-At CrtA Lai
6. If patient was hospitalized, indicate duration.
2-1If J?2--- l/zs/iq, ;
as^^<y'//z3/?9-puu:\
7. Is patient totally disabled at the present time? Yes jury or illness so that he was prevented from workii to and including.
No 0 How loongjhiaas patIieant been totally <disabled by this iry
From____
/IrA^PWcbeiC__ 30 .19 .IS__
d If disabled, what is estimated length of future disability?.
4, M.OS-
9. Is disability due to his occupation? Yes 0 No 94
0. Remarks or recommended work restrictions:_______
. In addition to the above information, % list dates of ALL other visits by
patient due to preaent illness or ! injury and detail treatment given
or prescribed. (Use back of form).
;^5166
Signed.
C~<
. _ _ (Andl rnv.lctn|
Clinrfrc. F.
M O..
Address-/v+J......... ~ -
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T,
: Uc 3Sia
Telephone'Nb.1,1 '
_Lo*te,____
VJ
DTKR 0000367
Produced Subject Protective
------- Order by Ford Motor Company
t*T
Attending Physician'* Report
<_> Date. /J-- *- -?z __________
.< it.
To fho attending P^iicion: ^
,1
'
\, Thf^lparer. addictive or fonn* employ*, repons that his absence from work is due to illness. We would
greatly appreciate you coop^ftion in furnishing the information requested below. This is important in protecting his
length of service with the Cbmpany and will assist in placing the employe on work suitable to his physical condition.
Failure to cempletediis form will delay action on the sick leave.
____
,, ,*
AHTHOHT PACEK, M.D.
7700 E. Michigan Ave.
Saline, Michigan 48176
ChvsCi)
Saline Plant Plant location Mailing adcfcess.1 2
1. Patient
If dm.
____________ S S No
IntrUI. Iit|
4<> l&
____Hourly ^Y'Salaried
2. Nature of present disability {diaptosis))_____ft---------------------------------------------------------------------------------------------------
. 3. Diagnosis based : (Pt$aae check) Patient's history 0^Clinical findings only Q . X-ray 0^*^ {Please
Laboratory findings erTor Additional findings:
Pumau Siop^K 'mencrc
TwtZAtjrw^
A. On what date did patient first consult you due to present illness or injury? 1^- - I > **~)8 5. If surgery hat been performed, date and nature of operation. THflencomrW
IcJ-iL-nUjisr \
6. If patient was hospitalized, indicate duration
j
7. Is patient totally disaibled at the pprr<esent time? Yes Vt No Q How long has patient been totally disabled by this in jury or illness so thatI he was preveinted from workingTFrom*1^19. to and including.
8 If disabled, what is estimated length of future disability?.
9. Is disability due to his occupation? Yes Q No
3 Remarks or recommended work restrictions:_______
I la addition to the above information, . Hat dates of ALL other visits by patient due to present illness or injury and detail treatment given or prescribed. (Use back of fora).
..........................
Sjgeed
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Telephone No..
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nam.
DTKR 0000358
Produced Subject Protective
Order by Ford Motor Company
Attending Physician's Report
Hmnku December $, 1978 Date.
To the attending Rtyaician:
/
The bearer, an active or fanner employe, reports that his absence from work is due to illness: We would
greatly appreciate yw cooperation in furnishing (he information recreated below. This is important in protecting his
length of service with the Company and will assist ia placing the employe on work suitable to his physical condition.
Feilire to complete this form will delay action on the sick leave.
' .'
'
______ __ ___ ,, J I AVISONT PACEK, M.D. 7700 E. Michigan Ave. Saline, Michigan 48176
` Chtrs*qisl `
Saline Plant Plant location Mailing address.
Uh 1 ' "
'*
(A)t. Patient xJ 0 ll Vi I O______
C* V ti V) S No. 3C>-3. - 0 ' /f yij Hourly QT Salaried Q
(FVt. miMU lattlal. IMI
2. Nature of present disability (dia^osis))______Pneumonia and pleurisey-------------------------------- -------_
3. Diagnosis based on: (Please check) Patient's history O, Clinical findings only Q , X-ray (^). ` 1 Laboratory findings QJ, or Additional findings:__________________________________________________
4. On what date did patient first consult you due to present illness or injury? ^ 22-78i|_li 5. If surgery has been performed, date and nature of operation_________________________ !
'I
6. If patient was hospitalized, indicate <k*rtinn hospitalized 12-l-?8
Emma L. Bixby Hospital, Adrian,Michigan -
7. Is patient totally disabled at the present time? Yes Q No Q How long has patient been totally disabled by this in
jury or illness so that he was prevented from working? From
M7 ft
13
to and including...
------------ ------------- --------19---------
atili hospitalized
fl. If disabled, what ia estimated length of future disability? pannnt. say
1
9. Is disability due to his occupation? Yes Q No @
$
0. Remarks or recommended work restrictions:
!
) In addition to the above information, list dates of ALL other visits by patient due to present illness or injury end detail treatment given or prescribed. (Use back of form).
l g 5166
Signed. __ X. Skufis,.M. . JfAffn*an-,iinflg*a 1W',^*iL!*sI,eel,m*"aii
^--
Address--jJ-3 Cb^^trnit SI--rAdrianrMl nh ,
.49221
Telephone No. 261-1191
Dale.. 12-5-78
DTKR 0000359
produced Subject Protective
Order by Ford Motor Company