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EMPLOYER
IN AND BEFORE THE
PERVISOR OF INDUS IAL INSURANCE, DEPARTMENT ABOR AND INDUSTRIES
SU
STATE OF WASHINGTON
GENERAL ORDER "
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, Brem. 9-19-68 370217
P 4360-1 8-3 12-13-65 9.1
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Firm Jefferson County Dept. of. Buys. ANY APPEAL FROM THIS ORDER
Names Port Townsend MUST BE MADE TO THE BOARD OF
t
A " Wash. 98368 INDUSTRIAL INSURANCE 'APPEALS,
k. OLYMPIA, WITHIN SIXTY DAYS
ORDER IS
S ,
.
FROM THE DATE THI
COMMUNICATED TO THE PARTIES
Order
AFFECTED, OR THE SAME SHALL
{ »
" and
Notice BECOME FINAL.". COPY OF THE
.;, .
.,,., APPEAL MUST BE SENT TO THE -
l
PF DIRECTOR OF THE DEPARTMENT. i
ANY REQUEST FOR DEPARTMENTAL
- RECONSIDERATION OF THIS ORDER
w
- MUST BE MADE WITHIN. SIXTY '
p Claimant Louis Buchillo "DAYS.A FURTHER APPEALABLE OR
- DER WILL FOLLOW SUCH !REQUEST.
" 19th & Holcomb
Port Townsend, We. 98368
_..I C ..
' Attending Or LAi30n 6 ItJOUSiRIES
Phystcion Roger Dickerson, H.D.
' 1136 Water St.
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98368 ,`J
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Port Townsen
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CEP 19 9
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WASHINGTON
OLYMPIA
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It Is Hereby O
rdered That: -
xy
SIX of '.maedesees allowed for unspecified disabilities for loss of small ---- $ 637.50
. 10% of'oexisum allowed for unspecified disabilities for cervical cord---- 1275.00
ecified disabilities for psychatric cord 20850.02
allowed for uns
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20%
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4462
$
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$1000.00 CASE AWARD AT TM TIM------------------------------- $1000.00
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Balance of Permanent partial disability of $3462.50 to be paid at '
A. the rote of $252.00 per month plus 5% interest per annum on the unpaid
s; a balance pursuant to R.C.A. 51.32.080(5)(Chapter 274, Laws of 1961.)
r.
UNIT ON SALARY.
'
•
PAT PEREABM PARTIAL DISABILITY.
I
U CL111]1 18 HEREBY CLOSED.
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ffiD YORTIHR NOTICE WILL. SE ISSOED RZL&TM TO TIM DETSRIV ATIOR OF PEIQtARE11T
PA8TI/d, DUAHILITY.
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'+5Y$ I DUANE S. STOOKEY BY--? Y-
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DEPART31ENT OF LABOR AND INDUSTRIES, 01ympla, IYashinctan
T. the Employer Addressed:
.
- - ? Please be advised that on this date ..-
the, ..: __. ._. ........._.,
the Department mwic n a -,d, as ahown bel-,. frum the Accident Fund in
reimbursement for traveling expense incurred at th,. request ul this o/lico.
EMPLOYED NAME AND CLAIM NDMIIEIt DATE CI.A.v ANIOITN'r
Day Yr.
Louis Buchillo - F370217 6 13 68 8-3 $27.80
6 14 68
7E COPY
8 STATE OF WASHING•Te. ON t-
1031116 Dp.,m.etnl OF ACCI T
11101 Clam Me .1 I Labor and 1i REPORT
Emplayrr must Complete Th . Tpart by FIIIinq I. and Sipn
9"'m"" lnq FmPleYsr1 5 )i B ---
8 of "be, Than Mail R•porl at on,, to
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Firm number of omnioyer _ o-1 i Tolephone
.(Numb s D p 1 _________
T_'S?35o5
No
ignod by
a or and Indu•Irlea
--' clef Scrunly No ul v Finan
e,rm , or
Jeif IGo
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t
oY Hi
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mplay
?a Address ___Port T_
h. 98
avB
Nave Ihic wolfrm
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on
hours boon Included In payrolls reported to this depmtm,MI? ____.y-8$-
8
3 _ _
_--____. 11 •o, in what claea7 ? II not 1 lad d glue reason- ___
'.. ---
_ --- ------------------------
-------------------------- , How I g f workman boon omployad by you? -------------------
a 20. yTg Rued toz?men
I ¢ _ _ __OccupaUon when Inluredl _ _ --
rJ Buelne 1 ploys R[i rRaiFYt COn8tr
i. Socalion of pl
3 a- (II nqa tl 1
ant Or place of work
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um
w
ere aecident - urmd
atalr Perllculur kledl - ---- ---
Ch
} or i, k 1 hi n"tlop d 1 wOrkm Y_ employed: Conatructlon ?
Oporation ? Ae Ir ]
t ?
cl LOLtie`T BUChMO Hue he any fin...1.1 Pa On launched boa
Hued k an
__
--------------- wrma
,r _......... ...... Interest in the bus! naesl.. _ IIO Solo __ Partner, Corpnroln officer? __
0 Will ih1 o k n b keel 01 salary during his Period of disability? Yeg
" H
o, attach an expl 11___ _
` a Io Pndh u Of Bccidedt 6-2?-bQlQ- AM ,. NO TTMIP
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We-,we --a :ii>
cts-y 5a k s- __ -I,CNto turn d-t - k -----------------
n engaged i Ih reg la Course of his employment h Injured?
" .
Did
.,.,r0dO1 oc on Your Pr Is _
7 .-- -_-
e 7 _nq .-If not where?- $t'8telij•Su?gY, -__ rc D ta6fid hgUF a ldanl p t"'dl yo 8 = 6 25-68 g7,I _ ---hilt h --------------------
w __ _ _ __P?r
o whom PartodW __$1? B }
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on
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ow f¢lalmC
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Metter if n,,a....y) IIO
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H w did cddont Kapp a7 d2I.4IIIPa county eQ13ipDI9yFf, in,.CoursB OP'. det3r ---------------------
-------------------------------
--
D terb "it") eadadl IuliY 1 ti q h injured _- ---
-----------------------------
t
Y whether Peron tell or was .truck, a nd all the factor- cooUlbulipq t th accld t 11
.e
0 • y ll.app,.
4 I declare that the foregoing statement. are true to the boat .1 knowledq b Ifal.
s D .a 'win •In77 xr r of J1t7y 19bw
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Ad7ndged non cant enfable exce t or - - - - - - - -
P f (TO BE USED BY DEPARTMENT ONLY)
rlfedscd Aid Bills - llowable by laws,. By__
clam- Examiner ...-- ?llele'oGi Claim No :.,:.
t Allowed for authorized treatment ..
f arld aLtfdn. of indicated. B}'------. ,...
- F
DUANE S. STOOK EY
irm No,-...:..
Examinar S p ,so, of 1 tl I l
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neu•anco
{ EMPLOYER'S COPY CIHSS
- MEDICAL AID '
AWARDS Am ea.
' Compwed Dale N ,ce -
O 311
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or CORI
` _ INot Claim Num erl
I 1 Non Cont ---'
Name of inlUred workm LOt._l is
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Sa"al S,CUrity
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true.. rmer ., L elephone No. _8_!_Q?
Ad res. (1 which all ..It t be _
rid Baspd) lCS_?j!1.
t'?(] (C t V ?j --
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' ---- --- City Bad -IaePS11 TU ?1 C'f.N
your lob till b Injured- .l
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-.Age (0_3.. Z3 H.ight S O. 7'L W fight b
Data amide t
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vedale of blahl
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worked _--Stale hear of accldenl _-
Give dale i t '?-CA -- ------Shill ho Qg
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- \O (I 1Ir-? //++ 111 1 ___-_ If -y/--h a altered work Div dot. __
? N me of a PI y a/_`'y.,? LQ.. - .J_!1Lj111?2 LLaF !)I-, F 1 - -_ ___ _ _
???.WWW JJ Addra.y__ (??_ U 6'1$ ?
n4,,
W re y u doing Your regular work
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time of 1 --(dent? _ _
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Q O D tribe accident In full% CQ-`?,(5 (? E•1- : -? f ? 1t
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Was Ih accident In your apt ton -used I 7'- -
-
0 2 any /a?yTby soremon
Z5?3 p O o r ..played by your ..plays,? G Data you .period Idm, to °mPlI,.,
here reported W(1,1 I
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n day
EY 11 ..Player w 1
= O otlliad the evma dale vp the acId 1 el n . 'j
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? _ Nam If Attending Physician IZ SU )1 1 '- I Add .- -
C ?C LV
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11 meet Il huxb d
y
;F II divorced 91 a final
croo data
a DI 11 dl or•d and y have I hildr•n.ubmit a °opy el the eperi order ehowlnp fagot cu.l
dl
h
--_- ---
o
on of f children. Also give pre•enl ..rite- o/ -h cu.lodiun.
R GIVE NAMES AND BIRTH DATES OF YOU' CHILDREN UNDER TO SUPPORTED BY YOU
- NA14C A I H.o0ip Det•'o181ah -- ----"- - _ -
M Da year Ae
NAME D I 1 HI rh
S7?? Y allon•hip Mo, Day Year
r I declare That the foregoing statemenu m 1 in to the boat of m knowledge
-Igned._.A?-f.!!_t. da
of ?l
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Y:?__1GJ.W_k1t P4?G a
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IMPORTANTOi` w
O
ARMAN SIG
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' PHYSICIAN'S REPORT
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Msm. Of Injor•d wmkmaa_Iouis.:_BUChillo.......... ----------------- sea
Ne53b-12-474$ Adar ..- .19th-da-Holoomb " _ clam N ,
amb.
--------------
wn
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aan
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Cmplayer_ Jefferson CI Iii
$h Dept.
Ad
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--------
dress
-
oYVnsend Wn
D.le InblWfi Dato if
p
6125,6$ -
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,., iroalm m
- - -.__ Workman'.Aon 19/3 23
7Dstory of Inju
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rrmllla• In1olrkd. q1,. right or Jol) . - - '
Automobile-accident --- . O1 IHIm'
driving County truck
in-course-of- regular
d
x
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uty-.
•- -•
- ..---•-___._.
a Ph drat Andln i .nett fit .rU.mlGn Inrolred, fir. right , 1.11) '------- °•
Y q °
ear :1
4
° Ctugiona;-both knees,--left
shoulder
-head
st
i
,
,
ra
n, cervical- spine-
en1 Examination,
Hospital
Pr
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,-
ea
ma -C mpound,
% ay Ilnding•.
-applied .......
ce;vica? col?ar
ati
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-
,
i . .._.. .._,. Neg
fig
ve for
fracture. ..............
?_ If workmen had porleu. Injury to great No
.. ..
H a u kman stet been trealal b
.... . _. . _.. ._-.. ..- _..._-. '
y .nyan. for Presser er similar conalnan} NO _ _n y.., apleln
a -----------
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that. eny pI• lainq disease W the -, In1urer17. NO .- .. ..,. - .•
.
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Will this or .n
y that P--,Uric Condition nYmplic.t. Delmont or I.1 M rrxnr•rY} 1,1
O -.... .. """.
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1. condiGan diagnosed Ih. lasuH Of accid
''. ^-_--• {
ent deacrlbed7
It ha Ullutkan Y°° r* Probaldy 0 Possibly ? No ?
N Wired rime hospital. St John Hositat
Addmk.. _ g ?,
T.•Ilmeled Ilm. Id d l0 1 jdly} - •A=sort -Townsend,
--Washin ton
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Au.ndleq Ph T•k4n uu P-1 type rose. ne eet a dti:a. _---
Nam.. ROGE I K1 R40N Tab r w k. •.no d -sir wk•n yned br lu.nud phnlaan.
?/?}???A D• .....-. ,. _._Adduw Medical...Sldg.,.--1136
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trln•• ?/27/6B P Y Arra I N Townse?,,?gcjl,
rMPtOYIN-'EMOVr $Hill IWO-PINK COPY IHIS IS YOU' COPT 1
- IU,• D.pt. Pay.. Arreunl N..6-1 f P1 ,('••4,u1
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DEPARTMENT OF LABOR AND INDUS -S, Olympia. W-111neton
'ro the Em Ploper Addressed; nYt} I G ?yCC
Please be advised that on this date
the Department made an award, a? shown below, from the Accident Fund in
reimbursement for traveling expense meuried at the .clu,,st of this o111- -
i ENIPLOYEF NAME. AND CI.AI1t NUMBF.II DATE CLASS AAIOUN'r
Day Vr -
t
Louis Buchillo F 370217 3 22 68 8-3 $14.80
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SfAiEoEWAm.nt oSNINDT°N REPORT OF ACCID NT Claim No
o.parrf
v _
(Net Cl+lm RN L bdY'.nd I Iris. __ __- _._
Employer M61 Pl.u THINP by Iii 11179 in and Shining Empfoyer'• Sortion F. . Than Mail Raporl a. O Io
N D parlm.n1 of Labor and InduNa••, Work, offic., (Sae ..v•... aide-Ear odd-0
,
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L Telephone NJP571147__ _ Somal Security No, of workm .
umbc t plc ro?
Film
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fix
bar a Iq d by Deport ant of ahar end Indueldoal -POr?a ?,ea8?-'ar
Co. Dept. ot
Highwtps Aaare.a _
Jeff.
_
_
a name I ai yo
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ha
l
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8
_ ----
ass
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__
Have this workmen a hour; been Included In payrolls r.Period to this department?.__ _.yes_------ If •o, In w
it not Included give r ae t. _____ _ _ ______ __ v- _. -------------------------------------------
20 yre _ _ Occupation when Injured?- 4ga_mEi1--tengnCe -_
flow long h workman been employed by you? _.
0 Business of mploy ? `14a1_nt LTC_COI1Bt2'.L H of plant or place of work where accident --"ad ----------------------------------
d
I )
(lf engaged in , ton work stale Parlic 1 kl
Check In which department workman was employed: Construction ? operation ? Repalr?] O launch d boat ?
l
¢ o owner,
Name of T,,..;? ??1?.?W Has he any H"'cul So
----- .. .. - ---- interest in the business? a0 __ .Pinner? Corporate olllc 7
.
J4xd0 Te HgchYE
k
a K _
------
_
man d
injure wor
O Will this worlarrum be kept on salary during his period of disability? no __.-If If so, attach an explanation _ ___ __ -
r M yip' - Lae, day worked. St111.VC)r t1ng_' Date returned to work -------- ._ _____
denll0 2O°u7711iCO
f
d-h
.
. t
Dale an
our
Was workm engaged I. the regular .... o of his employment when Injured?.. YOg--------------- ...__ . ___ Shift hours- 8:SAO 11:99-.
'o. Did aacidont :o Your premises? _ _Y'39_.. _ II not, where? ------ .. ...- _ --------------------------------- ; -- ----
A.M.
20-67L 112j0 _ _ - orzir To whom [eparted..lra1131 Bt1tBn8II ------ PoRitionsuetr...y ?..--
oaT.0
d to
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Data and hour accident por
1 J you qua I7 anc of claim? WhY (AN-1, letter it .... rY) .-- A0 - -- -- nor:
..
--------------
C117 Vert out o£ ditch' Slipped.
7 T•i #1TTllg
h
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-
ppen
H did a 1d t
+ ea
(, Ib i e ccidov (u Ir , tmg whether the injured Per ... fm] or was buck, t c, and all Iha floor. confributin9 1 the +=Idem If r Ina apple.
sine=y Imter
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I declaca'th r u Ioiagoing C t m is o t 'to the beat of my kn wled9e eliel. ?! ,,t.,o
19 Q __ _ BY____ OlIIlt.Y FeEj.mer' ___
--------- day of-------------- ____, _
i
.ed thl, -
_ t1i tal
1
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i
Adj
Atad udged Non COmpentabl; except (Or (TO BE USED 'I FY DEPARTMENT ONLY) Claim NO -
ical Aid 811r allowable by law. By--.- ' --
claims Examiner Firm No
T
Allo wed for autbon.'ed treatment. By_.
By- ..
are! saparvianr of maa.m+1 m a an=.
action al indicated. cl+lm,
Class -
EMPLOYER'S COPY
R
7
MEDICAL AID AWARDS - ComPUted
Ic e
Dsl*
ent
LORI
8 7,7 7.1. ? ?
INO, Clelm Number)
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Non-Cont.::.:-...
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Social Security No -
f inl rod -km jgtlls.-------------- 2-_-______-BUCI13110
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$olCOmb__- _ ___ City Rod. Sta$Ort_2YPdnaanda:-WashiD on
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19th
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Address (to which oil mat t b addresse
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POrt_TOVE18end
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place of bhih
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1 __7 _____________._state hour of eccident_________________------------ Shift hour.____---- _---- __.___.
OCt 20
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Give. data 1- k d____ _-Oct.2O_'_1-9G7----------------- IE Y h 1 d 1 ark gIapd.a.mle1 _________
Engineers OfficeJeff Co Court
Jefferson County Hivey Daft ___Aaar.ra_
-------- ------- ---------------- Poi t'3ovasandOn?Gadt
Name of ..Play ____-__ uh Y --
rcad .
_
8 On employers e U ?__ __ ___ ,---
promises?-.
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ace
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You k at time o
doing your regular
Ware
epd CaR188d_ al ------------ ----
o1iPPed
ditch
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Describe aCcIdem In lull: ----____ _I3fting..culYert_ Ou
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_ ___ ________________ _ _ __ ---
-------------------------------------------- ___ __ -----------------------------------------------------------
4 Was the naxident in your opinion awed in any way by someone employed by your mploy ? _-_(Y ng- )
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How long have you worked for this employer? _2O years. ---- -- - wage p Par dY __
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oyer ----'--
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Date You 9parted aCddo t to empl )
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,.,....:, . won H. Oreenp XX
Address
Port
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AttondlRg Phyel Ian _ _ _ - - - - -- ------ ""' ---
Name of _--
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-------- - ---??----
husband -___VObc'1 1_ $uChillO -_ __il divorced give Itnal decree dale ___- _
Yuli name o! Wife or
W ,
Al . divorced and you have minor chlid n submit a copy of the court order showing legal custodian of such children.
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Also give present address of such Custo
? Q - GIVE NAMES AND BIRTH PATES Of YOUR CHILDREN UNDER 18 SUPPORYED BY YOU
__-
NAMCT Rel+llan,hip Mast USY iYeer NAME R.Ietion•hlp Mo.1DeY 'Year
-
.___..
-Peme.Z8- uoh1110__-._ daughter- -.Doe-1954
•b i declare that the lotegatng .tolemonts are . Uua to the boat of my knowledge • d belief.
7 Port TDR'fnfb&] Ag,m. ---•
_.
67
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ID
Signed__. rday - _
IMPORTANT T7f" WOI(KMAN S1CN_}{F,RF ?-w!C `?! ""=? ----°-- ------ -------
-
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PHYSICIAN'S REPORT
R 8 N atCI N mZ 77711 7.?--. _s-
., Seer. Sae H ..i-
Touls T '$uchilhn _
workman _-•_. _.. _. _ -- _. .. __ cGlm Number ,
Noma of 1.1 ... d
, . _
address l9th.aud_Dalcomb-.:__- Cl Port Tovneend
Waahi M
t ?ownaend
,
Por
"'Jefferson County Hivey Dept Adama• .._-------- 01.-- _____
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? EmPleyer ----------- _ _ _ ..._.-.. _
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q-,Qct' 3 1923
.Oct-21- 67._.___. Workman
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Data lolurod Oct- 20 1767 . .._. ...... _
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and
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literary of Injury...... - Lifting culvert ou
----
n kYahetfi.di,y.I.d.bn Iayft ingulna1'herala
ai .0
3ak i•gnvll• 'Snguiti6l heraie.. .. _... _..
_. M. `
Y " `
wi w
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at" N..tm nl ...d
....
p ..
.. -: ..sense taken __ _.
X-ray findings ...... _, .. ......
V ? .. .._.
.-
.• O n tP Drs 1. .. .. .,... _ ._.
It work an had rerlou. lnlur
P Y ' right' inguiml hernia November 196$ --------
, 111, workm. over been ,,,,*d by anyone for present al simile condillon?.. Va., asplNn.. right--iaguinal °-'-
hernia Dort repeiredp see eecee*enyir3 letter.
.
. ..,._... .
1. thus ? y P Lung dues.. uI the nu Inlmuf7 _. ...
n.d ?
-every? _. .. .... ._.. .. _-
WIII this n any other preaxl•IIn9 condition romplluta Ile•Imnnl nr rei. DO'"' -
Y.. X] Probably ? Poulbly ? No ?
'
y 1, cundlricn diagno.ad the result of atcldnnt dncdbert?
11 haPNall.Nlon TaquUad ham hospital St• .JohnIs Hospital Ato
duty
aweek s for heavy
P eight
d
SCOVeryv
I
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-rr
six MOek9 fOr stErgery eD
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( f:myCd lima lu.aslucL NU Irl.
an b. , n d Ir wban d by 1'<r
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AI diag PAY cis : M. D ml or iYV Yo ' and d 1 .. - --._ _ r _. •d by n
p,Port and,-.Wash .-
.....Ada...--_.61{2Jlerrison Street
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1a1RY , , it
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Name....-.._
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10-21-67 P Y A r No 1
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D. n•t t
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j EMP107ER-•REMOVlI INIETIVO-PINK COPY-11111 IS YOUR COTY (U. Doe$, PaY•. A.awn. Namb, I -PI
71
EMPLOYER
D ...... THE r,
SUPERVISOR OF INDUSL INSURANCE, DEPARTMENT LABOR AND INDUSTRIES
STATE OF WASHINGTON
SPAY DATE INJURED CMTE AT OLYMPIA TYPE
aMNCH OFFICE
8ramertoa MDER
a p63a871 LASS
8.3 4;Z Cl AP 1 10-20-67 4-15-68 00
bl
e
t i d C P
It that this ..rkm-- This claim co ming on for consideralion, and the Supervisor of Industrial Ins rance having a pensa
the aforementioned dale and while he was in the course of employment subject to the Com lion Act, IT IS HEREBY
s lain
e -I Disease) on
Injury ,
(or Oc
ORDERED Ihal lima loss compensation be paid as follows f ;
DATES 'r0
TIME LOSS
-
Y,
N ME Jefferson County Dept. Of H19blayQ LOas
TI:waM
To AMOUNT MAILED
BE
port Townsend
98368 4-1-68 4-16-68 $126.00 4-16-68
Washington
4-16-6S 5-1-68 $126.00 5-1-68,
_. CLAIIMNT -
F Louis T. DuCb1110 6
19th 6 HOICOmb TOTAL
port Touseend. Washington 9&968
To Claimant: If you have returned to work within the
• period covered by this payment DO NOT
f
GASH ,his warrant. Return it to this office
for correction
.
F To Employer: If you have knowledge that this workman
d to work within the period cov-
' returne
Bred by the'above award, notify this office -
at once; otherwise the warrant will be
mailed sow an days after the date of this
awar??
ATTENDING PHYSIC-1 wCCpNDANC[ WGM OFPAPTM[NT NU [IN
rll'I? (:J 11:)Uij f DUANE S. STOOKEY
•
SUFIRV?SOR Of INDUSTRIAL INSURANCI
Hymn a. Crals". IL
b42 garrison Street -
CtAIMS ADJUDICATOR
port Tosnaand. Wash. 9896811. .y
d
NO PROTEST RELATIVE TO THIS ORDER OR APPEAL THEREFROM CAN BE RECOGNIZED UNLESS MADE WITHIN 60 DAYS FROM THE DATE 4
MUST BE FILED THE BOARD OF
THIS
W
TH
A
P
1
0 I
OF RECEIPT OF THIS ORDER. ANY PROTEST MUST FILED ,
TH
OF
TO THE DIRECTOR
WITH
INDUSTRIAL INSURANCE APPEALS, OLYMPIA, WASHINGTON, iF Vfl JP E'
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