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j TA 140
DOCTORS RELEASE REPORT
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- N _ DATE
PATIENT
DISABILITY DUE TO: Industrial s?
Accident
Non-Industrial
" Accident
' Jiro
DATE OF FIRST TREATMENT
/rV
DISABILITY ENDED
i DOCTORS RECOHMNDATIONS
f Signature of A t nding Physician
Note: Eeploya0 is required to present this release to his
Supervisor before returning to work.
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IA 140
DOCTOR'S RELEASE REPORT
Crown Zellerbach Cpn. r
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PATIENT DATE ?
DISABILITY DUE TO: Illness r
Industrial
- Accident
- Non--Industrial
Accident
A
DATE OF FIRST TREATMENT ?b r?
DISABILITY ENDED )gnp
DOCTOR'S RECOMMENDATIONS "
Signature Atten g Phyaician
j Note: Employee is required to present this release to his
Supervisor before returning to work
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IA 140 ?.
DOCTOR'S RELEASE REPORT
erb-n -Cpn.
PATIENT ?? `"'=!•? ..,TG !_.C"FL? DATE 71
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DISABILITY DUE TO: Illness lam'' -
'
Industrial
Accident
Non'-Industrial
Accident.
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DATE OF FIRST TREATMENT
DISABILITY ENDED 7 Arl7q
DOCTOR'S RECOM!ffiNDATIONS ,,..
tf-ld
S nature of,Attending Physician
4
Note: Employee is required to present this release to his
Supervinor before returning to work
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IA. 140
DOCTORS RELEASE REPORT -
DATE
PATTEN
1
DISAEiLITY DUE To% illness
Accident
Non-Industrial
Accident
DATE OF FIRST TREATMENT
DISAbII,YTY ENDED
DOCTORS RECOMMENDATIONS _
Signature of ttending physician
Note: Employee to required to present this release to his
ork
f
Supervisor before returning to c
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.? DOCTOR'S RELEASE REPORT
Grexre/6?/Ir.1-3erbneh
PATIENT Date (-
- DISABILITY DUE TO: Illness ?
Industrial
accident
Non-Industrial
accident
A A.
DATE OF FIRST TREATMENT
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DISABILITY ENDED
(f
y DOCTOR"S RECOMMENDATIONS
-.', - Signature of ending Physician ,
Note: Employee is required to present this release to his
supervisor before returning to work.
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RU No. 7649-111- 8.731
EM Govt. Unit Dept.
P USE ER
Refer to your TransIasi Reort of Ded.tn-
tlon,, Part II. Write In department number,.
THE FOLLOWIMr. 1
C
Lost
DEPARTMENT OF RETIREMENT SYSTEMS
PUBLIC EMPLOYEE'S RETIREMENT SYSTEM
NOTICE OF SEPARATION
ILOYEE HAS SEPARATED FR
Reported 1 5-3 .1399' 1a 7.?.5- ;
lame Snparnllon Da[e
OS-3/-r 3
TS PAID BELOW
Amount fabe
3M THE PAYROLL OF THIS AGENCY 1
EK.slgned
? Retired
? Deceased
? Ineligible Position
? Granted Leave of Absence
y
s
S Q. /
Terminal Leave
without pay until Daie
r {
Sick Leave
Other
fP.r!. 40...1:. ls! ae Y:.. a?FS ...:.
' '. n ule of.P sonn or Pay[Ol c ??,??
INSTRUCTIONS: Forward while and yellow pin to Aetl nt Doartl. Pink
The last manta's story and the adtlltlannl tletl uctIon for Trrminal Leave
nrl O cer. a
tmu tgber se
Parately. 1
y
GROSS PAID FOR:
Salary
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R.B°2 (Revised) 4-67
CHANGE OF BENEFICIARY -
fdember No.
_ _ zd t T,,; s•???/ Vlashin.-ton
Social Security 17o..,rri ?a•-z?z, Date:_ e-
To: lfashington Public Employees' Retirement System
In accordance with the provisions of the Act governing the
4lashington Public Employees' Retirement System, for the purpose x -
of disbursement of any accumulated contributions standing to my ,
r
credit in the Employees' Savings Fund, in the event of my death i. v
prior to retirement, I,110MINATE .:u.k3
r
' •F.? related to me as
?.> .. .•A
J
_
(Name in
full)
whose address is ,9 fr / er-k, ?77y/
OR IF THE PERSON DESIGNATED ABOVE PREDECEASES ME, I N014INATE THE
FOLLOWING B
ENEFICIARIES TO SHARE AND SHARE ALIKE:(If a minor show
birth date)
?- related to me as -
Name In full birth date] s $
¢
w
whose address is ,
w TT related to me as
Name in fall Mirth date]
} "I whose address is
I NOMINATE THE FOLLOWING BENEFICIARIES TO SHARE AND SHARE ALIKE:
related to me as
Name in full birth date]
° whose address is -
2related to me as
(Name in full ?birth date)
,
whose address is
?. I reserve the right to change the beneficiary or beneficiaries at
any time by filing written notice of such change, duly acknowledged ,
,
with the Retirement Board.
Witness:
?/y!/.rl7`se? ??P
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,^
(TQ Member's Signature) t4ember:s -S- ature)-
Addrosn:Address:
-
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p ? ?.!'1T T,.J'i i? ia.% i / !.l:?a? d' ? r
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?n ? / i !•s.^ 4/_ ' ?
A , Present Marital Status: Single 14arried_ I•lidowed_, Divorced
-„-
llama bf Employer:
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n t ? y5 't 4 ? r ?? ? ?, r i ? z ?,• ? ? ?? f6 ?56.2rtt'? A t?,nl .r 9 ?`.
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TYPE OR PRINT NAME PLAINLY) SECTION A. HISTORY
1. Name- .__.N _.._..f?//......... __
(LrM) (First) •-'• (Middle) (Malden, if married) ^
2. Mailing address ......_A/lJ.... fa,rr.._?:2 • ......... adr..z /p ?_• ? .... z? sdl ...... _.
(street) (city) (county) (state) _
3. (a) I began my present employment with___ ..................._,.....__.__.._.:_...._.__..__.
(Name of departre-t, commission, all .Y political subdivision)
on the-__.Z SZ __._.day .......
19.8
(b) Title of
(c) (If applicable) I am also employed by.-.?__.._.___- -._
(Name _o[ department. eamm17_1,n, agency, political subdivision)
4. Present rate of monthly compensation:
cy Froum Whose Funds
CasF. Allen
Comperatlon Is Paid
(a) s E2
4
(c) s
5. Record of service to present employer and other public agencies since October 1, 1947, to date:
Where Service Was Rendered PERIOD OF SERVICI:
Name of Depr Agent
mtasio or Till. of Position Ileltl
DeClMo. DaynnlnCYr.
Ending
Mo. Day Yr. Le Rih of
Per
(MoOuch
Ins) Salary Paid
1D 3D {
l0 19 f
6. I am a member of or receiving benefits from the following retirement plan or plans:
L's
7. Social Security No
8. Check by (X)-Marital status: Single_ Married o' Widowed-._ Divorced _
9. Check by (X)-Sex: Malc.t. Female-
10. Date of birth-_D. f!:, '?'On Place of birth " /!G rJ'' 1 L-_ !c!1r x. _
(lfonth) (Day) (Year) )(City) (County) (slate)
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