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Permission to return to work/school
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This is to certify that
has been under my care from
S Ib=- "' to /? - /,} - 7)
and is able to return to work/sf
regular work 0 may take
physical education
?light work E] may not take
physical education
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Comments:
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Epl.y., M.0 - WASHIN A?l G TON
6yFII? ?s,BBIACCID SENT REPORT
0 p I •nl 1 LRh RY and Ind 1 •., Olymp WRthINI.. 98501
• EMPLOYER'S LAO. 8 IN] FIRM NUMBER 1E1EP110NE NUMBER WORN 1$ SOCIAI SCCURIN NO
• E 4360 1 3e5-3505 ? 534-03-5495
GMPLOY ER'S FM M M NAME ADDRESS (EIp CODE
IY JEjf 3y.. Dept, o,£ Highways CourthTruse Port Townsend, Wash 98368
d I NAME OF INJURED WORKMAN - ----?W ORKMAfJ EMPlOYEO, IN WHICH DEPARIMENI7._..' IF WORKMAN HAS FINANCIAL SOLE OWNER
I CONSIPUCIION 40PERAiION REPAIR ONLAUNCNED BOaI INTEREST IN BUSINESS, PLEASE PARTNER
( Albert Ammeter - ,_ x I 1 _, I CHECK APPROPAIAT E CIRCL E: CORP. OFFICEP
WAS WORKMAN ENGAGED IN YES NO 151JIFt HOURS (DID ACCIDENT OCCUR YES NO IF O WHERV
j YOUR PREMISES? . x
RIE REGULAR COIRSE.. C`1N)URED MI57,
} MPl3}YMENT ...i
GIVE REASON I
O CIF NOT TO BE REPORTED.
IN WHAT CLASS WILL THE -
d WORKMAN 5 HOURS BE REPORTED? - 8 -.7.3-j-- - -_,- ()':
LENG••LLTHHp O?FryEMPLOYMENT BY YOU jjJOiCCCaUP 11ON WHEN INJUREDiiEAPPLOYER'S BUSINESS IOCAIICIH. IAN( Ox 1. WrIF E ACC DENI UCCU - -
_ R`!N6 GtB'PrfCV STLOCI dIG\N)PI!'?1. 1E PARTICULAR IND J.
' y ?iTa Rd A'WU..AVA MD S '. ,._.1 _. OE, {RENT il.
NO iAQYEP j QV I ASt DAY WOPNEp O 0
Q6 WILL IHI$.WGAKMAN BE YES IF VES AIIACN I IOW. 0_ 1111-1U,
KEPT ON $AlA'LS?KRII.IG R TTY yi AyyANy?? j1? . ?s•f •Y? n0 ti1Re 168
I;t pEPIOD,OF pI5A8 LINT U11Ntl t1AJ 1/1yy?yy11}},? r-, ]]j`•,- ],], Py J•yj y? .. ..
ON ' YES?NO IF YE$ WMYl
WHOM REVOREED-? POSITION f DO YOU O EES OF i CLAIM?
]?].??L ._......_?v-P•i'A?M L_E?...+ALJCLCBT.?_.CCl •...F.rII[xTi..•_._._..... L__. .__.. _._..___.._.__ _ ___ x_. (ATTACH LEVER IF NECE55 RY)
HOW DI ACCIDENI HAPPEN _ _ 11
• (DESCRIBE THE ACCIDENT FULLY, STATING i?1y ? o .,,,i ,y ???•? 1?:
WHETHER THE INJURED PERSON fEIL OR WAS..JTORTBefI_A.6T,lDe_.4 V_g.ET..::cRA.?.4_ _Na[?Q .,aA,Aalx_lIL __.__ -___---
• 57 UCK,. ETC., AND ALL THE FACTORS CON
TRIEWING 10 THE ACCIDENT. IFNECESSARY
WRITE A SUPPLEMENTARY LETTER)
I DECLARE THAT THE'FOREGONG LEMPLOYER ___-? - - E -_---^V- _ i---POSITION :DATE- -- ?- F?
STATEMENTS ARE I RUC?TO THE BEST .SIGNED j .BY Ed. LLWCker U-19-71
"
OF MY KNOWLEDGE AND BELIEF. ,
ONLY
.TEAR ALONG THIS P FORAiIUN . .. ....................
__ -.. .___• ... ... .. ... .. ..............
SHADED-AREA FOR DEPARTMENTAL USE ONLY
7 PP. claw w,neeRNO 10111E BIE CI MS ENAMINEE COMPENSABLE CL N13 EN4: NER LIAIM N-11
Br
637826 BY
MEDICAL a D A1-11 nMOUNt C01N'JJEO D>IE NO HCE ILIHI F Rr• I+Ufs E£P
1 CL.45S CONC.
1111 'r CRNI.rAN. FIRST MIDDLE + LAST { iELEVHONE NUMBER SOCIAL SECURITY NUMBER : t
j' PLE SC PRINT
II ^/? ^? '/,a?.? •y ?j.[?
ILOR NPE I. .E•. l-.___--__._..___V _T_.9L%.fl.E7-L E
CITY & AD _YW:_1-/._w-1.?-4
( M41l??ING? DRESS I IP CODE i
4 ?._E.-?1_iCArT CtL.fq _..__ .. _ .
- T ?- /--?--
DATE ACC DEN OCCURRED/ HOUR CC DENI OCCURRED SHIFt --- HOURS ---TROUTS JOB RILE WHEN INUURED SIX DATE OF BIRTH HEIGHT WEtGHi
GN Al tA`I WORKED GNE DALE RETURNED TO WORK, IF SO WERE YOU GONG Y UR YES NO f ON EMPIOYERS YES NO HO LONG HAVE
T O REGULAR WORK AT TIME pRFlA15E5tYO EMWORKED PLOY R? ///+++
S OF ACCIOENt?? THIS EMPLOYER? Y U 5
a EM DYE ' FI M AME -( ? ??`? - ^ 4D,OA/E55/ ZIP CySE ' r>
` - Z DESCRIBE ACCIDEN N LL AND LIS PARTS OF B i?IN LVEO: 1! ?/ `l 'J '
'+ ?y4.JC.l.CJJ.•JGi /=.Ch' -1C/- l.E.?.__/_?/?I?Y/-j-. /"'.C.?.G.._-cJ' E.COr-.4<.11i?G vH?S CIAN?_
NAME TTENDIN
1
3 l?--- ?i&:?.7 .!?7.v/f.4•t _- ?LT! C7'._.LG[_..L :f ?.r __
WASTE ACCIDENT IN OUR OPINION YES NO DAZE YOU REPOATED ACCIDENT io E PIOYER t?1O WHOM RE ORi`D (NAME d TITLE)
Oll BY YOUR
1 CAUSED N ANY D AY B. 50 CO E 1 /???// :_... ___.. .7FY1 _,?,CCA r•C?/C/C?/.G?EEi}_- F:
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- i NAME 11 -1 11 "U'l I I i ILVE IF INjURY - -F DIVORCED. GIVE FINAL DECREED E I D O CED NO OU N E O CH (OPEN SUB IT A
A- IF -
-' (COP OFI CCOURIOOE 5 O N4 LEGAL ESIODANOF ?..
1 "l L--'L _'?,•/ ?,_ :c_?E,-T•Y7Y 15UCH CHI DRE L50 G E PRESENT DORESSOF SUCH CUSTODIA2
- - - .TM p Z .__4AIE OE ry qIH + 1 DECLARE THAT THE REGOINO STATEMENTS ARE
NAME -7-J TRUE O
1 _ 1.. ••rJ. - -,?,( ME B
EST OF MY KNOWLEDGE AND BEUEF.
DATE
------------
/ l.J?? WASNINGION f
I ••
f •(
NAME OF IHUURLD WORKMAN ADDRESS CI
} (ZIP ODE -
J• •1raF._? _._._ _. ._
r O TR SI OF INJURY ._?.'.___ _. .._ _... .. _ _... 1_
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PIIr11CAl FINDINGS IN DEIAII _.. _ _- at-work ..__ ... _... _....,__.._.___..._._,. ____._.._,. _...__.-._?..
EXIREAPINES INVCKVFD.1 ,•L .f '
• GIVE NiGn1 OR-JEFF__-..?_-._?ye-sroller6"'a6sd?. •. '. ?.-
yam. u,...... _.__._. __. ....-.._...-.... _.-..__.____.-_...__.____?_.__..__?.?,-..?_
DIAGNOSIS -.?._.?..._. _.-..,.T._.- ... _...____-. .._. _ ,. -.-. __.._.-. ._._ ,
ala
.. Mular. I'-`- a are...'atrraillad as.:.. jcdn?._OapDUSA
" O GNE IFEAIMFiJT USED
Elmmination 'aped
with eleato^ry.?_ y
-RAY FINDINGS.. ..-.... R...... z Nogatwe for faaarEvrs
r? HAS WORT( AN II ITS ND i HAS WORK NFAN YCT NO If RCS, [NPIAIN ------ --
- ? ?'- --" '
DREYIOUT NNRy 10 10 N[Al' FIT ENT 61 ANYONE 10
' N x + PRESENT 0 OR S I
IMI A COnDIIIOM 'x
f '
3. IS HIFA( ANf ER AREA ING Y!3 NO W E ISI OR CONDITION IT YES NO 115 CONDITION D AGNOSCQ YES pROBABIY DO35 BlY NO R
.. , ; EB1 T INY OTHER
1 DISEASE OF BE AREA IN1UA(pl L -ES VII Of
IOH 4ECOVFRIYICAIC O .._." ,
..
I ..._F.N1 0_4 Y :INCIDENIDESCAIBFp7
, M IIOSDIIAL17AlION 4fOUARE O. NAAP! HOSPITAL AL ADOR[)T -
'' '' D• ? 211 CtlOC
none QUU*d
W IL (EIS W(WFMAMRC CFF YES NO 1
ESTIMATED TIME LOSS WILL THERE UNDETERMINED
WORK DUE IO (HIT INAJ4Y') ! DUE TO INIURV DAYS; S PERMANENT DI ANYSABIl Y[! NO U
4 .N'-- 1/Y7
1 A71f pING FHYTICIAN IFLCA SE PAINT OR IYF[ YOUR NAME AND AOOACSSI PH
,y ?.. 1iA/?n,.n4CSS i nn CODE p(f.? ? uavuoNB NUA1dFR OEM= "14
W,5/5?'W '-- M ch TOM=111?e?Rlf11? 9. 300,c[oHrlr 305r2300
....
J ••+•_ ^'^_•_-(-_.-... _?..._._....?..G4?_--?? )C f V YL! ACCOIINI NUMBl4 SIAMPI
EMPLOYER'S COPY
rncE
EMPLOYER) COMPLETE PART I„ "EMPLOYER'S REPORT," UVMEDIATELY AND MAIL THE
ORIGINAL TO THE DEPARTMENT NI OF LABOR INDUSTRIES, OYLMPIA, ACTT WASH. 98501.
I
WE PREFER 10 HAVE "EMPLOYER'S REPORT" " BEFORE TAKING NG ACTION ON CLAIM.
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lY Wn!'._?f`fiSiYs.-?.?rl,?Ve"dew-...rv.?.....,i..r.+.•.r1l:L'w.SSu..,....uvxvv./tl-uY? »?.. -1t ...Gt i51.t .- ..,?...i??.......ii1W?:ll=
STATE OF WASHINGTON
DEPARTMENT OF LABOR & IN RIES
?
OLYMPIA, WASHINGTON 98501 =? .
; ?
°N - ?fEB28'72 ? DI
4?AS? P.I1?D 1729V
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ACBER•T,?J ANMETFR EMPLOYER
JEFFERSON COUNTY HIGHWAY DEPT
COURTHOUSE
.?. -,
8-
- - 6234335 4,360- 1
3 PORT TOWNSEND WASH 98368
I1-10,r71 7-29-,72 BRE.4ERTrON
8
NAME TO WHOM PAID CLAIM NO. AAOUNT
CLASS
C&-3 EMVLOYEE
AMMETER AJ lLIT 'H G OSI It3;71 G167537 _ 1'0P45
10.45#
i
j
JEFFERSON COUNTY HIGHWIAY DEPT
q', RM NUMBER F
CUURTHOUSG 07,26(71 4F3G0-01
PORT TOWNSEND t:ASH 98360 STATE OF WASHINGTON
DEPARTMENT OF LABOR S INDUSTRIES
OLYMPIA, WASHINGTON VBSDI
? MEDICAI
THIS DEPARTMENT MADE WARDS AS SHOWN AROVE FROM THE ID FUND NOTIFY THIS DE PARTME NI
D LO THE WRONG CLASS
A
BB•
e054 RFV o
5 F
AT ONCE IF FOR ANY REASON IN OUR OPINION AWARD I5 ERROR
10 .
RGE
OA CH
r"y
- N + STATE OF WASHINGTON - -- -y
MNMBEG
P 5 1 D.pDHmRdol I.
- r aid I ,.,
bo ACCIDENT REPORT
Employ.! MURI C4rnPlRl RRp4H by Filling IR pM SigRbq EmPIRY.rI S.Hien BRT ., h.n Moil R.poH 41 Oncs b 1
0 P Im-' oI L b nd Ind H Oly pi., W hjNj.. 98501
EMPLOYER'S ?•,' - EMPIDYERS LAB. b TO F RM UNDER IIEIEPHONE NUMBEN ?? WORKM N$ SOCIAL SECURITY NO
4360-1 1_385-3505_____
___
FIRM NAME f. ADDRESS ."".. 534 03 54951P . CODE
2
_ _.__ oo LLOO
Jefferson County-Dept._-of_Highwaye _.Co 4CLLee Port Townaend_ Wash
M NAME OF INJURED WORKMAN WOIIylM EMPLOYED IN- WHICH DEFA-Tow --' F '-?U3W
?IF WORKMAN 1i
CONSIRUCLION OPERATION REP PAIR NIAUNCHED BOAT' I NTERFSTINBUI FES . INANCIAL ASE SOLE OWNER
PARTNER
N Albert_John,AT Rjeter _ 1 _ `,CHECK APPROPRIATE CIPCLE. CORP OFFICER
W WORKMAN ENGAGED IN YES
THE NO SHIFT HOURS DIO ACCIDENT OCCUR YES NO. IF NO, WHERE? .?. "-- -
WAS OF HIS 1(Y' O u ,
REGULAR COURSE
} EMPj.QYMENI.W.IIE.N,NIUREDI'. #-, - _ 6 V?4=3O NYWR PREMSES)
IN WHAT CLA55 WILL THE I F HbT TO BE REPORTED GIVE REASON 1 """
?- WORKMAN '$ HOURS BE REPORTED) 8.3 ( -
:4 W IENGIH OF _EMPLOYMENT BY YOU IOCCUPAIIONWMEN INIUREO IEMPLOYERSBUSINESS i0[AI OrvOF p1AnI 0x I0e wN[RE ACC D?FNI OCCUNNfL
?e Road- Maim . R, Main o & C onetr ND I I
Q WILL TATS WORKMAN BE YES NO
d IF YES AN CH I /p VITA 4A NDA
KEPI ON SALARY DURING _iN<L fOVt WEL'a -LAST DAY WORKED aiEN LO ORF
o
HIB PERIOD OF p15 fl A' E%Pl NA110 - _ 1 _ _
<crot -1 • . _._. __ ) NO TIME JOS
-110 WHOM REPORTED POSITION DO YOU OUESIION YES NO F YES WHY)
ALLOWANCE OF CLAN i
,.P.M.J_,A+uWial,Apl...HBCkerj CO En CS x' IAHACH IETIER IF NECESSARY)-
DESCRIBE .`IY Ib? DENT HAPPENl THE ACCIDENT FULLY, STATING y
WHEIHER THE INJURED PERSON FELL 4)FWAS-...-,.&ie...Plew,int0 t2R1C]C Fled 8tl1.IIE hiTa in the eye '
- STRUCK, ETC., AND ALL THE I FACTORS CON
? IpIBUTING TO THE ACCIDENT. T. IF F NECESSARY -- -___-? -_ -? --??-- '?
WRITE A SUPPLEMENTARY LETTER.,
DECLARE AT THE TEL FOREGONE—— E PLOYER' '_' "' ^' ----- ._ -, - •,._
- STATEMENTS RE TRUE E 10 THE BEST - POSITION pA1E T?-- i
OF Y K IOWLEDGE AND BELT F SIGNED -Count Er$ veer 6-14^71'
, +'t ^•--.- --_•.. .-.......... . RAIONG THIS .
PER ..FORAIION O lY
F
q/?J?•L/yu(l' SHADEDAREAFOR DEPARTMENTAL USE ONLY
p J' I I V°? 30 aCOr. FL .E Jl_ EV. t1INER CO.MPlNSeOIE G IS FXA
i ?LJJ BI
'n-D CaI 1. p --DS
Uvl CO+?PUIEO pn?E N+JIICE 11 11 Aln n'Oh BCP
CCA55 CON( - ,
I NAME OF INJURED WORKMAN FIRST MIDDLE 1 LAST TELEPHONE NUMBER 'SOCIAL SECUR 1 NUMBE
I R J^.
CL OR IYEN(/
MAILING ADDRESS ?./.? ?
CIIYb SfA1E ?LIP?DE
r ??)J ENT CCCU/7) Gcs?)//) ?lJn c`
(SATE fC /GGJENi OCCURRED /TOUR
16 UO 1NT OCCURnR.EDH•I/F?I?,HOURS
.? I?(yV-O(U_R JOB iITIE WHENINJURED S/IXDAZE 617BIp TH ?MEIGHt'.
IE
- '? GNE DALE LASE WORKEDTGIVEE RE?URN TO/WOFRK, )F 50. WExE YOGING Ybtlk YE Ir"`yE MO??NV (QJ
REGUTAA WORK AT TIME ?-RENT SOSiR 5(-'r THIS EMPIO FROR(J?/; J
` Y D. .NAME OE EMPLOYER -~
O OF ACCIpEN(?.. .ILPCODE??•-
W
ADDRESS
LIT
icFCr._/
Z `L+c'JCi?IBF ACCIDENT IN F L A D CITT pART50F BO--? TOT NVptyFO:. / /- -U - ?j-(?CjT `/
0 7 E FCATTE NDING PHYSICIAN'---?'--? ?
.Y 3 WAS THE CCIDENI IN YOUR OPINION YES ODATE YOUAEPOAfEOACCI0ENt70E PtOYER?TO WHOM REPOq 0/T 'N4?EI?
CAUSED I NY WAY BY SOMEONE. ??
NOt EMPLOYED BY YOUR EMPLOVERt I S '
3., I FULL NAME OF WIFE OR HUSBAND AT TVAE OF INJURY IF D OACED GIVE FIN4l DECREE DATE IF DIVORCED AND YOU HAVE
COPY OF THE COURT ORDER MINO CHILDREN SUBMIT A ?
SHOWING lEG l C($IODIA OF
SUCH CN IDREN ALSO GIVE PRESENT ApDRESSOF SUCH CUBTOD AN
GIVE NAME ANDBIRM DATES OF YOUR CHILDREN UNDER 18 SUPPORTED TRY
N' YOU ? ""` "
` -f I DECLARE THAT THE FOREGOING STATEMENTS ARE
»_ E AEI TIONSNIp DIE OE.BFR7 TgUE TO THE BEST OF MY KNOWLEDGE AND BELIEF..
Chi/c/%cra
7 NAME OF INJURED WORKMAN ADDRESS' CITY ZIP CODE' t
_Albert r.kmater?. C9ifmaaTOn » hf?}/?ton- -98325'_ ___,_ _ _------ ;
DATE IINNFED. JDATE FIRST TREATMENT III STORY0 IWUR`Y
IF E%IPEMIfIES INVOLVED,
?. _5?1873._.---_i__.5?18?71._ _ tlLrvEylcy,opyEF,_ ),_.Bee..f.Zew..into-right eye...FOht1e.-at
L, HIS CITY
l nN.)
PHYSICAL FINDINGSIN DEI IL - ? --' -? - "" ""- f
IIF Fx1RENI1 E51NVIXVED i
,GIVE A GHT OR LEFI_
j y
! _?_ .-y? .E}1r(Zq{on under right- ITO 114 --------
?4t"17'AITNT IISTIS .-.. .... -..... ._ ..._ ... -_ 9 '
0
°R-.Y.xmEwnR Eton,...treatment.
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zl
HAS WOR MA .NAO YES NO HAS WORK( NEVER BEEN YE$ NO E YES, [KPLAINI
PRE y ! _ IpJS JURY IO AREA? ;NEAIED B NONE FOR
t V x I PRESENT OR, SIMILAR CON,T!OM F
X
- ITS NO WI I It THIS OR ANY 0THCR y
' 1 1 IS IH{P ANY P [ C 151 AK. ES F.O ITS COI DIAGNOSED TES PgOB 84Y POSSItlIY Nq
1 PNC C%Ij11NG CONDI O 1 COMPLICATE IHF RFSUJ SUIIUN OF .. i
D IS - 1111 (A5F F AREA -ID' .T
.? AT .,. .,,. IREAIAUNI ON GEIAGU ECOVERYI, „_, IINC OEFII DCSCR BFD7 _..
d ` J HOST IAtU ON 4[UU ED +.ue( nOSp t l ADDRESS
k
f
r WILL I'll WO4 All 91 OFF ES ~NO ESTIMATED TIME LOSS WILL ANENT YFS - NO U NOLTITMINED
I WORK DUE TO IS INJURY 1 PIPMA, FNT DISABILITY?
" _.. 1 DUE to Iwum ? DAYS, DR
,.,-, EI
' ? AITEPO•NG Pl/$LGTAN EPl(AjE PRINT GN TYPE YWR NAVE AND ADDRESS) AfC+[S$ t IEL(NIONE NUMJ
I W CIXH T NUMBER
' •S?afA?N o't,..Fort'ToEDnesnd,..b' tington .l ?, Tf. ._....!-•rGtf ii' "_....
ACCOII NI f, Y
`? '. ?? ? (USE PI. PAYE Af,CWNI NIIMLEN $IAMPI i'.
,r EMPLOYER'S COPY PAGE
EMPLOVERL COMPLETE PART I., "EMPLOYCR'S REPORT." IMMEDIATELY AND MAIL SHE i ?`.
ORIGINAL TO THE DEPARTMENT GF LABOR 6 INDUSTRIES, OYLMPIA, WASH. 98501.
WE PREFER TO HAVE "EMPLOYER'S REPORT" BEFORE TGKING ACTION ON CLAIM.
SIT
DEPT. OF LABOR & INDUST IES
L MPIA, WASHIN T N
9 l96 -4.J
DUANE S.
3 Svpariwr d Induar( 1--'.
BY .......... ...................
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