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Home My WebLink AboutReel_0024D (7) III ,._._,..._..._.. ....... ....._. m~ -"---' ,.. .. __,. ,:. ^~ ,"_..:" '.' "~'I ~:".- ."r....,~ ,~...,~~ ..,.."..,.,'... J . r-""-'-"~- -~,,~_. '"--.~"~. _ i- . .-. .,,-. _m ,/':1-/ i' ".;l::,,;'~:' ,,:,',; .~..",.~-~~~~. ~... "","",~~ !f'W' .". ....... - iiiilll~ '. --- .' i'. :" .: \'.' ;', ~~,; ','{,,; .-- ~-- - v-~ ';/',". - -- . I~"". DEJIlTMENT OF "RETIREMENT SYSTEM~ Public Employees' Retirement System Final compensation Report "compensation Earnablen in Final Two Years of Employment SS!,;,;: ~.3q.-.i...;.-5011 U::F,T: 22u9iJl RUrJ u~TL: Je/~~/8b T~P.r-1li!..TIl"~~ w:' TE:: *STATEMENT OF WRITTEN LABOR AGREEMENT COVERING THIS EMPLOYEE: Dl'.TE SIGNED EXPIRATION DATE CERTIFIED BY NAM~: CO~iY. JOHN W ~ Dollars 1. 3!1!l '/7}JI/ 3. Amount of accrued sick leave paid at retirement. ~O Amount of other earnabie compensation paid at retirement, i.e., retroactive pay, severance pay, overtime pay, clothing allowance, housing allowance, ~ etc. ~ ArJR. 7~ 2. r:/ NOTE: We can use only that annual leave, sick leave, etc., earned in the final two years of employment for the Average Final Compensation purposes. You must, nevertheless, transmit contributions on the total amount paid at retirement. Sick leave cash outs are not/to be reported for state, school district, or higher education employeeS:- ~ Dollars % Payoff 4. Amount of vacation time accrued in final two years and paid at J:li 43.:1, tJ / /~o1o retirement. a. Accrual rate per month loAM. b. Hourly rate of pay /~.(N 5. Amount of sick leave accrued in final two years and paid at LL dl).f. YlJ PiS-% retirement. a. Accrual rate per month 'liM b. Hourly rate of pay I,p,/ll 6. Amount of other earnable compensation accrued in final two years and paid -P- r:7 g at retirement (see number 3 above). , . * IF THERE IS A WRITTEN LABOR AGREEMENT, EMPLOYER MUST SUPPLY DRS WITH A COPY. / .-' "..,-. HIGHEST CONS~UTIVE TWENTY-FOUR MONTHS' ~PENSATION Please indicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Month/ Hours Includable Month/ Hours Includable ~ Worked Compensation "~ ~ Compensation *6 d:L $ 3/?t!J_ ?:\" $ .frL /6? ",?/,f/. 7.:z- ~h 1/6 ,?, / fl. n !f/.!L /76 a ;1,.1. '/-:h ?h6 /6! A /tI.f')J ilt /(00 ~3cj.9. "lb l't~ If;/- ~ f344i- Total of Compensation Listed Above $ ----------------------------------------------------------------------------- ~ ~ l. Does your agency report on a calendar month? 2. Does your agency use lag pay? 3. Does your agency USe pay periods? 4. If other than above, please explain. ****************************************************************************** PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT ...***....*******.*.****.*.****.*****...****.**************************.****** Return to: Department of Retirement Systems 1025 East Union Olympia, WA 98504 Phone No. (206) 753-5283 SCAN 234-5283 Certified by Agency (Telephone Number) (Date) ~ ~""'y p~~ . 'q 1I''!IIllI'",~," "..'~~ 1 _It ...- Til l'RJ '--tl"lllllll ~' ; ;~', .~~: ~;" t, .. if, ~ ~';. L. ';.':.;<. .'. ',-,' ..,;;,.; ...... .' r-- ..... .'. .'. '. .' ; ':,.:.. . :::''', 'C' 'i ;. ::. .' 8 . '" ....: .-;" .:""" .: ;; .. .:..... ."' ....' ..-~' ..c.... .... .' .., ."" .'.', :'; I\\:,::f"~: .' .>, , .... .....';... . '. ...... .. . '.' .' ':'..' ....... , ::. '. .:.....'... . .' . '.. :" . .'. " . .:......:< '::'" . ....'... , .. . ..' .... .,;.'. :: . . . . :.:.' ...... . ........... " '. .... .," , .' . ; '. ".' .::.;:., .. ....:...... .... . . : " '. :.... .....,. . .:'. .' . .... . ....: . .... . ,.':,.: ..' '. .... .... '. .... '. .... .' <<' . . "...... : '''"., . , '. "'..' '>', ..... . . .......... ...... ...... :.... ......... . ':,::. '; "" ,: .. '. ....:. ". '. ::;:. .....; . ........ . .' . ......"...........:.,.... ..... C . ',. .:...... :., . ." .' ......;. .:' '. '. :'. ,<', .;:...... "". '. . .. " ":"': '. .',. ... I ; 'I " " ,.::~:..~~'~!.:/f?.r.r,::'...:~~'.,.,../>~.(2~~... .. Date I S~CIAL SECURITY NUMBER "'/1 / I"'" ,J" /J .If// RB No. 76A9-(Rev. 8.731 DEPARTMENT OF H:ETIREMENT SYST~ FOR Govt. Unit DePt,. PUBLIC EMPLOYEE'S RETlREI\fENT S~l\1 EM- 1- PL,?,';-;'ER ? < /'/1 0/ I NOTICE OF SEPARATION Hc(cr to your Transmittal Report ot Deduc. tlon5. Part B. Write In dep3rtment numbers. THE FOLLOWING EMPLOYEE HAS SEPARATED FROM THE PAYROLL OF THIS AGENCY Last Name FJrst N3me Middle Name I Separation Date I o Resigned (' (" I t -'.. ) ( I ,^-j l' ".....I . ,') -. I - -" t..~ 0_Rctfred -- / ENTER GROSS AMOUNTS PAID BELOW 0 Deceased GROSS PAID FOR: Amount Month to be 0 Ineligible Position Re:ported__ 0 Granted Leave of Absence i l_' l / Salary Terminal Leave Sick Leave Other INSTnUCTIONS: :i:: ":;':'" ... . '.,:..:. "''':' .. i::' '., ::.: .::'..< "'. .. .:.::...... : '':'''. .. .' ....... -- ~I / //) ) / / It 1. t; . ., ',' ,,\1 "I,'","; ,;?:,', i-\' '\i ," ':;:1', ,I"~ . ":\:.::::.)fl;::- without pay until .....'oiiic..... 'J 1,/ (: '.. .I, I (') ) : n - ! ..:'.....~,.~~~~::t:::~:t:L~.;~~::,"::"..::..: / ~fJ, ./ --- J <' ) }'orwnrd while .:md ycllow'cupl('s to Hl!tlrcmcnl Board. Pink copy gocs to Agency Pnyroll/Of1lcer. " The lalot muntll's salary 3ml the ad{lItional dcdul!t1on lor Tcrmlnal Lcave must be shown 5l!paralely. ~~J ..: > ,,' ..-:.. ":" .'. .. '0' o' 00 00 " '.. .' " . '::.' " ...::... .... ':. ......., .' '. . " . ....:..... '.. .,' .:....:.. .... .... . .......:'" .... .' .. ',' .... '.:: .....: " '. .:. .,..... ............ '. .:c:. .:'.: . .'. "':. '. . '.. ". .... :.....'...:.:. ,..... '.'.. ..,.......,. '.. ..... ......, ",' ......... '. "'"i ":>', , ,:,::",:,,,: '. '. .: .' ..... .... '." ','.. :-;. ..'" ':.' '. ......', . ..;;,:,' '."',': :,.. .:. "., ..:..... .:>:," ." '..' ':':' :.'::. .... . ..': ,:..: ,..... ". . .,:......,.' '. "', .., '., '.' . .'::'.:' .... ' '. . . ., ::. .... .'" <>....,: .., "" .., . ,.'" "., ,..... ...." . ,..:.... ',", ,,. . t'. '" . .' ....:... '. '.'; '. '. '.. -" . : . ':," '..:. : .' ,: '.'- ',;' "':'>;':',: .'.:: " ':' :,'" , .': ' . ": . .'; ..: ::....., . ,. ". ".'" . , .~. "', .:, ".: :.. .' ... '.: "', C:' '.' :'. ...... .: : ' .... f..... ..,:', - ',' J .,,', I ..', .: ,: r' c>:"l &\1-': .-:;~ r-"-_....._'_._"_._-.,.,~-' ._--,."~,, ~i" l/~allr- 1 '" ... ' ...' ~~ ~'. 'I 'l/82KCR: !).: (;1 r, CGmp cltr.g $(':-,\:)~' ~ OW ~ 1(lf p ,If, . 1 " I .. , "Pr'"' ........... PHYSICIAN: Complete Physician's Report, D~h top portion of Original where designated a"ubnllllo.~ep?I1III(;:1l1 I poijeSllbmilltJdb'1 of Lobor & Industries, Atlention: Accident It. :3rt, Claims Section, Olympia, WA 98504, Del_he PhYSIClon s,Copy l ph1~,(:.un.lo..er porllonof (3rd Copy) for your files and promptly moil the balance of the form to the employer (this includes the bollom portion of ! pogesubmitted by the Original and 011 of the 2nd copy). Lemp'uyer. ! PHYSICIAN'S-eary OEP1. Of LABOR & INDUSTRIES CLAIMS SEOION ~L YMPIA, WAS~lINGTON 98504 TIPE OR PRINT IN INK - REPORT Will BE MICROFILMED, @ ~,r~:rijo;i!t~' Co..., .Submilorig;noltul&los WORKER: Before completing section below sh d d IN~,,~~,;Jrovurse sido of this page, ! follow~. roppQrtion of PHYS!ClAN: Comp'?te Physjc~on's Rc~ort, D.huIO:r;~~f:~~f ~~::~CJf:~;:u dusignotcd a_ubmit to,~ep?rtment : pog~~ubmlned b~ . of Lobor & Industnes, AHenllon: AccIdent ~rf, Claims Suction, Olympia, WA 98504. Dcl"he PhysJclon 5 Copy I ph~$lcllJn,lowerporllonof (3rd Copy) for your files and promptly mail tho be/once of thu forlll 10 the employer (this includes the bottom portion of I pogu $ubm,ned by the Original and all of the 2nd copy). Le~~~~::_____________ !EMPLOYER'S COPY ... :1 . ~. :J~" v~~-- .~. . ::.'.....-:_" -.~~'.' ,~ !' .'. ,,].~. ~.,' ___. ,._1._ _ __,,0 ___" .., '". .. -. 111- --rr 111 -~~.." ....".~,~~.~.,~, r~ll!l~~ """-V"~ 11,,__- -.-- ---,'II ,--- -,.. ~ .-' .. .' ....,., ,. ". , ,,-- ~-- .- -- --- . ,.~,",~.,.,~..~-!'.<~:"-.: .i1IO__ ___, .,..:--'.'.....,~....-~'::.\' ~~,_' ,~,i'll~, ..J-.~". :~...~Jj._>:~~'....... - !!R~,,,..__.,,,,,~,, _ ----, '- ':.._:. -'=-,( .,..J....1,', <: :~" '" ,.~~~ I{',:.': 0>' ,t.',:_",-;..:..I7~" ~ .r ,- --- _~'" ',,""_' ,__ ,^,1lI1 ~ fl] '!1T -, -- 1'Al ~ 1- "..."..__ ,_," . lL_ ~~ 1Ii_ r - -- II - if .., '::~ ~ ,'j' ,,/,.<.;:;;,, ;r.b~ :.A.' ':,\X: -..",.. ...... .-- -. r-- ~--~~ '" 'J":" ':;~ 4'~ ~ '. ;:. /"'_._' ...,,.;..~..... III. - lWlll _,_~,,~ .._..__M1, .. ." ill - III n -"'"'>"~-""^' .---.-- ,..,., -'. . " 1'~~ "..,,-'..-} ~', .,' ',,,::/, ~"'-':~ ~_..tJ'""""'~"'" -~-,,""," ,,-,- -- J','IT .., - - J iijf='-"~ IR _ - . , " "~ '~'l,'."', ',-., -,-'~"1 ~ '" .... .... ", -. - ._1Ii'" ' -.."" _: : ~ - .."... -'-~-'"'- &' ~ -. :"~.I-!'~I ~ ~e'_/:-. \:"~..~...; '.' ~"".",,,." .. ..--- -- '.. "" --r"-~' --T ,,'ll . ',~ ~~,'. .'. \- 1-"- ';,.. ~""...,""";"',~,.: .. r-~ --. WI om,,,_. "'''" Rl _ft -- -~. . . ... . ~ EQUIPMENT NUMJlER ;:::J ?0::; <::: /,4' /?'?':~J'" TRIP SHEET ( DATE OPERATOR HOURS CHECKED REPAIRS -HAINTENANCE OIL IITR. FUEL SERVICES CO~~LETED ~ /0/25 l1-l P C-- s 8 ~ 12.0 ;}{iC,J. IJtd(./ .G", 1:1 rl/3/ IZlPC 9 - _ ..y t7 .{"..e.",,,r.l ;1// 1t..t1:J C f( ---' - 1-/0 /;/1.. 1/lIP c. fi. 'cd -' 10 iI~ hI ~" (D "Z.,t,l / (;0 I\.. , , . ,..... \'""' {r; '\ i!./!d:4- (J. ,,;. I V Sr-J- ,....,'" lJ. .,.",,,,,,/ ",,' / 1/-1-77 !/t{t,,{- 1 v :JS -" V " t", -' , ! I ! . - I ,-- ...,.~.....- ,--.--- / ! .. . ,~. JlIII!l!! ,It -bcbaf IT ll'--.;r ~~-~ ,~JI_ '"'V .,_..__~~.......IJ i~~ -'I"l!'n ~ .. "..'. :,:"':.., r'~ .. _oW""',"'" ~ " ~ .~ . - ..-- 'l'II'V"'~' .~ \ . ". . .... , . .... , ,;. ' .. ...... ' ',' . . .' '. . .." '. " . ...... .'., ......' .' . ::i-' '., ..... . .' ... .....'" . ..' .' ....... ....< '. :.'; ........ . '.:.' .... '.' "'. . .. .... ....i. :.," ..... '.' .'. . '.. . ,....:....." .. > < :'.. ..... '. .... . ..' .'.' ". .'., ,". :""...' "', . . . '..' .... :". ..' '. .... ':',.'< '.' . . ' . . ,.',> ..... ...,' : .' ....:. c..... ..:'. ,", . "''''. ..:.... ,..':' " , ..... .' , :... '.: .... ,.. .: .; ., '.' " .' ...... '.: .;. "'" ...... . ..... ., ;". '.. . ....:. "..:" .;';' '.... ....:.., ......: ......... . :.' .. ".,' .< . ": '.:' ';.: ."'.. ~~i;"" ...:,': :.:". . "'.' ,,,..,..., " :,lH'f4Vl<,(/P Of 'tj[JIJ'.TRI/1l lflSI1fl,\N-:[ t)!:f'/lhlMlrJll', ,t,l'lOIf I\r~:, IrjUU~,TRrfS ST/',Tj Ci \'JA',Hlr'IGlrJ~1 "'Y'," \ ,_ ORDER ALLOWING I~ND (\ OSING (t ;'.:f/. f OH f,.UDICAl iRE:\ TMHI1 ONt Y r::~.~;; ;'~,:," "", ,',.. ;,:~IO'~~~;":":,,;::~'I I " "',' ,. ,.. .. J" Hip~, In"" I~ I ! ."eo, "'_.=- ,_ "-'J i :- - d__., '.... , . ''':;:;:;':'::':::':~''':'2::,,:__.1 ANY PROTEST OR r,EQuE~T rOf( PFC()/"..jSIDt.~~'\l)l)!l Of lH;5 CJliOU~ MUST ilf MADE IN WRITING TO THE OEf'/dHMENf OF l....~O~ MW I~WUSUiIE'i IN 'O,\PIA mlHH4 60 [lAYS. A FURTHER APPEALABLE OROER WlLL FOllOW ~lJOi ,\ ~E(.jI!E~T. MU 'I<OM r!-il~, ORiJfR MUST BE MADE TO THE BOARD Of ttJOUSTP!Al IN$lIHANCC I<f'PEAlS ('lnWIA Wr711:,..j &0 Dt~Y~ FROM 'HE DArt: THIS OflDER IS CO~MUNrCA1E) 10 iHE P,\IHI($ OR Tm SAM[ SHAll i't"::O~.H rlr.jf'l .; . .:. :: :", , . ". ~:{\/;~;. ';;:;~": ,",., ..: .:, .': .:,. . , ..:.., ::: .. ,:..:. : ','-" '" '.:,; ", ':',.;" '" ,.',," .: > , . ;', . ''',' ,: ..' .,,:'.. ." "', ',: "...:.... :, :', , ..... ,.'.: . ...., ". " . . :::. :... "''''. .'.;" . ''':'', ... :':<":.. ...... . ,'. .: .' " '.:" . . . :,.. ": . ',.'.,' " .;, .." , . "" '. '.:.,. '.::''': :,.:....',.. . . '" ......' . :'''''. ..,...... . ,':. " .:.'. . . ,'.'., '.' .' ..'. : ,. .".' ":,,,...: .:.. . " .:....' .' ',."'''' .',,,: ":: "." : ',:.' ". '" :..:" ":' .'''. \'..,:, ....... (. .... . ':'" ':.. '" . '. .' ':. .... :". . '.: " ;i':,. '''.;:. . '.' : '"',' .\ "',', \, WI .........---....... -~ . :.:..'" .' ,;,:....:. . . . """.< ....:/., . ':.. .' ...... .:. . .i '.:: .:. . I. ..i . .: ....': __~. ~'."~"".o:r>-',n..,~ .~, . ".".".,,~,~._._~,' ~~.. .'~J ::\.1" J., '-'.' '; < - " -- ..-.' ," * '.<. ','" ~.~ '_';~"H' ".~,-' ~...~. _"~I " ".... ~'.~r..\:,,' -,--,---"""," .._- ,-,- P...... ------.--- Iinl -'...~-~~ ..~ I!III!I""F , ..-." Tiil'lV_.... ..., 'I; ',':',):::" --~_._- mm, <_.,,,--- 'lI ~ .. - /~ ". ,~J'<O--' . '. . . ".' I '~'.l ;. 'd f Ih' ,,: Dep! 011. 6. I (01)'( ,,;;^,ORKER: Before completing seclion below ~ded orea, READ LEGAL WARNING or,1 reverse 51 eo. IS pagtl. I Top ponion ~vbmitlud I PHYSICIAN: Complete Physician's Rcporl.D"'h lop portion of Original where deslgllalecA:JsubmllloDepart~lb ' h " menl of lobor & Indus/ries, Allention: Accidoill Report, Claims Section, Olympia, We, 98S'-Delach the PhysH BY r Y$jCi(ln b' d cion's Copy (3rd copy) for your fjles and promptly mail the balance of the falm 10 the employer (Ihis includes ! b:I~:~)~:::lfon$u rmlte the bollom porlion at the Original and all of the 2nd copy,) I 1-______________ : EMPLOYER'S COpy F--- --_.,,~ ,~--.., . ^,,~~ .~ 'Il :: --- -,......- ~ ACCIDENT R ORT ploj.,Mull Compl.,. ThI, ..pori b, Filling In ond SllJnlnlllmp I S.ctlon a.low, Th." Mall Report Gf Onn fo D.portm.nt o. Lobo, and Indlolltrl.., Olymplo, WOlhln,lon '150., ATTACH lETTER IF MORE SPACE NEEOED, . lM/'lO:YlII$FIRM NAME . ':^AiL'NG~ob'iiEfs . CiTY, STAn lIP'c.oaf' ~:"::::=.i."'=~. "....,....~..:=::..:'"e?;S1-.. ~ORGAN.ZAflON . () $ ~: John Edgington 538,:,,50-9:5~~ . ~~~lom "--;;; r~;;~;;~;~;;~~~~.,. "'yis. millo ....,FYES:S;TATfWIUC/j...NDGlvtflliE EMPlOYlRSlAI.&INDF'PMNO INWH...TCIASSWIU DIV.OROEPr.WHERE ~ S~jc?~~~~l'tE~~:rCU? ~~) ~~ ~'8~:f':t?fY:Mf[D? 15-~ ,:1~ui6~:~~RsoN 2 L'~", -: 'tM.P,~OYu. EMPIOYf.o'~ W.H.~itDfPARTMENl? . : ADDRESSOR Loc""o'N, INCtUDINGCOUNIY. WHINE ...C(IOWI OCCURRID ST...reWltER( E't:J81~~~S ~I C~NS{~CflON i om~N r Rl~R i ONt"'UNm~DIO"'. Hadlock Shop, Jefreraon county ~mPlR~~ xx ~ Jitj~1~'~::ii~f~~E Yls. .NO . IF-'~fS. AnACH'.~ATEOF ACCIDENT , TIME o...n AfPO.RfW '0 YOU TIMf CHECK HERE 5il;~'::~:V~~K::V_OU? :?:~X EKPLANATION. 4~i-i7 7:55 <<ix: 4;;'1-77' 7:56 tu~o\Ci~~~~r~D ~:::' ~ ).,:,'4-1.-77 'O;';4TE~t2f:N77EOiOW6RK ~1SR~~~~~~~J~fs~~}D.m YES NO SHIFTHOUIlS e:;tT5Wyogn~'~,~? YX'.' :E ;..~._.,.__'O:.,..,'O. . 'EMPIOYMENTWHfNINIURED? xx 8:00- 4:3e . ~'O ir.Jn:~L~:~~~H~SltlstOYU ~~~~':::r:l?nn ~ jDURING,mUOOOFCIS"'IILITY? c..>. (NOO'lERfIMl) $ 6.68 ~'O! ~~~~.~~~ .":"A~E NAME SCHEDULED CAYS OFF A. ~~R~~~6~1C_'O S saturdq & sunday -} " !H.. i I""" W"'SfMPLOYff tRANSHRtD fO "'NOTH(RJOB? HOUR pu;.x m IFU"'N~fEIlED. x ~~~'l~:Nn .~~r~tarting.grader he step>>ed off right side, missed step and :fa II to ground. ' fM~lOYUt Dept. Public Works r::&... .', C -<......,' ___ , '~'~::,: '" '. "'/fo.."',~ 'lL,QN5lo._r~~l ~,f~f.~"."'.'if.~.QN'1' . ,"~,. ,.", ",'" l FlIlST M'oDld l~'O . ntEPHONENUMSER i"A",.oA'''''' .. J/1S li/7J l,p~;l-'l-~g l'H/fo...t$ ..~ L .... '. ... ." J LtAv .. , :r4~/'~'7tCb<j- f ''''''7$S'' %,""'.0'" .'O'''O'Z'.~'.'.UR(O 'O. M:Dg:OF:;I:Ht/? 'H6'2'lj~_ IGiVfD....'ElAS"iWORKlO.... :G. ;".."".".."."'.'. TO WORK. 1'.'0 .' .'WERE "'OU OOINGY ~ V'S NO'".' ,0..US JOBSITE t- I IIEGULARwou...n'td't . . ST"'TEWH(RE PREMISES S G - I" 7 7 ; OF ACCIDfNT,? ' til ':c: "'CCIDENT OCCUUEO '" 3.:~ (OFEMPO......-.:., " ",,'.~' ,,,.,' ".II((r"'DOIIE". . ~CIT . Q"~~O'-HOWLON.G.HA'I; ~ . (1 In" c " .0' wn..,n m, C/ ~ . (f::J~,....'it'~ THISEMPIOYU?l ,~."",.,,~,-~o,,4-r ~,,,o,,_.._...z:".."_..o.,__. . . .~,..~.~"" ~:~~dg::p.f.-d,-' S~/k1? r,?~:2.S-, .' A_-I-' WfO. NAMf M"'CHINf "'NO DlS(,RllE .. IJI' ~ '''''lG. PUtIINO, ruSHING Oil C...U.... '.. W- t-t:i(d'~. _ A, nCR'.fD AS INDOOn OR OUfCOOIIS ' .' '-1 ~~~r;;b 7~~~~' NO, ~~' RIPOAffO ACCIOfm TO YOUR IMPIOYfR o. 1-/-77 If EMPLOYER W1,S Not NOTlffD JIl[ SAME DAfE AS un ACCIOENT GivE: Jl[ASQN 'OW"O""'O"". "".i'~ tJJ~'~::'~~JO~.uOWC>D"OII"(lvtlIOVI: 611,HlI~ PUOAY ,.PUWEEK PER MONTH "aIVORCtO AlmyoG .'AVI MINOlll CHILOR~N SUBMtr A COpy OF fIlf COURT O.orR SHowme ttOAI CUSTOOI"'N OF SUCH CHllORfN, "'UOGIV! PNUWI ,ADDRISSOF SUCH CUSTODIAN DArr TH[ 'tf' OING SfAIfMfNfS A'" TRU( TO TIll ~:~~l ~~~~Ps~fp~~f,~I~fro~ IJ"N...OLR, MA' III (Ivrl ORCAIM.~...t"fN^lrIlS L/ _ J- fl ~ -I-. ( ~._<u..o legS' aehand ~~ :"'HUEA"lY'.((KIUING ,0IUMI OF THI "lIfA INJUREO' trt\ . N~" Wrtlll~"OIl AN1 0111fll vrs' rr m~r~~T~~~~~~~I:~~~cC8~~V~An ~;!J,~ COUtDIHICONDITION YIS PIIOI....LV POSSIIIVN? gW:,7m~~D~~~HcM~~~Ho? i~} >o\D. \~~ {~ : '11\.'. ,..'..... O..WlfEOR L'~~.IDAT TtMEO'. '.'. UIlY . . ,. If D''IORCID. GIVE FINAl DrOll 0"'1,'. ~~11Ji~A~~~'N UNO'.,. SUPPORTEO:YYOU' ='7. ~"" &...?,~. 't I ~;'i-i=~;""'.'"''':~ll oit gar, s..tr, !king hoad, both (Q.\l'lAINU AND l"HYSICAI ,."Ol,.,o".N Olf ",\ (:I~~'I~~:~~ ~~r:"VfO.) ,ciiAONOitl. ,. .,. ..,.. i 1. : HuJ.tiple abrasions and contusions 5 ~OlVfl'I':':i~INfllSlO' ~ i'",~~7'J:,at1"nt hospital call, aX4lllination, treatll10nt on, ~: ""'tllrol'IO'III"""IH ~ ,~:1~'~?M~t~~~"...,(~Ot"O"~ (:~ f ~ 1,'CA\lII"IUIO 10"~''''1' tlOCtOI (".,.... .."''''. AHt'l..OO'''' = 1,...o'''''4l.1I1D "'....IOo'HQ"II..L - 1""""1"" outP""I..-' ~ : ''''i~'''''''o<''. .~1",.'oo1IlHYf/S.p..lil1PRKI'1 lIospital - Po!:t ~"nd. Waahinq,~!ll), I WIlL fUIHMPIO...f1l1 Off WO'KDlIf TOTHI'.HIU.,., ESTIMATED TIME LOSS DUE TO INJURY... om NO U~Olff'MINIO Will ".IU,1 ir.'l'" "'",,..>j1'1I0t\"RIlU..., x liP COOl 90368IflfPHC'" NIl""'" 9~I1P"cn"., ",;u.],'l:::lJOD 15120 ' jU" PI" ''''" AC(oo"" NUMII" HAM' I rAGE '0'____, ,.. ..- __"n~~~f_. "'JI._ ,,' " , ' , " . .'" , ',:",', "'. : ' " I ' , ' " " I. , ,r ,~ ' ..__.._ . .1. r" ., 'lII''''I1!IBI ~-. .. ~ . a 00 a a z 0 Z MOO M ~ I ~ . . . . 0 0 = " a- N""a:> '" (; ~ 0 a:> a- z M z ~ ;: 0 ~ .; :; " ~ z '" X ;: ::; ci MMM '" (; ;: ............ ~ ..... ~. z "''''''' . "'''' '" '" ~ ~ ~ '" '" '" " N "''''''' " "''''''' "" , a ~ 00 z" 00 z. 00 ~5 50 ~~ rz .e ~~ -< Cl Cl Cl ~~ ~~ ~ I- <0 zz a. .. Z Z '0' w 00 DO 0 0 ~; Vl Vl VI -' -' -' >- OJ ^O <. a. '" '" ., ..0 Q~ <C <C '" :< M LJU U J: OJ ~z ----------.-------- '" a- ,0 .... l- I J: ~~ ~ ~ ~ VI >- '" <z >- i: z .0 -:> a ~~ 0 z u w Z Z Z '" VI Qz 0 0 0 OJ Z V1 Z ^O .... 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Z w ::E I- <( W ~ I- ... <( u c :E ~ o .... ::E -l.I.. ~~o~ ",<t 0 or:( J: V'I~U ICI..U~w w::><(co u.' 0.." w-' ~~::~< (. 0.""0:I: \"'- .i' o~w~ . \ :~2~~ t~~~~~ . ;::~~~ ~o ~o<~ 0"" w c::.~ ~ :8~~t;;:: ~~~55: ~~~~~~ V'H1........... ::H:(OO ::;;'" .... ~~;~ OB:o< o~co~ ~<~5 ;!:vil-:E o~8~ o w ~~~!!! :~:E~ ~E~o V;::t;;~ 8~~~ WO;: W er::.....Cl:1- >-w<t CC"'oc 00", ~ OW .t;~ V'I~ 'I~:n'i:::;; o~....o ~:;;:E~ QC~~V'1 loz~~ ....-"""0 IEo~o ~~~-o _____.-.JO"o<O"{~ ~5~~ ; , ',,~~~~iij;ltJ~~~i~~';l~\1k~~~~t~~~~1~~1~7~~~mzQ2:1~~!;\' ~...".".._...._...,------ ~ '0 _____..,........._.._. .r .'~._~..... ~~_"...~,~.~. _ ~ --- w Nt _~"'=:i "IIlJ'I""1K -'- F- ,..... .-.-"-, .._.I8iI ,: :,':"h'i'",;,,~, -;': ' ;'.': ,:~~ i <;';,,; , \ r,~ ~, ;.\ ~ ACCIDENT REPORT CLAIM HUMBER Employor Mull Comple1e '_ i> port by Filling in and Sign1ng employer'. S.dlon B,I en Moll Report 01 Onee to O.parlmllnl of Labor and _1~u'lriIU., Olympia. Washington 98501 EM'PLOYE'Il'S lAB. I!. IND. i:1~ NUMBER ~IElE'PHONEHNU"".BER W'ORKMAN-S"SOCIAL 5ECl/lllrY 'NO:' 43('io-l : 38$-3$0$ I $38.,0-9$$~.' ~'II.:Mo:~;;;;~~;:.~o~tLlleP~~~t.~f-~J;~~~: A~;.thoU~e .1'CJrt T~ncl'~llllh.. ._.. m .IZIP~8)'~i~:: ~, N~ME OF INJURED,WORKMAN h,"._....WORlUMN EMPLOVfD,IN..WHIf:H.DEPARIMENl1., ..J IF WORKMAN HAS FINANCIAL SOLE O,^:,NER . ,~_ ~ W_Ohn _~~~O~. __" _.'_._.~. .____. ")__' '. __._.,"".. _... tC~~~~.~.~.~~~~.l~~E~~,~~,O~_l~.~~~. rN ~~~_:fq.~~L~~,.I.L~~:<<;~~.~~R~~~~~;l~},,;~~~~,E~~~~~*!~~.f!~,~;~:~ ~ -I WAS WORKMAN ENGAGED IN .' YES NO SHIFT HOURS I " jOlo, ACCloEf:\lT ,OCCUR -I YES ,,\0 ) 1&.t.'lO..W11eR~1~;.." ! : ~- ~ 1.:e~~~~~~t~~~~~~~~~?._.,_-"_._~~_,-_~....L'1'~"'~ _4~~.Qn...'~. tO~ Y~~.R.P,~EM,I~.~'~1. '~'~h"_-~...f ..._ ' 9 t IN WHAT CLAS'S WILL THE \IF NOT TO BE REPORTED, GIVE REASON ~. IL;~~;~~:~:;~:~-:~TE.";oc'i~~~~NwJENINi';REol ,M"loi,.;,;,;"",,, "0"';0';&"'''; O.io,w,iii,cC;ri'N;'ii"Ji.iO ~ 1~,.~t~r~~~___~.~__.__..,_.J !!~~!~~I~!'_' ,__..1I~Mt!"Atlo.~~~~~S~\!glg~nWJtYt~JIICEl!:;R_ KINO,.,!,L -"'~'~I""~-~~'~~'~~-'-'''- .----_. '.,,- ---". oct WILL THIS WORKMAN BE YES NO: Itm~ YlOUMIoN'S R...n 0' ,.0.'1 Hi A"UCA8Lf i---- ,- ,.... - l~ - . ",CCoO ~ ~". - ,--- LAS I DAY WORKEDO...IE ~(IURNEO IOWORIC .., .' ~f;"~'8~0~~h1~QI.~X:~~L .~_~.~.. ":1.~~!:~~~~~~~~jh;r6I~;~.~~:~:~~.I~~~~f=~'.MI~~=t~MI1?.~~-l, J.O~;3P.::ih:__...!IQ__~~~_ :t.~~,__,_. _,,'n r-..-.._.~.; .11ME.A.CQQ(~I.R~OR!tR!Q}9V, >.,,~_,_.._.;TO WHOM REPORTED POSIIlON DO YOU QUESTJON YES NO; IF YES. WfiY? iij.!~:!~;~l:f~~1?~~~:~.1~~~_!-~!lE:J__,~~_~__~,~.,_._,.._,~~~~::~.~_~F^,.~L~~.~!,.__.,._ .:",,,.,"~.l_J~.~!~E~}.~T~_~~!_~~!.S!~.Yl_. HOW DID ACCIDENT HAPPEM . ~~~~~~: :~~E t~~~~~~NJE~~g~.;~tlll~~WAS___ ___~~~~~g:...~~,..!.._.f~!8!!~~j~-~--~~-~~._~._--_._-_....._---._~._. . . 'STRUCK, EIC.. AND ALL THE FACTORS CON- . .. ~ ~~~II~uT~l:E~7;~~eL~:rER~r NECESSARY : ~:.~!&i~j~~~fJ~~i'-'-~-~::o-;;;f:'c:~fl;~-~''{f-c;:~~:-'-~-:---'-.---.~~Tti;~o;;;",--:'-~-- ."..:.;~~i-'-.:'~~.~,~~'~~~.....'.~...~..:.:~;J.'"..':-..;-:'.._-..-;:__~*.._........~~~!l.~~9~..'!'!~S.!~~~~~~~!~?~~~!:'l_l!_.*......~.--~-_.....*..'~..----_...........---~-_._-_.~...,........~-~~~*.......> SHADED. AREA FOR DEPARTMENTAL USE ONLY e.lAl0s fX,AM~NE~ ~~"-ENSABl~.. " All QUESTIONS ' " MUST BE ANSWERED ' t NAME OF INJURED.wORK~N; FIRST MIDDLE lAST JTElEPHONE ~UM8ER, ~OCIAl SECURIIY I (PlEAS"'RlN'l' "\'1'" r.:-r:"_1 .'''1:2.-, "/'.."'2 5'29S-0C~ . O.!!... .'. ,_____.".,)Q 4J\....--.-.--.-r=~_=-U.q.;."-1s:::t:0-"4 ---~" .:.--~~ ""'>-. It'.. _:'L.,-..:Jl MArLINe ADDRESS ' ...J V CITY & STATE ZIP CODe . t-%.g!<..":..-'7- <'S,SLb-:-3.,":L-fSHiF----TI--.-Chl11~:BC.......""'1 ....W-asbr ~3?s= t,D~E At!i:M. ENNTT,oecu~' ~ ."O....UR ACCIDENT O~UR,RED' IS. HIFT HOURS ,YOUR JOB .T.".." W..."...EN INJURED I...:.SEX .O"'.E.. O. F BIRTH HEIGHT " IWEJ? ."1. _':2..~./..5_J~_~ L9__._3__0__1_______ JS\l1i(':,d:An.~..,-.L~_LJlt.<~.Ly..::. -"-:'~,,;t.J13 GIVE DAlE lAST WORKED ,GIVE DATE REtURNED TO WORK, IF SO WERE YOU DOJNG YOUR YES --No r~~' EMPlOYER"S YES NO '~OW LONG HAVE _ r"J:!.-._' , . g E~-:~E~;;~ME --~tz..C:.1 t. - ..,~<-----Lf~~:~'%?:~:E:~' ; :l.S~~IS'~-E'~' :;~ i~,~~~1?1e~?RZ~Cg: :;: t__e._~_?Cl f'I_____.9..~1'\ "'1_3__~~h-\.'d.:':.~-.-~e-----.....:.....'2ll1:?.tKlA~~3~. $:::. :Z:' I ~RIBE ACCIDENT IN FUll AND LIST PARTS OF ~O~y )NVOlVED: '. ~J__. -f2~~'(.I.iJ. JS-..~~.~-d-I;;LI..I-eJ~--....._-----'---.----..-:E.----.----. -.'-'--'---. ::.:: F-"c'''''' NAME Of ATTENDING PHYSICIAN ." ~ 1't::i..Y-.e..._t&. c:l.~__.!.c!.tLt;I, L~-e~({----..-.---------.]--__--. _~~_~,s;....hQ...'.L€.L-_ ..WAS THE AcelDENr IN YOUR OPINION YES N..O DATE YOUREPOR.TEOACCIOENT TO EMPLOYE~ TO W. HOM 1l.\PORIE. 0,. .' {NAM.' & '.IHEl .r . ('\ CALl"OINANYWAYBV'OMEONL ..... "o'<,.:....j_/ /<:; '7 -;.- . IJV"'-) .P-.... . "''', '.., "'<-,...'. == ~ 'EMPLOYED BY YOUR EMPlOY~,RJ_-=._~~,,~,_.:.!__~_.__, _..<>>.::.~._.., _ __:~_,_.~_~_'_~_:"': ~,:",_._,~r.:x_ =1..:....~V.j'f_"i(;).-y.:C..:-:.__~<t'l1~~ ~ __ ____ ________u____ _ ______~_ ____~-.-~f~3~r:~~~;~[~~~;f~~jS:~~~:~~ tJi:ULL NAME OF WIFE OR AT TlI.-IE OF INJURY I IF DIVORCED, Give FINAL DECREE OAJE IF DIVORCED AND YOU HAVE MINOR CHILDREN SUBMit A . . F"~' I I COPY OF THE COURT ORDER SHOWING LEGAL CUSTODIAN OF .. , ,~-~..b~l----i-"=-- \ 'I" :t.~...:)__J ____ SUCH CHILDREN ALSO GIVE PRESENT ADDRESSOF SUCH CUSTODIAN ... , ~ GIVE NAM AND BIInH DATU 'fOUR C IIDREf'4 UN::lER 18 SUPPORTt:O BY YOU I ---''""'-~_._. ----~- -,-_...-..-~~-~ --. -------- -~T.~ -~--- -- ---I 1 DECLARE THAT THE FOREGOING STATEMEMS ARE NAM' tRElATlONSHJP __d'AI,IL~!.BI~t.ljT._ TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. ::S~t:\i.\=e:=-e-cl:'si';:"sJO:!i _~'52>-~~ --I~'3,;.r; -9210.i,-" --- --.----jCih-.: ------ -----------------,-.--.-.-------,..-------,.--- ----: Co- I&-l'-. L ,-,hI \II'\/\.c..... ,WA,",NQTON . . ~.:=~~~~~:.~.~~~:=~~~:~:~=~r~~=-==~~.I ~~-.=-',~': ~ ~ ... -..- - --- -~~----~----- .. ADDHESS CIN JZIP CODE : _..John F~.Eda:1nJrt.on,;,.-..Box-~~M'- c~.. Wuldngton-.9$325-----.-.-....---'"..,-- -----'---. .~~IE INJURED, '--7A1't" FUlSff1lCATMENT !r~ tXTl~(e~TlrsJ~~OlVED.) .:...~~1~l ..--.-....1,.l>-a-72 - ,__.t pNE__liIGt-lT,OR_Hr.,-..,..., .. \'lhUe \::....new.:1nto...,,~_.~.e~.. ....""l(....~ "Nnll-..o't II'. O{lAI~ "- n".t"'I1>~""NVO..,j(O, 1!lInl'JL~~~:::,:"_~~:::::_:.,:';"___;_..-. ,,,',,..::: .:,' ~i^ONO'~~"---"----'---"------' --...-- -----....---......----.... .~..i.c.,v~~,~orei8n-~.'~t-07..--.----.-------..-~._--..-...........---...-,-.......-.---.------.---- ~1-i'.~t1oll,.treatllllmtJ fOl'Oign. body'NIIIOved.iron. right. eyeunder.locaJ..aneBthet1o..-...._-.. I. t~~~~~~.;~:~~!~~;;;:'-.:~.l:.-i T~~~!.~~\;t~'lf~,;,~~,:-. ii,- 'NO~.." ,iS~C'PlA'-~- --- ... -" ........ -_:~':'.:~:'~~'~-.-. : I"~'~;';'''N "'''~!I'''' ,,0 1;;'i'[:~I,~~ ~b~.?:~~COM~'C'" '" N" n~.f~!ft;:;oil ;;"GNom; if," "00'"" 'Oliiiiy'. ',;;;' = 1 ,~I,S.~,~~~ ~. ~.~, ~~rA "JNJ~Clf_~'.. . ,n, .. Y ) '~nrl.l[N1 OHl/HARD lltf'JVf.li,", x- ; :,!:":.,I.O~.M O[,5C~~,~,~I~_^ ..':'x '\,1, f i IfIHO~'ITAtllAtJONRlOUllllD, NAMEHO~PltAr "n. _. -" ,., ""0011[55 I ; Will h1l') WObMAP>I If, CH H~ N('l (F.SnMATEO TIME lOSS ~ j WIll 'HUE IE AN'!' i ~O,IIl' WE 1.~.~tHS IN/Vim : DUE TO INJURY""""" tlAV~; I'[IIMAN(NT DISABIlITY? , Af!(t-l)ltG r'fV~JClAH 11\IAS( P~INl Oil r~f"r VOUIt "'AMr ANO AnCHIUSI AOD/.t(~~ lIP C.OOt ; mfPI.ON( NUMUR .~,:!i~~~~~_,~~:=;z 98-1~;~~;l,~~POO"""'" '\\.~,._.~_.. (un (lft.'r."-rtlf~ ACCOUttl NUM/lfR STI.MI'1 PAGE VI!. NO EMPLOYER'S COpy IMPLOYER, COMPlerE PARI I., "EMNOVER'S REPORT." !M',,[DIATELV AND MAil THE ORICINAL TO UtE DEPAR1MfNr OF lABOI?.\ INDUSTRI(S, OYlMP'A. WASH. 98501. wI: PR(f(R TO HAVE; ''[MPlOYfR'S REPORI" DEFORe 'AKING ACTION ON CLAIM. 2 .., t!,"j'ti...?t. .";'i'!""" ..--,,----- rnll~ l- e. w 0 >- ro <f ,,", " '" r '" "1 J '" '" (!l ~, . / ).~ J: :r Vl >- .. -~~-~ ~ I- '" .~/ , z :0 D ./ " ~) C z 12 u lU '. W Vl c:~!,.~ ';1 z OJ' 3: 0 " Vl C C' '" I- lU l- I- u.. C< u.. :;, C>. W C C '"l U a. .'1' Z 0 I- '" 0 ',. "- fi 7' lU >: W "' '" co C ~ V1 zz 0 N 0- 0- "-0 , ,. ..... G.., z "', 0 J..--I :c' ..a :'; !;", l2 0:: .... , -.,-,,\ :>:0 " ~ W' .. ~ , <~ z = " en 'i: ~" 1: ::..... ~ ' 1=" ' ~u.. :: ';, f" J\ '\- ~~. 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TO WHOM PAID JF 'F-!'hPLSU:j J D UA1t " AMOUNT ClAIM NO 09 2'\ 71 G2l389<.J 2~C() 2~OO* o ~-1 ~DG I ~IHIN ,JF.FrEt)~~ON Cnl)fHV HIf~rH...j^Y 0EPT CU0-< rH')US~ PO~T TDW"'l<;En:1 HASH ):1 ~6H [)AJl FIRM NUMllfR "1 \.)1,27 72\ 4,360-011 STATE OF WASHINGTON DEPARTMENT OF LABOR & INDUSTRIES OLYMPIA, WASHINGTON 98S04 "l~t?'-:'''' s I ~(l~" NIl,' '0 THIS D[PAlHMENT MADE AWARDS AS SHOWN AAOVE rROM HiE MEDICAl AID FUND NOTIFY THIS DEPARTMENT AT ONC( If fOR MlY RlMON Itl YOUR OPINIOf>l AWARD IS IN ERROR OR CtIARGED TO Htf WRUNG CLASS. ",. '\: ,:;:,\;>::>,::~,;i:,. ,',' '. '.,,:,;>i':,,~:<' ";,,.j..,:'....'. '., ',;.,':,',,'''' ':". I:r,';'\,i" N;i~'(':;'-,:;' '1',,', ,'"." ',~(~;,'i':I';! :::'. :.'L:.,~,' 'C:.' f ,;.",' ::'~';. 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J\O G235326 JEFF~PS(n CCU~TY HIG~~~Y [JCPT CCIJRTHflUSf peRT TC^I\'SENrl "^SH c.fl3t~J :31 :72 STATE OF WASHINGTON DEPARTMENT OF lASOR & INDUSTRIES OLYMPIA, WASHINGTON 98504 THIS OEPARTMENT MAor AWARDS AS SHOWN AIlOVE FROM THE MEDICAL AID FUND NOTIFY THIS DEPARTMENT AT ONCE IF FOH ANY REASON IN YOUR OPINION AWARD IS IN ERROR 011 CHARGED TO THE WRONG CLASS TI -- _il.BlLIIIJ>......lIIIIl ~, rllll'rp_ ....,".. ' .. .... '",," ..,,, - ~ . .. '\ . "~"_''''''-'''-';:'''''"'-''''-'''!' ',~~ ~.."-,,...-..::'t'--"-"'-' 4 ",,' .. ;i .. - , " . ,'..',,: ' ,'..", , '" " l' '" ,'.., .' ',' ", ,,',',.. ,,', ,', ,'.',' " ", '.'",,',.....'/: ',;,; ....': ..' , :... .."...' , " ,", ",:,....." ,: ' ," ',; ',' ," ..', , , '",', ..,' " ,,",' .. ',:, '....,":.. " ,..':......:,.. ..', ," ::'.. ;.., : :....' ,,',',.,', " ,;' ',', ..: ',' ',' .. "..", " " ;,", . ':','.,,'. . ' ',', ,', , ,'.. "," ' '.. ':",'.. , ; , Y..", , ':, " ",,' ",', , ',. . , " ,: ',:, " '.>.. ,',"',.. 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'Ii\ I,.,',:\SH 0PJ6i::l ( "" I "'M NUMB" I r MO "., " , , 1 ~T.(i'E dF1WASH'lNM8i\i01 ,,'~1~"J<"" s, t.OS9RrV 910 DEPARTMENT OF LABOR & INDUSTRIES OLYMPIA, WASHINGTON 9l1S01 THIS DEPARTMENT MAOE AWARDS AS SHOWN ABOVE FROM THE M{DI(Al AID FUNO NOTIFY THIS DfI'ARTMENT AT ONCE IF rOR AN'!' REASON IN YOUR OPINION AWARD IS IN ERIIOR OR CHARGED TO THE WRONG ClASS Q'J. ".:,: '"..,'"" ,": ." ,.", :, ,..,:..'" ,.' " ,',. ",' " :, , ' ~,'. ,,' , ., ' ::': ,"', ",,:, ",';" ",'.' ,,'" ", . , :.... , "c! :':" "..,..:..' .. ,", ' .o," ':.., '.' , ,..,'> ,',', , ',.. ',',',' "~"' ::....;: '\:, .,' ;.."., :.:" ',' ' '..\' '. , , ,',' "', ,:' ',' !.(': " i~' , 'y, ,), . ,.' " '. ".,..,,' , "..:. ','.. , "" ..' :,':, ': '-,':,. :. :...,,',.. ':' " "'.', ',':, '" ',::, 'I::' ',', ' ,..', ',,::" :,:' :',,:'.' :', "', ,,:'.:, ','.' , '; ,', .',', '; :";,' ,;' .',. ;:;,'.... " '..:: ",:: '.. ",:'..: ',.., ": ..,..,: '," " .: .., " '., ,:',:.,:.... . :... ''', ,,:. :,: ....:', ,'" ..' :"", :,'..' ',,',..,: ".': ''/'', ': ..', , , "':,.. ':" . ,'..: " . . "y,.. '., ','..,,', .... ....",.. .'.. ,', " " '",:.':,"'....::, ,,' ";..:, "::",' " " " .. :' , .. .:,' ': "..,,:.': ,.' ..', ,: '" "'," "" , . '. ' " , "..:' ..'.".,. ", ' ". , ,,'\ .', ,':...., " , " ..: " , . ',,' " ,'" iJ , :' ': .,' '. .,' """ ,....,'.' ,.',.. .., .' ..., '.. ,..' ", '<, :'? :',,1 ,"', ,; ',: I, :' '::';, :,..-:'. '.., '... .', . ....,' ..,.."': .,,":i" , ,..> " ",' . ,.'. ,:." ,: :,:: ..," ':' '..' ' "..' " .,:: :,:', "",:'" :,,;;,,"',: ',;. ',":,,'.. ": '....' ":, , ',' , ",,, ' : r--- --... .. . .. ' -- r illlliW La - -.--.-----..~ - --1IIll ...,..... ::i , ~,: 'p ,ii, L;;",:,~ ~ ACCIDENT CV.JM"'AJ~ER ;f:",:., Employer Mu'l Complete " .port bV Filling in and SignIng Emplov.r'. S.dion e.IOQ". Dopartmont ClI Labar and IOdu.lri.., Olympia" Walhlngton 9850' - '~~.EMPimE';'S'lA'B:&.N1~FtRM'NUMiiE;-"" ~"T/EiEPHONENUMifR-.'-----~~'--~-wq~MAtlSSOOALSECUiilNNO:"- , ',.., , . '" ..,..4,3h6CJ:O,.:t,.......""...h___,__J._ ..}...~?-.?~L_, __. lJ ~~-62-O~213 ._'_~,' I EMPLOYER'S fiRM NAME "'.. .. .. ADDRESS .... "', ...." .. ZIP COOf .. . Jefferson, Coun~_.Department of HighVlliYB - Courthouse - Port. 'l'Qlmsend. Washington 98368 -:;;~~;~t,t::::--.~-,...,.-_._--_._~-~._. -t::-:'-==WORKMAN.f.MiilOYfDlN.WH\CH~N IF wo~i=iNANaAL:", .SOLE~1i ',....J !m....F ~'gin' .,.,.,..,' ,\;, " ;Co, NSTR.lICJION,IOPERAIION,liiE'PA"IIlPNl,A lINC!tEDBO,Af INTEREST IN BUSINESS, PLEASE PAIlINfll ,.~ 0.. . .. e.....on ..~. .. L L' ,': X:.. U; L 0} .. i CHECK APPROPRIATE CIRCLE. CORP. OFFICER f';' WAS WORKMAN EN AG-EDi~----:-YEs-r,jo-rSHiFT-Houjjs~" --/OIOAcaoE'Nioccull -YESNoTif NO, WHE~E1 '" . -- .~~~~~~it~'~~~~~1,:':. ....~~L~~~:..~ _:~~____l~~_~_~~!~~:.~~_~ '.,:) t . "iN-'WHAT CLASS WILL THE ">. IF NOT TO 8E REPORTED, (jIVE REASON WORKMAN'S HOURS BE REPORUD? '-'~~...,.;;..:.-. '. , "~"""--::'"I""'~~-':"';''' F-<7~ENJ' B~YOU'i . _' EN.'I~IUR_EP' ,:l,E~Pl~~~Il'~ ~U~INESS:. . f ! I ;'.: ,:., t . ',', '" :l~~A~l~~~~~~.~, ~~,)~,,~.tfN.e ~~~,lOfNl IXCURR[ .~-1!.:~.L-_.-.-~.__:~.!.-.__.~. 'EHi(~W~AjtM;'N:t.~IEOI";:Y~N-';~PLiC~8U~. _=.J'~'IIJN~' A '.- - '. . . - WORKMAN E Y~S ,.~e: IF YES, ATlACH l._"...8Q!UlHP~7...PQ-"'O!.t/'1~UlOl.t"'ij:WMI,._.._ _P.".ll: _-1!!2!JI' l. .... . '~.ieft,~,:Wlii\te,i.."-~:':::,__L.._ ".::".... "',-,761r:TI" ,9",-23'" ~. 30, . .9.::2.3=Th_9~=-71_ ~::-:::;l10 WHOM REPORIED POStIlON ~~6~~N~~E~iOC~AlM7 Y~,:. ~ ~ IF YES, WHY? . - 09-"'2i..,,7J.:...L.. a.ij _..,L._.f!jWalJ,y"Bowrnan.,Su1J\;......___ _. '-':.' x, lAllA'" 'EIlER' NECE.~.". HOW DID AC51DENr HI\~" _ st~<!....~:!. ~~C!t _~~yistedh.i8 book ADDIlESS , .'Iz, c. E " -. Jo!m .Preddck .Edtlinlrt.O~ Box 35~ - -- ,...._.......Chimac1.llll,--Wa .....J..9i32;~ " DATE INJUR[O llo"rc rlllsr 11lEA M[it( - I I~Slg~:E~~ll~~J~~OlV[O, _.9-2J,,71. _h_ __9-2J-,7~ h ,(ew, ROC"' 0' "" ) Patient.stepped,off-truck_and_twisted_back.--_" \ HlS,IORY 1(01"1.1 ~-,lb,:\~~~~~~~~~',l,,,,,-~, e~umbar, muschapasm, . Lascqus, 'Nac~~:~'~~:~:~:~::~~~~~:~~~"~:e~te' I-fJ~t.tvtJ.._..patient'in ,. ""talgic, posi tion to left..eide"h-Io{arked- 8collo8ie--of'"epine.-----._ lie c'#.Ufl\~~,~Tfoal..atrain.complicat.od" by.. su blUX&t.iol1,.of"5th-lumbar"vertabl'a'&-deter:l.oration'"r~ g 5th lumbar d.1ec., .. III ~ ~ ;;; ~, ... 9~tmff\at,1c...adJuBtm.ent. n .__".._'_....._...~.,...".~..., '." _...^.".,.._'''._'''_..~_~_.__~___._....;..._~___~_ No apparent oeeeouo pathology. marked t.lWul.ing or 5th lumbar disc. .Left. superi;r t~=~Mw.;.~f'-5th ",,l. UlDRl1., , rl';llP~f,lIll';IPJlP!tMIS., "., BalfJlrll,olumMnifl1iRlloeie..---.-....----.--'---- Pllf'vI(XJS INIUIlY TO .&1l(AJ , IX,:". TQ(AlrD IIY ANYONE FOA: ~. ,.,: . . _._~~..~~-- .".__.._,~"~,~_.... ~~.~, .L~.~~.S.~,:,!!>!=?~ "S~l~.~ ~..~~~!II_~~.._..." ... ",_::_,:.George_Steverta-th el-a.pist ._____._..., ._:.; _.:.~~ 5 '~.;~;[-~~';~~:f~~Sl;';~h'-""'" yE,~.'. ..r'~?' ..... I DISEASI! OF 'HE AIl[A INJuaCD? "'. '::r',~ i 1"~~';1o:;PiIAi'~A,i6;~ -rcr6u;lifD."'N'"".~^ll;O\PjU,~ ~ nona. r~~"~~'i;;;~-~~'~~~'~-;ll'( (H Yf~ NO i ESTIMATED TIME lOSS ~ ~.~~~.~.~I.~.'_?,..I~I.\.lf~~,I~~ ,~__ .:_ OUE,T~INJURX,. ~ I "lJ[N)lfG Hn'SICIAN (PIlAU "~tNl 011 TYPE YQji t-tA!,tE 1..7'1) AO()ilf5S J I Juo" Carlson D'~C' lJ3I, LalfrCllco St Pt.. - I (" IU'l ) (\ " ~QlP. EMPLOYER'S COPY 11 \ EMl'lOvrlb COMPl[T[ PARr '. "EMPl4y~1., tAl.OAI... IMMWIAlny MID MAil ItI[ ORIGINAl TO Tur OEPARTMEr-H aF li\60R,. INDUSTRIES. OYLMPIA. WASH 98501. WE PREfER 10 HAVE "r.MPlOYER'S REPORT" !lUORE TAKING ACUON ON CLAIM. 'I~WliL Ti1IS'ORANY'''OIHER ,..."...~ .... .-.. , PIiF.[llISIING CONO,IlI,ON COM, ',LIC4Tf ,TPF.AIM(Nl 011 J.lffUO llECOV[ll'(/ AODPfS~ yrs" -~--'llls-co~iiIO-,N 'PjAGNO-S[O-(~'_.-PAOOAiii:Y-pos51Ili.v.~, i ':::"~'. ..j ;~JI~~~~bgrC.RlII(Dl \..fe' Ci . <:'~ 'j'~ --. '."....'h.., .... _.::]~~p'~'..~~=' r~;l~"~~'[~'E tal ANY'"' -, YES NO UNO(fUlMINfD 2. DAYS!. "fll_~~,N(NT _O~SA~I~I.lY? " .. ~- M)rHH\~ . . , . f'l"'rfl coor -'I"lr~r~',;jor"f1 ;~;~;'('A--'- Towas,o'An"d, Wa, ..,L 9f!368..L ::l8li-0322".._. ! f'AYII. ACCOUNt f".A.IMM~~'. , lust (ll"f PAYU ACC;OUNI .~J"~./IfM ~IAMr, , Q-21.-=2l...- \t. IUlltf'V. :).101 ~- l:_'_~", ...,_,.1"" ; .. ~ _.',."' _.,. ~ .," .'\ ..:.,....,.~~w<,:." '" ",';,;" ' ,',,' i HI IIIII~IIIIIIIIIII ~II j if! 1I11 III I' 1I11I1I11I I i II .l.U.I. .l.U.IJIJ .1.1.1.. .1.. .1.1.. 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'. .... . ';. .,: '. ." "':0::'> ." ,',,': , ..'.',"" "',:"",.,q :'~ ::": .,,:, ,.-. '\ :~ 5Uf'ERYISO~ 01-' IU!JIJ!i 1 h'1t..l It/SURAtKE DEPAR1M[Nf OF l/dl(H firm INDUSTRIES STAll Of '/',\SHING10H , :::', 'c' , ," .: ,,; " ORDER ALLOWING AND CLOSING cl/,'lr:~ FOR MEOICAl TREATMENl ONLY .. " ,', ll:'I:"".':\''''~ - ..- ::.,,"'.'::-:--~-~,:.',,:~:;:~'~~::,: I hlll)' I\! " j dr, d rI I ..': ',.' I' 1",.,1,,,,,\ " Il",,'hl ,I .~~J ':~ ~_" I ~ ~)_~... t',! ~_~~~2.: ~~ l_1 ~::~~~ ~~.:~_.J ANY PROTEST OR REQUEST FOR R[CGnSjrJ['u\lin~l (JF HHS ORDER MUST BE MADE IN WRITlNG TO THE OEPARTMENT OF lM:.OR AtW ItlOU',rf.!IFS In OlYMPIA WITHIN 60 DAYS. A FURTHER APPEALABLE ORDER Wilt fQllO'h SUCH ," Pf.OUE"T MH ,\PP~t.l FROM THIS ORDER MUST BE MADE TO THE BOARD OF INDlJSHi'I/,l ItJ'oIJ'i/dl(lC- ,\I'i'rtd,> OI.YMPIA WITHIN 60 DAYS FIiOM THE OA TE THIS QROfR 1$ COMMlJrHc.t,1 fI) TO 1m t',\l,>llf:-.. OR lHE 5f~Mt:: SHAll BECOME FINAL. , , .. .' " :"..:', ," ." .',', .. " ',' ' ..'.' ,.....', .. , ;,,' J" ',,' ,', I''''':' ",,:..,..,. ,',:' ',..;', '..' "..,: ,..': . ... ,:~,,:"':/"',," ': ,':' ':'" .:.., .,' " :,. ".",' '.', . '.:.", '\ .;; , , ','" ',', " ' ,. '....,":.. ! ,"..' :," :. ..., i "....". ,':;':"'." ' :", ".' , ...' ::'...'..'" ': ,".':', ," ,.:' '.. '.: . ...,..', .'" ': ". ",' ",.' ,."'.'.',,.', ',', . ....", ',.: ". ,,'.. '.. '" ,:;, "; : ::. ::', ,.' ';',' '.. ,', ' . :i ,'.., ' ;, ...' ,....; ''', ,', " '., /"""""'..<;., ,,' ',: ,:" ': . ,:.."...'..,'...'.','.'. .,' . '.. ' , " .. ..:": ", , ' , :: , ~ ,: ;: .. , : " ::... , . ....,,:' " ' '..,., ' , '"..,:..:, ," .,,':: ':;',.....'::' ..... '..' , .:..',' ,;:' " ,"" ..' ..,'. ..' ,:.;,', .': .':,.', :', " "":.,' ," ',ii,,', ': ',' ... ',.. -,':''- ,,' ,:',...:' " ".. :',,":.. : ".. ,.', , " :,' " . ..:' , '.:....',', '.,", ,:'. ' " ,,:.. ", ,'. ,":." ,': ".' : '. .'..." ", ,...:..,' ." :". " '...., .':' '. . .,"".. ..... ,..' , ..' '" ',.,' '/': .' ,..,,',,' ',...-,..',:.: ','. ':' " :,'", ." ',",' > ,'.., . " ,,' "", :' ';'i">,' ". : .... ' , ,.,,"". .' :,:", " ,'. ','::..,..., ,,',", .. , ' .'.. ". '. .,: ,/ ..." " ' . ',: :':", ',' '::',','" .' . ,,"'.' ,."!': .'......' ...' ';;','.. '.. ' ", '.",'....:, ,,:,: ...", ' '.. ".:,,', '" '",:. ,"..' :,:.", " ," :::: , '.' :',. :it!;.:; ; .' .j- j, " ':: ," "" ,'.: :~'~;, "' ! ':r ;'?~.~ '1"',':', ";..",..,.'.' :,<' ..', "~::i l'>~'\',' " "i;;;'}:'i]'.' ":,::'~E:;,:' ".."", . r-- \ , . . .' '.. .-.- ~.~.... -' _. .-.~.. .,', - J ,.' . '7 \ ,,'. . .~.... I,", v':..,/ ~~"-~" "_'v .;, -.' .', ~ , '1" '\ ' . ~ ',,- ,1"", '''., . __o",_1I\'NI .... -1.-......" _ ,_.. "., ~.' '.' - . :, "; ":, ... ~- " -. " '.' :, - ( ,. '1~. ':_ . ? HIGHEST CON~UTIVE . TWENTY-FOUR MONTHS COMPENSATION Please indicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Month/ Hours Includable Month/ Hours Includable Year Worked Compensation Year Worked Compensation 01/84 ~ $4,904.71 .Q.l.li!.L llL- $ 1 q71 S2 ~ ~ 1,725.76 1l.L.ll.... lll..- 2,203.36 ~ ~ 2,065.40 !.UJLL. ID-- 2,063.78 ~ .ill- 1,979.08 ~ !ll..- 1.894.44 09/83 1.12.- 2.141..06 !!.9..Ln- ...l.!:L- 2 ,014.18 08/83 ll.L- 2.100.08 !!.Wl..L ~ 2 743.84 07/83 .!..!L- 1,834.48 ~ l.2..L- 2,203.86 06/83 ~ 1,979.60 ~ !l.2....- 2.190.38 05/83 .!.E..L- 1,981.76 05/82 l2.L- 1.990. 76 04/83 .li2..- 1.807.83 Q!!.L.l!.L !..Z!:L.- 2.021.82 03/83 ...2.1..-.. 1,803.20 !!li.ll..L .2..2.- 1,792.68 02/83 2,055.68 02/82 ~ 2.058.68 Total of Compensation Listed Above $ 51,527.94 ------------------------------------------------------------------ ~ No 1. Does your agency report on a calendar month? .JL 2. Does your agency use lag pay? L 3. Does your agency use pay periods? ..1L 4. If other than above, please explain. * * ~ * . * * * * * * * * * * * * * * * * * . * . * * * * . * * * PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT * . . . . * . * . . * . * * * * * . . * . * . . . . * * . . * Return to: Department of Retirement Systems 1025 East Union Olympia, WA 98504 Phone No. (206) 753-5283 SCAN 234-5283 Agency i ~ I j '" ~ ~ ! .. ~I , "'l j~ 1.d; !~ \..9 v II ~ilB " >- 0 i~ u 5 lIS it- ' .. ~ jl; ~ ~ ~ z j i5 '" I~ 0 '" ~ ~ < a 'S ::; !< I~ \'6 III ~ v !i I::: 12 ~ > i~ I '" 3 ~ Il ,~ ~~ il il v Co ,0 '" :0 il ;; j~ e. 0 ~] ~ o~ '" C 0 i fa =~ :J 'il ;; ~i ,!l .!l ~ ~ ~o :!! 0 0 1Il~ ~ 0 0 0 ~~ 1;>'5 aJ~ Z 0: S~ ..Ill 0 '" :s ra ~ E: :I: SE lIlZ -< .. !Z! ~ ::; E~ !ij -< 0 ,:J "'5 ~ &: ~. lO r.:l Q 0 8.5 Ei rJJ ~ il "e lOr" 0 if.: ..", ~ It: ~ -e~ o~o ~ ~ ~~ .. S r.:l fgN is S Q _0 :l1 .... III fii: ~c ~ < EO :I: ~; ",:3 Z S 00 =.2 "'! o 0 ~:6 .. cd ~~ . ~ ~ ~~ ~~ 0 ;j ~ij i ~J! 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" ~ ~I -r -- ~. !--.!-- - i- -" , .. ~ I - i I-~" .. 1---1-- .--: -;-' 1-- I ~ ' I , i=i=n i .+ II ." f---r- -" - '1- 'sii" -r- -- ---. 1---+-1-1-- --f-- - - 'r '-fe- . ----j-- - "i-- '-1--' r- I \ - .. -I-- -'--+ ..,~ -- _-+- __ ,!-. \u -,-, - . " -1-1--- i '+ I- T""'f-;I-. ~I I p= ~ =1= "f "== ==,L ' ',u i 'I 1 j, ~ =F~i::Yi" -~ f-.-:::t::i=--=::.1= - != -j:::::: = - ~ +-I-~-- ;-+=-,...-- --- "...::~---. .....:...::~,"-:T.= --I-=t::t=-=---- - .~ i= --- - tb=r~i==,=tl=+,-H==-- ~= ~ ~ ...'='-=~.n~...--JJJ:.1_- ,.~L~r:~::::- ==~i'-" --1--'. ___- .=~~ r~"-= ~4=' ="j=t"ttd='=f~=H='I=f='"= = '"~r= -:+"-F='F= - -....,::.: ::::I=::I==~=',:r-:~:~rH.:: =~~T=~~~f'::::j:=i::,= ~:: ::::::,:::::: ::::l~:'--'" -- --- I 'i~fl~i~[rmflffl~",~~:: . .~ -,' j ~ Ii +~ I'll I I ~, :< ;;;croo1'"i ~=i~l:ii:q~' ,':!:-r~-r~l~Tiii;;l~,ji:l-(~'!iGher~j,~, "~ 'g- --I i; ~ ~ " 1--1- I-- - , I-- .. ...... :', . '('..~"./-: ',,, .,~." d 11"', --.....,.. ''''.,.. "'" _ III _~_ ",.~--...- -.IIIllj ..' .. "".. .", ',:' ,,' >>'",',:' , " ' . ',,' "" .o..,., " ',' "."',.",:'.: """,.,.'u", ' " ' ,"" ,: "....:': :' '" ':", '.,,' : " ' , , , " " ',: '" '-,'-':," ,,".' ' .. "'" .. "':: :" .', ::' . ":>, , ,',: ,,', > ' .' ' ,,' ','."',',',: ," ,', ','",',' ""'" ' " '" ,", ' :' ,"; , '>", ", ',':'.:. ".,',,',' ',,' .." ",' ,'.', ,,'" "., . .. ',::..'.' ,'". '.; ,: ',.' ..:" "," " ;',' ..", ,,' ,': :, , " , .' ',' ,,',",'" '" , ,..,',....,:.::,,".',',',',', ":",, ,.,,' ,: :<: ':' ','" .., , '" , " ' , :" , ." , , . ,',', ' ' " ":.' " " ,,'" " ",:." " >"', ,,'.. .,',:.' ...':, . .. ..', ", ;. ':' ",,' ,', < ":,' '~~~:~:',:;~: ,. " '~"..'" , ',' , ,''', ;'" ", ., ",/; ",'.. ~' t,( . ':':':.. .. , " ..',:' ,: , '~ "',' ,,' "t ... OEPARTMENT OF LABOR & IAsTRIES ~ OLYMPIA, WASHINGTON 9if'1 ~ ~ ~ .. (0] ~ flRSfClA55 MAIL I US f>OSrACE PAID 1 0' P(h',IIr-<O '" ~ 1BR.t.1:f:m.j~.Tl;l.J.1S.11.1;U}.I.IiI:t ~;,jIl"~~"".I.I~iIIillKIII a4IM"tjTSH.."" I RIEC'ic JA1::S ,~ J'C,=C,,:), C"'''HY HIGHWAY "..0.,' - 1'0"""" "",., ~ I ~'o"J - I U ,H ;" u' ,: (ODI H:.4::7f'"t 4.~c.n-01 =.:: :I'I~r T=,I.'~Jr'[."u YA":H tlAlfl"IUUD I DUl,"Ol!"u/<, CUh ~~-23-7; n0-0~-7; 15-1 DEDT 9B.~r.~. ',. " ..:' " , ,,~ .. ",,: " : ',', ':,;)', o.,'; '" ;' :, :',''' .... ',' .',' ,:,:' " .' t ':1 ';'1 .... , .' ,. ,....' , , ,'.. :' ,',',:',:'." ...,.'.. 1: "a " .. . "," '"....,' ':' <: " .. , ' ,'-:, ,,', :, '" 'i',' ::-,. " , ,'.. '.. ,..'" "", " '" ",' ;': " :>'..' :' ,","",' : , " '......," '," ,,,: ' ,...,," ",": I' '-: ..,...... "," ',":" .. ',',' ':; ':;" ..' ,'" ",: ' '. '"",,, " , ';'" " ..:i'," '.. ,",,' " '" ':.' ".,>.;< " , ,,',.'''> ,,', '., ,."~."i 'J :::' ',.. ,: ',",":. :"'<',1 ", ::i' ',' :;, ..' .,.' , .' ,.',;" '. J,: , '. '. ' ,,' ,:,'..,', , . ' , " ...., .' ,: ~' , , :, ," , "':" ',"",:' .' '."',,, " ,;' ..',' '" "."" ,...."..,.. ' '..',' , " ' " " ':..',:,.. ",....' ':'" ".. '.. ..,'.., ' " "', :' ",":',:' .',,:',.,.',' ":, i.. ",'" ' ," I ' ",,.,...!,': ,.,'....', " :,:::",,' "'..",,, ',',,: '",."i"i"., ',..,':..', , '."" ':.: , ' ::::,'" ';:. ,'" ": ,,';:' , ' , '. ;1 ,; :' .),; ~'l :" ,.I~. :',:: ,\ '.. '''',',;' I, r"'" "'" "",-_....------ .....~-..~. " .. - -.--- Arr-l --~ . I. ,'.. ,<. .'. ' , ' ,I '" '.. .'" , ~ ", . ' ..", I '. I' 1 , loop/. ofL& I copy WORKER: /..1efore compkltlng :;O'crlun bul~'odud oroe!, I FGAl WARNING o~ revMf side of this page. I Top parHan submilled PHYSICIAN: Complete Physician's ReporW'ach lop portion of Original where des'gn~nd submit loDeparl-1 by physician ment oHabor & Industries, Allenrion: Accrcfont Reporl, Claims Section, Olympia, Wo. 98504. Detach Ihe PhY5i~ I Bollom portion submillcd cion'sCapy (3rd copy) for your files and promplly moil the balance of the form 10 the employer (this includes : by employer Ihe ballam portion ot the Original and 011 of the 2nd copy.) l .--------------- l EMPLOYER'S COpy \_\'.,,.,-,.~_.~,"~,,,,":,,,,,~ ",,~ '.~'" ,.., ,-~>..;:tJ-~~" . J":~~-".:,.J;;:..,.._.. r __........ ," _,~l! --", lII!lI1ll~~~^ .. IT ~_'llI l'_H_~~~' ..v. '...."I~...~.l....... ....,~ :.:. .'... ~~ "-ff''';:'"/.'' .{......f~.. . -, .~, - "~,d" .... .., .,.." ...m - ._-, ~" - \ \..~ .oI:..':r.----:"...:;t.~ <.,.....:.. ~~ "';.,.:~...-"t~...-"!r~~.:~~. . . 'STAn 'orw4$HlNOfoN . Dtportni.nluf Laborondlndv I.. .pa':J;:~~~ ~oJ:~~~~ ~~~:~~~== ~~~~~~ ~:$nh~"s;~:~n99B~~:. 'AC~::~::'~RBI:t:~~:~=c~.~~lt~~~~11 at Onu fa ~ . '~~~_":"'';-'--'-'-''-'''--AoDmf-\---._-~-'-'''- .--......-.---,..--+... -"i:'II'Y&-SIAii'"-''-'''~'-''"--'-'-'---'-''' "-...... -ilpcooi -..-.. _,. .',_.-!.., ':!ferSOE,..<::~"E9.'-.IQ" !!hW~lJ~)?~-,-!_._"Qo..Il,!J;.~~"use --........--,'-..J'."--~,.~.~~Il."-~ll'!'...w,l'''~.I1''-- ,,2?~6...?........_..,.__ EMPlOYfllSBtJSINfSSl5TAIE IYPEOR NATURE Ofl _ ',"_ _ _ _ _ - '_ [MPtOvWSlUEPItONfNUMBfR _ ~~::~,~",-:-,.,,~,:~,~~:';5i:='r":,~;:eCk:~==~"-"=:':=-D--=r~l~~~~~~;:~::::= ,,'';, -'~~NciW~rl~l~~J:i .. .<~~:-, Nq.lf YE~.S!".lf .W'iIC~,:"'NDGI~E ~In~ " EMPlOYER.$LABa.lt!~. ~I~M ~U1.w1;~ER: . . ~~I't'~l~~E~~IL~,-, '~',:_ . ~ ,. :~=~'.~~~~~~~~6'fu'Njji~~:6~.AjilM:'!!if=-,,:::poo;iiiOilOCAI'iiN;;NCWO;NiiCOUNii:wH;ii;~~'~:jOCCUiiiD ....'.'.-..]-sTA1E ~~~~~~-~~;~~!".,-jQ:~.:.~-OTHER--. ~.' cONS~i~jcrloNlOPE~~~;~lo~IIl~:r#10'HAU~~SEDBOATJ._ Jefferson County, vlash. . 1 ~~RER~~ P:;:~:';:~' i~X ':;)}.; ~',', -~5~!I~~A~!~~, ,;;;; 1[-~~~~"~/_~~/*;'~=~,-1i9::_OO,.,:':=,,-~,_,-,.. ..~, '-D~~/~LI~~~.-:I:~~~~;i[~F,'-,_"ol,I~~,..,I~~E,~~__=====...._.. 9. .lAS10ATEWORKED ~~~'E/!EIUllNfDIOWORK WASEMPlOYEEENGAGEDIN' YES NO SlilflHOURS f OOYOUOUESllON' YES NO IF YES, WHY? ~ _.~:/19~~.-n~_~ m:_:.o.~~_,_ ,_ _~~~~~t~J~~~~~:O? ]]<?' ~~':~_ _~:~:~_?__n___L~_~~~_~~~.,.,L.~~_?_~;~~,~.,,_..~f_.j,_,E~~~~~C?",',',t_.. WlllVQUPAY1HlSEMPlOYEE YES NO IF YES EXPLAIN [t'HEREMPlOYEE.S OI[tK "'PPiOl'l1"'U CiAO.E, t~~~~l:e'!R~O~~~~BILlTV? "?S' ilj} Kept on Sick' Leave' ~~6Eo~E~~I~EI $ 4.23 PER ~;~ll?j/ ~~~K , M~?>.'H :~;~[~:AG' I -- =I~],t.~;~';-==rAMESCH"U;ro:~OFF ~:.~~~=~'~.=~~=~:=~===~-=~~== . 51Art fMPl.OYU rm Of( WAS NAMEMACHIN[RY~~_~~~.!~7_1i~~~~~~_~.de 'o_f_~ead _while_.cut!:J~" :fa!len.'.'~___ SHOUlO BE NAMEO. NAME ,.:;,' .."..,.... ','".,'.~.E.=-e of.!......h!gh ,power _~--'--'--'-_________~ l.tlll.c.;.'.oi-;;\ :"tl.~'::~r(;~~'.~1;:"~1~:~ t.rol1t";;';;~'i-~~d-'"rx:.;;;;,;;,;,;,,,''' ".'."'" "'~,..."","...,.._.._-,'....m_"'...._..._...._...._-...cc ,...',',', .. Wlltl,hod, .&., ~dre,,"", OO,I,.j,nj ...X..t.anua.7o.xDid.DI..L,_..." __'....._..., "'........._...'...........__....'__..._'..__.___,,'.:..._ :'. .;;SfWltprfl'~',':')::':.' ,U$. :', NO ../ ~:~~rol'll~'l~~~rf~Ji.~, ". vrs,..o IfYlU)(/'LAIN' , ',': '': ,~~i~~.~~~~......'~~_.~q_ ~.~~~~.~~.~,~~~~..~~,tj~.t.~~'_~__ \ ~ ~,':.~;~~;~~~:~:.:::~,..';,.:~~r~:~. .~OO'~..:,..';"',.;\,' ',o,i,-'I.,'0,'o,' ';I~.~T".:M"'-""';:"."" IS I COtJIO Tllf CONOIIIOl'l Vf5 o ... J'",. ...,..... ......-....... ;,..".",,'. .' ~':"""." "X' '"--I''.~,;,.;~'''''"''~''' ~,',~, ,~,~, .,'"_.,l,.'.~~I'..;,,_(SVl~",,'~,.,I,,D.:.".. ,.,'"'.'..~~,.,...:,.":-..','.',.,",,',,.;,,.,,'I...~.-' .,~"....,,,...~~_........- Vi Dtsr:'SlOfIlI(.UfAINA.I"O~ ft.:1 .J( : .~~~,~~f~~l".~~~~~.~:~I~~.~".".... . V'''" "'_.... ~ ~~'A-.~" ~ "'~_.'W~'.1iitt)".'_.'-".-T.N:A:;.li'o.' ij()l),'.l d I ~j (;~~~ OJI ~i~t'. i . _ ~. I S ; ~~;':~;;;'~,:::.:::'; ;:,: 1:! ESTb~W81m'JA~OSS >>-+ ".,~: ~:~~;:,'.~::";:':"",, . '" ,~~ ., u"":;;;'"1O A.1""IJNon4i.\I't4'1~'''''' 'I'\i.!.( 'tlN! (WI'II"( Y()lJ'IIA~f ,l,NO.OflIlU I AIII)~111 I/lP(OOf) fflf""OI~, i~.IJMftfjl- 113'~'il'f~ ~troG~ ,Port Townaan~'>A,~ll1Ohinstonl ~l)?,~C(""",:,,?,.~~-J300 , /IlAff..::- 1...._ '~~2'bll.2~,j.;y"l~:'...~f~JtjI"'J~RIIl"AM'1 rAGE ,,~.,,2 : If . '.. I . b'::t:I;~:~C\~o'.(,(~'''O' " ."I(I"'UI;l'"'ll('.... ' EMPLOYER'S COPY- 'M'lOYtll COMf'l(IE PAllr I, [Mf'lQYfIl S PCrofilT. IMMED,ATHY ANOM.AtL tHE OP!GtNAl fa tHE Orf'Ap.IM(Nl OF I^RQQ,\ IN()US1PI[~, Ol YMI'IA, WA5tt. Qfl~O.1 WE pl::'rru 10 HAVE EM. J110V[P !.1\l(POIH R(rop( rAKIN(j ACT IOU ON ClAIM r-'" ",..,' ,..~,_.-..,....~- l' - ,-",." .. ,-" IF!\! " II ~;4:Cl - .--- --_ll.__l--J!ll "' _'!!Jl!11l!Ul!iI:. ' ,nlll =" ~~~ 11__ -~,_.~~ --~~--.: ""'.",; .\' ',~,\~~ ..:_;.r.'...,...._~":":i; - ""'--""'" ---- " _Ill_ 1 - fill -,--- Jm :J'tlteTU.l8 to.totcl IU liAS WORKMAN HAD 'fl PI!fVlOUS INJU.... 10 .ur..., t~ '.i' U-wO"IiiMAfTNrA ll[rN 11lf"'[D BY "''''''ON[ fOR PJlf;YNl Oft SIMIlAR COt-llIliOp.,Q ..,n:-FJO;II"'ylf.'""b:l'i:AJFi--'--"'--- .:ex: IS 'HlAf, AN"I' Pff(-Oll\llr-<<:; "'Vtr-f jrrTU~"Oiii('------_PYB--~.lO-~lIS Ce,"lr-()1Il0N CIACN(fSI:D-.,n-PIlCflA8lY POSSlot't' OIUAU 01 lU[....tA It-OUIU>> _~'\ Z. ~:ur~t~~~'t;.';bO~f~~""r z :~~~~l6~c"\[ol z I~. tt'!J '~=:~:~":~Ll.iO' ~-=~~__ ~~" __~-=.==. --~-~~ ~~~~=-~=:. J 1. COO~ :6'~H~:~~_~~~' . _ ~3 ~U ESTlMAnO nME lOSS DUE TO. fNJU~, ,'" DAYS ;~t~~;;~~~N~~f~~ ,t1~ ;;~~~I~;:tu"~.~~;AZiJ~'~;;~o~~;;'~~;:;'~~~~~:~'~:T~~rr;:~:::::.~.~:L~;;;(R Ibrvo .,,"'" , 'OArf. PAYt[ ACCOUt~l NJMIlU ,;; ll/14/?O 1.58'1 EMPLOYER'S COPY PAGE f.Wl0Yl:1b COMPlETE PART I,. "EMPlOYl:Il'S REPORT," IMMEDIAIElY Ai'D MAR IIIE OR'GINAl 10 TliE DEPARlMENT 01' LABOR & Ii'DUSTRIES. OYIMPIA. WASH,9B50I. WF PREFER 10 liAVE "EMPlOYEIl'S REPORr' BEfORE lAKING ACTION ON CLAIM. 2 1.1". Ift1JI"'I(V. J/IIIt' .'-" ",.j<,.,::,.._"-~,-",-,__~__..,,",,._.......___~~'~f)" ~.I'.. .:~I"",)..':- ":,.'.."'1...."'\:"\\ ;,; :3 " .. 'R - '" ~ oS oS .. ]- 8 '" ".. ',: , ", ,!.. " IIIII~IIIIIIIII III'~ II II J j j j j j i j I Ii j 1II1II j j~ UJJJ~ ~LU0 JJJ0 JJJ~ JJ0 0 ~ ~ ~ ~ i~[11 II1I I I 111111 II ~j- tJ :;t" ,,~~ ~ll- ,,'" :~ " o ~ .. -:S w a (l) (l)CI) O)C)CI:l(l)C)Q)C)CI:lOlCl'l CDCl)O)O)Q) C)0)Ct.lC)CJ)Cl\(l) 8 ~ rJ4>-........ ....- -.... :~ E; .5l;> ~" ~ ~" ~'~",:'j, g ~ Co>t-' ..B . ~'.'~ (J ,,-, ;;:-' '" [:i',:;: cn~ Co': ,.tj 00 'j; :',g ~,',,~ g .. ~._"C liI>.r:I o:Pl o..o~ ~""~ ~~~ ~.:~ ~:ll< .:_"....."'~ f:t , !;!,',..~ Co> " ~,,',.~ r ~l:; it Ill.,..,~ ~~ ~ll :i E] ;.~ ~:J.l en ""Q.I 'E ..' ": t: r:j; I" oS a ,,::!!l '.,,-r'~, ~ ,\ ""... 2 ..E !2 J '1 i !~ ~ ~ f~ i ! J' I [, I ~ ---r./NI..'..!"!..,...,"'.. ~I::!~ !:l1;!;1~ :;! ~I~I~I:? <1111 nl'"I~~1 ~~-- ~ C) C) C) CI:l Cl) C) C) C) (:) CI'l (:) CI'l CI:l C) 0) C) ~ CI:l CI'l C) C) (:) Cl) Cl) CI'l ~.... -- -- ~1;> ~ ill d ::l I , :', '~ " !;b ~ ~ s'" g;a ~ u ~~ ~ u ~ ~' .~ ~ .'01 7/'" > ~ ~ ~.~ U o. ~ 5''<: ffl S ~ ~ =~ -< 0.. ~ IV s.. ~ ~ ~........ o ~ ~ ..,... I ~ i~~ ~ U 1i...L ffl .~ -5 '\ u qj , ::l ~ '" " 0 ::> '~:J p.. Po'p" S 13 8 z ~:M Sl :".l'l'l! ~ u ~5 5 I~ ~ '" !-< ~ .. o t:l o l ~ I ~ It>, ! ~ ~~ ]~ "'il '8< "k * (j " ~ 1-'-- I ~ J~ ii ~ i ~ '8 II II ~ o ... . . , ',.1/'. -""il - ~. - - ~ ' ". ' ' ~ ,',.... ,'., ~ . ,', "'''-... - ~Rl!llllll :r~.'..,:::'; ;.,:,;i"/:' HIGHEST CONSECUTIVE TWENTY-FOUR MONTHS COMPENSATION Please indicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Monthl ~ Hours Worked Includable Compensation Monthl Year Hours Worked Includable Compensation $ $ Total of Compensation Listed Above $ Yes No l. Does your agency report on a calendar month? 2. Does your agency use lag pay? 3. Does your agency use pay periods? 4. If other than above, please explain. . * * * * * .. . . .. * * * * * .. * . .. * * * .. .. * * * * .. * .. * .. PLEASE RETURN AS SOON AS POSSIBLE TO EKPI~l)ITE MEMBER'S RETIREMENT . * .. .. .. * * . . * * * * * * .. * .. .. * .~ 1( 'Ie * * * "., * * * * * .. Return to: Department of Retirement Systems 1025 East Union Olympia, WA 98504 Phone NO. (206) 753-5283 SCAN 234-5283 Certifiod by Agency . ' > .M ",",H,'~" "'...... ~' OVEHBER ,g" ~~ ^ 5OOAl~ THIRD PARTY LIABILITY EMPLOYER/EMPLOYEE MEDICAL INSUJ.:ANCE QUESTIONNAIRE b. 1985 EMPLOYEE POTTER ... SSN BIRTHDATE TYPE Z U5b-Qg-89UB EMPLOYER , JEF'F'ERSOfl COUNTY 10 NUMBER J 9QS07710 :/ 11f'," , /1/ /,jj)(rlf f /l aUESTIONNAIRE CONTACT PERSON (~O( 1.3J',j=-.;J.. /(./ AREA C DE/TELEPHONE NUMBER COURTHOUSE L PORl TOIINSEflD I/A 983bl!..l DEPENDENT BIRlliDA TE TB POTlER....OHN T 08/10/'17 B POTTER....O A 04/01lSQ B POTTER....EFF'ERY 03/08/72 B POlTER.SHANE 04/03'74 9 CHECK BOX IF NO OEPENDeNT COVERAGE [2g COVERAGE EFFECTIVE FROM N / p, TO FROM TO FROM._~.._--3'O FROM TO FROM TO FROM TO -------------------------- 1. NAME AND ADDRESS OF INSURANCE COMPANY ORUNION TYPES OF COVERAGE CHECK ONE OR MORE NAME PHONE 71p' _ DENTAL _ IN-PATIENT HOSPITAL _ OUT-PATIENT HOSPITAL _ PHYSICIAN _ DRUG - NURSING HOME (SNF,ICF) _ VISION - OlliER MED. (AMBULANCE, SUPPLIES, PHYSICAL lliERAPY, fHIROPRACTIC, ETC.) MEMBERSHip NUMBER . ADDRESS POLICY GROUP NUMBER --------------...;.---------------------------------- 2. INSURANCE COMPANY OR UNION TYPES OF COVERAGE CHECK ONE OR MORE NAME PHONE 71P' DENTAL IN-PATIENT HOSPITAL OUT-PATIENT HOSPITAL PHYSICIAN DRUG NURSING HOME (SNF, ICF) VISION OlliER MED. (AMBULANCE, SUPPLIES, PHYSICAL lliERAPY, CHIROPRACtiC, ETC,) . ' MEMBERSHIP NUMBER ADDRESS POLICY GROUP NUMBER II' auesnONs PLEAse CALL l'llOO.ee2.S1311 OSHum ("IU ItITURN TO: MEDICAL RECOVERY MS HA-Il, p,o, BOXIl2l'oS OLYMPIA. WI; Il9504 ....-l(iJf,~.}i!!D'-' pi'vi.~: L(,oc.l(' ,'-:;((~(JI ,"".~'.,1/1)/LV.~:Vi":-,)LI.IL~ ',' {Ct. ,t.Cl!/((('~4 D., l{Vl;{ - , ' '{-iJ1\.f... e,CU'J'~ f(uu...l. jO"U '(j /~",,/-..J.I/l,A- u) t..A Le : d. ' tJ .I1J.. 1,(1_01 ';"vO I-r.c:_, ( ~ ' .<. , Vi!...t /,u:--- (t, ty/',U!/l (<.~e....' ~t...i."'ci 7::,II./.- ~ /. N..v / If' }{O{"( I . I,," /tt1 /1~:h i/ ()z.~ - I C J>> . J,"J, ~"th~U/"J /l. U t/ ' Vl../L--V U .~ c7 -'i ~_~_m'.~. ,~~~ . ,..,...__, ..Jll ___IlIll'51l " "--" 11 -q7 ~ ',i,..., .-'~~ -.'-:,~-\"I '_' .~~. ~,i' 'r.'I;.'~ ~ .'~"f; .......- - .illllllfJ._._ - -. ."1.... ~.', 1'. \, I .' ,:...... " ~ _':, :,,~ f:. ff' nET GEMPLOYE~'S FINAL COMPENSATldllkepORT ~~ Mo n thl flours Includable Honthl Hours Includable ~ ~ Compensation ~ ~ Compensation 05/80 1-1.428.08 _05/81 1.709,76 06/80 1,6G2.02 06/81 1 ;969.99 -.O.ZL8.Q 1.532.86 _ 07/81 1.871. 79 08/80 1.763.73 08/81 -2,950.35 09/80 1,634,72 09/81 1,86~.88 10/80 '1.494.72 10/81 1,660,66 ...JJ.L.aQ 1 ,563.04 11/81 1,866.88 12/80 1,607.98 12/81 1 ,968.44 ~ 1 .683.53 01/82 2.639.27 02/81 1.912;75 '02/82 2 .'047.04 03/81 1.632.88 03/82 1 .786.40 04/81 1 .788.32 .ML82 1 .888 gO ....95/82 2,196.42 Section A: Sub Total (Total of Compensation Listed Above) S 45 ,187.41 ------------------------------------------------------------------------------- Scction B: Other includable compensation earned in the designated period and not included above. Annual Leave s 1.489.02,(;\<7 5/7.'1.?- 668.98/' Sick Leave Camp. Time Other (Ex- plain Bol ow) Section B: Sub- To tal Grand Total A , B s 1. 2 158.00 4/:340.'.11 ~1ust not include payment for services prior-rD the designated period. Same as above. Same as above. Same as above. NOTE: We can use only that annual leave, sick leave, etc. earned in"the designated period for Average Final Compensation purposes. You must, nevertheless, trans- mit contributions on the total amount pitid at retirement. Sick leave cashouts LIre not to be reported for state or school district employees. above: Explanation of othor under Sec~ion B !!Q!f: If your cdshout of items listed in Section B above is less than 100%, l.nd1.cate the payoff percentage here by item: Annual leave Sick leave _ Camp time _ othcr_ and the hourly salary used ~lculatc the payments hero $ . Even if the items listed in Section B arc incorporated in Scction A, the in- formation must be provided. ...........................................................**.................. IMPORTANT, PLEASE RETURll AS SOON AS POSS.r.RLE TO EXPEDITE IlEIlSER 0 S RE1'IREMENT .......................................................................-.--.... Return To: DUp4rtment of Roti rcmont Systems 1025 East Union Oly"'pia, WA 98504 Curtificd by, Agency,_Jefferson County Department of ~~~~~65WorkS " ~ Nl z ~1~ ~ ja ~ r;;j ~ >4 ..:I rtI: 0( :0:1 ~ ~~ Z ~1;; 0 !aE-< ~ :rJ < is:;: ~ -:;l < iil!:: ~ .. '" r"I ~ 0: 00 "[IJ r:.. ~e 0 ~S r"I :;;~ ~ t;~ E-f <0 0 eJ:s Z Q~ .. ~l! lto> '1: ~s '!;o ~= 0_ t= ~ &~ "" ". t N 2~ N ~; " " ~ ~" .s ~" S ~' J ~a ~ ~~ ;; e s" Sa: i Qo ~~ :1 o'!~ . . ! ' . , " irs V'): 1~ ~J :'0 . ..' l~ 1~ 0' " :::r ~ jQ ui~ i ~ .0 .. ~I~ iGi f 'S i g ~ ::>' . ! e . ~I~ > ;c.. ~ ~ '" :i t'iE i'a 'tl ~ . " s:::lW I~ ,~ e :c 'l1 ~ ::>i :~ 0: ~ " '-'i ill ~ 'il 'il e oS s:::i 0: 0: ~ .!l " '1< 0' I~ 0>8 0 0 0 ",! $..: a.1: :::1 ~i . N 1:~ . 00 s;: :- ~ ~ Q Ol :i& '" ; ~ ~~ :.: :0: :0: '" . :l ~ r;:; ~ '" ~ 0 "" ~l Q N N 00 N ..,. ~ Ol "': r--- ~ ~ \0 '" <Xi ..,. ~ j '" 00 '" U'l ~ ~ ..,. '" M '" N ~ ..,. . ~ 0 "" ..... Si ~ [!l g ~ .. " OJ 0: '" .... ~ i1 ~ . '" ;;; :<: > ~ 3 . 1 > ,~ w ~ ~ 3 " ..J a ;jj ~ -n 5 " co iil 0 ~ 0 z " " $ >- u Z '" t:l .. VJ :;: !-< r.. o '" '" o ~ ;e '" :t: !-< .~ ~~ Q~ ~~ ~c ~~ ~" ~1: <g SE .. ., :3 ag ...-g ~~ ~a ~~ ~.; s~ i'2 ".9 s~ ~1l ls ~ 'J ,. ~~ ~~ ~~ .co ~E E~ E: .l:~ ;; '" o ~ ~ :; o g; fl ,E-< .. ~ '" '" VJ ~ '" ~ ~ ::'. '" ~ ~ o j 2 r.l 15 WORKER: Before completing section below shaded area, READ LEGAL WARNING on reverse side of this page. PHYSICIAN: Complele Physician's Report. D_h top portion o~ Original where designated a*ubmit to Department of Labor & Industries, AHenlion: At.eidenl fl!JBrt, Claims Sachan, Olympia, WA 98504. DetBhe Physician's Copy (3rd Copy) for your files and promptly moil the balance of the form to the employer (this includes the bollom porlion of the ,Originol ond all of the 2nd copy), - _~."''''''____' ,,~T"T""'"'. .,- _....-...... ----- -- -.....,,___,... iiii_-.. I: ,I ':' '",,' , " ' ,,':, ," ' ,;'~': ':.. ,.' , " ":, ;. " , ' , ~ ACCIDENT' EPORT !"A<M""M'" DATE NOTlCE SWT FIRMNUMBUI ClA~ flltST lAST / I TelEPHONE NUMBH (P~t."i:::~') WrlL.TU( LfjpD/c ,i'?5-{y-/9CJ g--_-);l7~ ~"'NG'bOX </50 , If-I.:< H (;jc<..'{LJ;;!:ltJ ~J;15I-1, z:g~ O'''OfACOO(N' f"""'ACocrN'OCCU"'O ';?J<<'""'o Iii "'"'IO''''''W''''''N;".;o---r:-S~ID'''O'''''H H"O~ ;fW"OHI, ~3P-~2'? ~U:<:2Q :'-::', 'iJD-I/J!JYtl!16/-f'.L-...J/:1-L'&..:-.!2--:? 5Ld.,j]J:.L ,,-.- "i:;'VIPAIi:-15""wo-..'(O-' .O";.(D...I[lInlJIINWrowo.....'~= lWI..tYOUDOINGYOUII V NO I S'AnWHEllf Ima.."'\\~ J~ 011-1ER ff#!!;~ifd:~~'i?i!J!!rr~~ o O'!C''',^WO'''''"''', "'''''0 " ,eo,mo,w,,,",,,,,, J "~' , ,)- ~ lNG? fAl ~~L1~~~ll~~~~/-U/.IlL-l2gll!!/l!lrR~C.B.L-~~b.:~w~' w 21..21'R T ~~EcHFMrCAl : T")- /"')L:::')- ..Ltr:- ..,' " , . ',', . ",' ,""'~' , ,,'..'. . ,., _ ~.kLJLl..__...LL=__:n:k-.-kl21.!J....!l.r::o..QtU--.LT.L..~LD..~r ~..A$,uj~,',~./iff!ll#-Y-l!!-~~~."'oo((!,~,~c",-fkc;~,"MPiO;~.A1.~4f,~Jje..L,~~~ ()1!!-Ii,6,~f2,.".-, ,~~,-~,,,~,.,.,,;~,-,,~0~'?__~><,Jl;O""'30":"':Z3'_.~___M~'1.!u9.El:C~l....afOI!~mH-N ~ ."nuo,u" IAU 0' 'A, I" ''''I.'CAILIIOl II~OW, DO 110' 1"(lUOI OYI.'I.~I "t:: . . --------..-.--l--------- ~---- M___ .-- ____rv~P(.O,,'t',' ~r~ t 'U~Tfl,': .l:p. fm~NAM! 01 WIfE OflHUSllANO'" TIM! Of INJURY IF OI....Ol'(fD GIV! fiNAL OEel/HOArE Ilf DIVOv(EcJ'N~-~~~~OlltN SUBMIT-;-' ~~,:- !/J~G::E" r;: J!lC2.8..tL_~,_,____ ~~~~I:~;!~~~~i&~~~s'ftIU'l~~~~~cg~~~~~~ODII.N -. ~~m'~i"''''''''Y''''''-''''-~-' - ml"';'"",,;""o~' i". ~> -- _..__~__________ __ lAllONSH ~_ _ _ I or'A',n"'\H,r_l~r.F ~'^Nn"l"T"NYMJSOfPOfSHjf^')ONllYMf./O~O 73 .~~~.~~.~.~-:_:... - . . _~. ~'_ _~~.LJ. . .::~..' _ . .Il~ j-",~~"o"T~'~~2~~~-'~" .-- '-- .-,,- l'J^l'OJII..,,'I~I"'MIN'lI'I"O'" -- -_. .. ---~........,.W~__.._7~~____ "...._.J IIlA.S(M/'tOV([IIAO YU NO '(OM~~;?llq;:'D';.1;t:A'l';lril)lt4(;~t'(ilt!ft\o' driving' s' oat" on "il tilt .1o'1bedwhen-the--cnt._.....--."._.I~~~~..~~..~..J.~~..~~~_._~-~~ (~IW:t'tW'b1\'l?"fX"'P.) ol1d oft tho lowbed on its aido; t.he cunopy Ir~TI!Uf"'N'1'P~fIlUST1NG ,"as,NO l.o'W.K).i.ls'.,._'~_._."......., -....'. '_....n._ .' pinned '. him' .aeroos -hiD" back- \tth:Uo' 'ho "wn8~on.,th<<t-4-,~r~~_~.:'~.~~~~~~~~_.~....;..%~. gro\U\d. I ..p~,ll~~\fl~~~~g~'.g~HOMpt'CAff" V(S NO l.r..ontuniOtt,--bnCk'" (-lumbar 'area) .. .-.. ......--.-. . ....,,,-. ..-......-."......-....-, ..,~~~~,~!?~.~!~~-~~~~:~~._"-~?_,2. =: ',_._..____.._~_._______,......_,_.... ........,_.."...., J~~%ii?:f~fii'~~WO~ ,~~~ P~~I~BlYf\j:l.Y':: g I C-....T ItfA.tMHlI U'liO ..-- ...".,~.~-...__..~-.... .x~ 'tli1if. ~ It.;W .T"-'-- ---~-._~- I W1ILTHISlMPlOVlflltOf, YlS NO :: l'i u~.G:j~DQC:K brnce -..- ~-. __u._. _~~ ___L~_l(~~tl'S'NJUI!'f1 ~7J ~1}' ~ ~.._.._ .._... _ "". [ESTlm~TEDTIMELOSSi~Tv";::-'- g ~~~~~".~Y1M~~~g.. ll~ '10 "YI"r~~AIN - -. -- ~-------- ~--~ - ~-~- f.' __~!~!~~~Y~_._.~~!.S '" ~~~~~~~'~' _. ~j!. 1tl~ . ~.~. .____. ~~~:,~T~r~vr V[S NO \JtlDUUMINtD f " "'SI lIt,uetP TO At40M"1':0(.'01 C,.l\1,."A,lrZoAOOt($.\ _."~._A.____~__....____~._____ -~.._-~...~-~ ._--~~~ ....-..~_ i .~(7;~~:~:~~~I::.~.~i..._--_._.._._----_._-_... '..-.------..-..... ..'al'--.....-------.1'''.',..--- I ';lliuOl"";;'';rr5lOA~ rI'\[A!l ","',01: nl'( "OUt HAM<< ""~ll"Of"..<.s.1 .rJO"I~~ 'I ..: ,.- .., -,',...,.. .."".... ___,___1, "'--"'-'-"'--'~" II' 'on! ..... IfLlI'lIOHltlUM/lft , .,' tr.D.;~jp~~h~,r. E-q,rhr.OE"""n~""':a. '9p31i&""""".'Ilc;..;J;JOO I i 11-2-7 j '\J~ 1M. ,'AJJ;}DJ.i.'(I~lIIlUA,lMll?AO,\r, ( PAGE _...2 fM'lOYElI COMPlETE PAP' I., "EMPLOYER'S IlEPO'U," 'MMfDl^'flV AND MAll HiE O!:!IGIN^l TO HIE OrPA'HMENfOF LA80R& INOUS1AtES. OLYMPIA, W,\SH. QB504 WE Pfi'rrfR TO HAIJ[' (M. PlOY[~S ~[PO~T" B[fO~E TAKINGACIIO,j ON CLAIM, ":'~"",'L : i':-'<'.-!-". ('" ., ",'1iHV Hnl i, \ ; :';~::;~::?;>:") '{::t:,W},,,"'~\r"'"" ",1-:,','1/""'" "'\' "'.', ~ . ,1:',',,;; "---:':''-,,/ ~ -- ": ' ,-,"': ';,' " ; "'1':"'::;" ./';."",',"':,' \'--\'" '(,',' "'I':;,i'; i\),' ;>~:;:! , "I:' J":~ ;, \. ..,:,:;.,'; ',:-;--i:.\''-" 'E:':;::;' ;,!~'~n~'f!~;':i1!.,';i:S::;'f~rtit,T;t!" ':".: , '" .- __.._c .."..,.,.,.. .... .. J ..-...., - -- - _."'\.~-~ r-~~ --.. ..., .~".., - ~, '-- " ~-., -" ..... ,........_-~,..!._~".,j~-, '. >.-', ~-_....~~ ~~..~:-r-\~- . l1li .. r--'''-~'--''''''''''- -.-..-''" -. ...-.. I>1I!Im! "lli "'-'- v- ~*~".,.,., - 0".' ;.'~!_~ >~.~.__~..:. ' -Ill ~._--- ~-,-,- . ljM ""f" " -" '.,,~ -- -- J ~. ',' .-.--.....-,. ' ,. [._~'l~L__1 _,__,; ;1I....."',..... _ _,... " STATE Of: WASHI'NG'TON . "_ Do~rlm"ol of LClbci'i'Qnd lnd . ~ ACCIDENT PORT (lAlM.t.UMBEII Emplgy., MUll ,Complollll 1 ,..,' pori bV Filling In and SI9n1ng EmploYIt,', Sodi!)" e.r on Midi Report (II Onee 19 Oopartmut 01 u.bor aod Indullrles, Olvmpia, Walhiroglon 98501 EMPLOYER'S lAB. & IND. FIRM NU.v.8ER iI'ElEPHONE"NUi.i8ER" ,WORKMAN'S SOi:iAl:SECLlIlHY' t~O. 4361?:1. t3~5:"3~5. : 556-)4-1274 :'_ ,eMPLOYER'S fiRM NAME " ~. , " ," ADDRESS _ ._.L.... -. ,- filii c'coli t;' Jerterson C~ De!'l1. or Hi.ghwS:Ys'( ','''''[. 'Courthouse.' port; Townsend. Wash. 96366 i o AN~M>"-'OF'~ "UREDW--KMAN --~.-- _~-- -...,-:----~~~.. '--~"'i '-'--'l..::~":"!.:::yr "R.(: "--NiMl?lp~;l'D'"it{V/j~~ti-'E:P4ilih'- . t?'~;.IF-wij'RK'-'-'N"HAS:;'iN~N"Ai:~' SOLE OW/'ll:R ~. Br: "~:i!t \t...'~.,. ': ,.\q~";:~~r_~,;,:,;,:!~'~"f"'":~1 it'.~~ :~,..",..:..." ..t.'1" CON'SIRU~TlO~'OPERAr:ONfREPAIR ON~AUNCH~BOA'J tNTEREST~ BUSIPlESS; PLEASE PARINfR a::: :::~!!l~~~1!~~~_:..~~~.~..~_.___~'. .'_ ,_ ! ..:. q" 1. __.~ ~__ __ L _,~ .J__...".. _.v'.. .__..L~!:l~~K..A.~~~,!~~I~!,E. ~,I.~,c:.L.E.;__ CORP. OfFICER ~ ,j'tfeSRfc~~~~Aro~~*Ag~~II~' . Y~ NO IStrf:04~S30 i~~ :~~~O:~:'\~S~~~R Y~ NO :IF NO. WllEIIE1 >- J;Mft9)'M~NL~~.t1.~t!.,U::lJt.!.~~QL_..,___.._ ...._.___..1_,_.,.._,._.." """"'~ "'__ " ..".._...... _'.. .9, iN ~VHAT' CLASS WILL THE jlF NOT TO BE REPORTED. GIVE REASON a. WOIlI1MAN'S HOUR~ BE REPORTED?" 49-4 i l' ~ ,,'. : '. -. ~ 'liENGiH-OF~Pi'OY~-fN'6YV'O'U"_.-)oCCUPA'ilO-N"WHEN~INJURED" lfMPLOYER:s 'BUSINeSS - ,-, '''iOCArION Of'PIA:;:'l' ojj' ;oa~~'fi~~-E-~'-(iii:ii:'Nr '-OCCU~Rt(' ;: 3 _ ~B ".. "" " ,t _~ M~~e_~c,~" ll~Ell~~~co~s'_~~~~Rx._ SIME ~~Rrl'UL~.R_ xINO.II. .., __. ., ____" __, _, "~, ___ .__.. ...._______ ,.. '.'" _.. +. ._, ~, w~trHi5 WORKMAN'Si:- ... 'v, ESM-ND : -. '," . . r . i:Nil~ WOI~MA;' S I""" Of ~A1IN ;'PPLlCAMI r.. ,,_ .1IM( Of ,A"'OW' ... .. ".. ) lAsr DAY WQRl:EDO",n I(lUINlO lawa~ a. KEPI ON SALARY DURING : IF YES. AJlACH I' -. .O.Il..mOw,,,DO.,....~~.~CI\lOf.'OVfIT~':~,~_ h.-- .IIA'I" . I" ....-"ljlVA..,...; 4 1 4- 7-12 .:::::~~:~~,I~t~~J~~~N~~~.,ii)~..._o.;--:i ~~l~;:~~t~M.RJ~R~~6 ,",1__.__"._..."".. ~~!o'slii6N' DO Y6lT5~;i6N'" _..1 9;~.s ~ci' ;~~7e~HYi.J..- . .a.",.__ -- ...---. r]~~'::1:7~~-~~-~"_-.:.'.tsf:~Q'o~~~.'&l~~~,..~_~..".~~~^! ..m', AUOWANC~~~F.,~_l~.I~,~m"._...__ .."'_-...__.._~...L_.J~}.~~~~.tE!.'~~_~_~~S~~.s_~~~! ".. HOW DID ACCIDENI HAPPEN? . rDfSCRlBE THE ACCIDEN! FUlLY. STATING Working on cJ..earing project; a tree l!~~P~~,,~_~..__~~. him in back . . ~~~~~~~rr~~ ~71g~L~ f~;SF~~T~;~ ~~~AS -"of' 1eg;-'" . .-.-..-..-, -''','',,''.-...-.,. ..-.------.,..- -.. .------.--- - --, _'._..~....,,__"U__. "--_..~" : ~ ~~rt~~~T~l~E~~;~~\~:jER~f .N~~-S~~Y __~~~~pJ.~~~ k~._~' si~~~~ve-_=;~~.!~~_ ::~!!.___,__:~__~....~ ,; "',Ell". '...SlGNED1Ej~f!ersonCounty.,",..,',. t~l.:..v' c:.~J.ci;'~IlEri;AIE4_27~;<, TEAR !-_~<?!':2. .'_I-!.~~!.~~~~~~!!!?'::'.2~.L_V__h.~~';'_::.~_~n~<:~:.~,.'~;.:.l.~.n..=...~';-.::~ '-~:._-;+-';'~'----T.-.._~~~."''''~':''.'.-.' _.' . ~o~~,2~^"~;'r:.~,,:;----_"__"_"._'-:"_--,-:--..__...---_._.----".- .:~~~~.~t,~tJ_W:t:....18g_.~~.l.).~_}~~,.~~~~,_~~~~._~~_~~~_._~__~_.._._._____ ,'.Jl-tAy FINlINCS ',' t:~~~i::::~W,tu;,"lT:~~g~,7;~~1~tN'-'..""'~"-v'tf",~ ~;'"~~'V'fS.-{KPiAl'~-"--~'"'-"-'--'-'--' \~ ~ t-~--'~..~~,_._..._.,..^-"._'-'._-" Xl ~~~P.~.~',~~ ,S,~!~.:'~.~~_~!!.IO_~,,~.. ~._,_~ n .."--.-...-._.... E!""l,;;;;;i;;~;;'."n"i;;~.. ,...,..;i~...~i't:~';~~I;~ i6~:g,:@~ ;.;:;;,~;;;... ii;'NO 'I \r~~iti)i:"o;oi;;G.NOiEO ':'". "6iiAiiV""po.'f"ii--NQ' ~ i'~~~:~;::~:~,~:::Xi:'::' NA"[::O''';~ i ,l"~'M[NI 00 '''~,~:';irU!?" '. ,; X ,,!'."~O.'~l DE"'~'O'"... ,..X__, :.,~:, Tii"~oo,""::~:' r;;~";';';~'~~;;~~-A'~'er'C;, .,,~(.~.. ~ 'f~'nMATED TIME' lOSS ~ "'"fw It. THH'E er ANY VIS NO -~'~NDn[RMINEO L wO"", (>Of 10 THI'5 INJU"'-' , .". '. ::...1. , OU~ TO.I~URY""""" DAn ~ Pll.MANENT..Di'''',D.I~t~ . j ATlftl')INQ I'HY51CIIo"'- (PHA.'St '11,..t ~ IYP( YOUI ~aM[ AI'~ "'DO~!')51 "'f)O~[sS j ZIP CCO[ jlf:IEPtlONE t.\JMPtA , 'l1'~t. Port. Town.aond ~II1llIdn:tonI",9$6a!. :38S-3300 ~ ..... J ~..( , " t" . ,~~bAI~ ~ t : t ! . I1;Ar(( jt,~COUN':t4l.lM~U, " .. , . ....____~72 ,,\' (}J~U . IUS[ t>HI, PAVIE ACCOUPll UUM6(1l SlAMPl . ' ,i PAGE EMPLOYER'S COPY , ,../,' EMPIOY!r ,~OMPIEIE PARI I.. "EMPLOYER'S REPORT," !MMW'AlEIY AND MAil THE , 'ORIGINAL TO !HE DEPARTMENT OF lABOR ~ INDUSIRIES, OVLMP'A, WASil, 98501. WE PREFER 10 HAVE "EMPIOVER'S REPORT" 8EFORE IAK'NO AClION ON CLAIM, o1,r;)l~"" 2 's,r IU',HV 411. .J.>,.. ;1/ . . ,~."...~\ IIIl11ll....___, _ " ..11 ""M,r ::<,~/.i(" : ":~ \'o--':~ I: .! ~',' "<, "l"~'""~.""r ....:~ - ~ i':~\.~<:\,,':.:.; - 0; ...~ ::; ,o~_ 1l i~~ ] _c,o 3~~ " ~~~ .a " "'" ~ i::~ ,,~ .:l~ " ~. C) a CII 0) CII G') Q) ~ Co') Cl CII Q) C'l C) Q) C) Ol 0'1 0') 0'1 Q) C) Cl C'l C'l ' '8 ~ ......................... '''oj .... .... .... ... .-I .... .... .... .... .... .... .... .... .... .... .... .... _ J:l. .E1;> l:: ~ ~Q ffi.~ III .., tJ't'-o" ~..~ ftI C'l CII 0) C1l C'l 0) 0) CI) 0) O'l CD CD 0) 0') CO) Cl 01 C'l en Q) 0') 0) Ol C'l0) U.- ~.... .... .... .... ... .... .... .... .... .... .... .-I .... .... .... .... .... .... .... .... .... .... .... .... .... !> -' - ~,~ ~ ~it~ ~ . ~...o ~_ ~: ~ -5 ~."8 if:-.'E o ~ If:~ ",r.c,:~ 'aGi& Z .~ u:t1< o.s ~ ~ ~, to) " t ~ ..~ ~ .~ ~l: U <"' 'S~ ei :;0 ~ ,~'~ Z ~ o,cv ~.] f..)"'C1I I<.l ... tIl'" " 'E '" "' ... .s ~ " ... .s ~ 5 '" c. c. '" '" "" '" e ~b I r ~ llll <- " ~ i ~ " ., u ~i 5: S ., ~~ s !S ; : e Z ...' '" c :g 8 ~.8 g;fJ :~ "'"" - ~ ~ " E~ .~ : ~~ ..'" > . ~ ~.~ U 0 ~ ~ ~'" ~' 3~ E B I ~ ~ ~ P: ~ 0 o ~.~ Iii i: ~ ~,g ~ H ~J CIl .... '" " 0 i>: t~ tr., &.. go ~ H, ~ o.q ~ i:a .. "'- ... :s a 15 ~ @ ~~ 0; ~~ ta:I t:lU ~ ]< a il ~ ~ a , D&TMENT OF RETIREMENT SYSTE. Public Employees', Retirement System Final Compensation Report "Compensation Earnable" in Final Two Years of Employment NAME: NELSON, LLOYD C *STATEMENT OF WRITTEN LABOR AGREEMENT COVERING THIS EMPLOYEE: DATE SIGNED EXPIRATION DATE I~/.$I/"S' CERTIFIED BY SSAN: 538-12-91~O DEPT: 220901 RUN DATE: 05/02186 TERMINATION OAT[: 04130 186 1. Amount of accrued vacation time paid at retirement. ~ Dollars' 311 50 ...J1.,Ji 2. Amount of accrued sick leave paid ,at retirement. ' 51. 00 578.34 3. ,Amount of other earnable compensation paid at retirement, i.e., retroactive pay, severance pay, oVertime pay, clothing allowance, housing allowance, ,etc. -0- -0- NOTE:, We can use only that annual leave, sick leave, etc., earned in the f1nal two years of employment for the Average Final" compensation' purposes. You must, nevertheless, transmit contributions on the total amount paid at retirement. Sick leave cash outs are not to be reported for state, school district, or higher education employeeS:- ~ Dollars % Payoff 4. Amount of vacation time accrued in final two years and paid at , retirement. 27.46 311 .50 100% a. Accrual rate per month 13.3341vu. b. Hourly rate of pay 11 ~34 5. Amount of sick leave accrued in final two years and paid at retirement. ...!B.....O..O ~ ?~i a. Accrual rate per month 8.0001vu. b. Hourly rate of pay 11.34 6. Amount of other earnable compensation accrued in final two years and paid at retirement (see number 3 above). - '. IF 'l'HERE IS 11 WRITTEN LABOR AGREEMENT, EMPLOYER MUST SUPPLY DRS WITH A COPY. ~. ""' HIGHEST CONeltUTIVE TWENTY-FOUR MONTHS' ~MPENSATION Please indicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Month/ ~ ....H.M.- ...l.ilE- .Jl!L .' ....J.nL. .1W.L 11/85 10/85 ~ ~ ...:!..ill.- ....E.ill..- -2lM- Hours ~ ..1.:l..L- ...liL- '~ ...1M- ..11L- 168 184 168 176 .1M- ..l.2.L- -1..H- Includable Compensation Month/ '~ Hours ~ J:lA-- ~ ...1.6.!L- ..1..B.A..- .J.:l1J- 176 1,84 ~ .JJL....., ..ill..- ...liL- ...1M- Includab1e Compensation $ 2.085.84 1 995.12 1. Qn4 40 oJ, I)~.I. ':1;1; ?,??O 94 1,944.80 2,p33.20 1,780.24 ,2.142.74 2.215.09 913.56 Total of Compensation Listed Above $50,657.97 . ___________________.~____~_______~___~_____~__MM____~._______________________ ? 055 08 $ 3,OOO,O~ ,..-4/.li ~ -2../..B5- -1./..li ...J.2.lM. 11 /84 10/84, ~ ~ ~ -6.I.M- ~ ~ ~ l- Does your agency report on a calendar month? X 2. Does your agency use lag pay? X 3. Does your agency use pay period.'~ ? L , I 4. If other than above, please explain. 1.995.12 1 904 40 ??QG ~~ 1.995 I? 2,167.22 2,210.22 L 927 .35 2,199.51 ,2.286.26 1. 968.52 2 131'?0 ...*******....**.**.****.**.........***.****..****.***....*....**.**.***...... PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT ..******.......****.....***......*****.....*.................... .*****~.. Return to: Department of Retirement Systems 1025 East Union Olympia, WA 98504 Phone No. (206) 753-5283 SCAN 234-52G3 Agency _...=...........,..~ V'JRI _ II ___ --~.- "iili'roP!lPnllll..m~I..~....., __,_ ...~ r--......---.--....- HIGHEST COJ!tCUTIVE TWENTY-FOUR MONTHS'~MPENSATION - please indicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Month/ Hours Includable Month/ Hours Includable i ~ compensation Year ~ Compensation J.:zL $ .3,000, o~ :#S- 3.L $ Pi tJrS:yt/ - fA" ?u, NIl /Y''?.5".//U J!=L /i?9.r.1;V ~ 160 /'1 iJ./. 70 ?is- IbO /'1't/,fJ& '~b -L1L c51~cJ'['''', (,,3 ;1/ d~ ;?';:>'f'C.3~ I~ ~ ~p.tJ.9,i 1 "''9.1 /7' 1'f9.r-; I~ -1.1L 111.s" I(gP PI{P/. -"?-' -1f.L .l.ZL 14</';'. f'tJ 10) .f /11/ .5< ?/tJ,';';2/ ~i/ ;%~ .AO:> 3. ,>-0 %-j ..lil.- /q~7. 3~ q'g'd /bO 17f"tJ.;f f ~ 17(, ,!</qq.fl 1,,1 1ft) ;? / ',I.;', 7f!' '11/ IYi/. ./1..;2 f't -.:<c, fr+' /7{' ,;( .;2/..J: (} 9 0-/ ~ I"I/.?~;b /1! It.! /"l/3.~b 0~( .J!L ,;21 :3/. tilt) 0# .A.:L ,;.JtJf.J, or ~ Total of compensation Listed Above $SO.,t.57,9'7 ----------------------------------------------------------------------------- ~ ~ l. Does your agency report on a calendar month? ,/" 2. Does your agency use lag pay? I/'" 3. Does your agency use pay periods? 7 4. If other than above, please explain. .*******************.***************************************************~***** PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT **********....******.**********************.***********............._.......*- Return to: Department of Retirement Systems 1025 East Union Olympia, WA 98504 Phone No. (206) 753-5283 SCAN 234-5283 Certified by Agency (Telephone Number) (Date) ""'-::,,;;i;~>; .' '.: .;\' .... "... . I.... :....: ::i. ~. L ~;~ ;~, ~.. . , .', ~': 'f~\' .{,~.~ ::;- i t, f ?),' I' }~ ,. i:.. ~h , "' :,,1' ,". ~f" \: If' ~,;. ";' \' r"1 ' '!~'~f~.;:~ :.'I} \ , , ' ; ,.~, : :<'.' -. :." ',( . ,c.:....:.,.. .'. :" ~ .:,::.,;.':}/{:;'"I . . .' . .........\ '.:'," . . ...... .. . . .'. ..'.....,..... ':' '.:.: .,..: '. .... . ':. '. ..' '.' '. . .': :. . . "', ..... ;,': . .. . ......:' ': :...... ",: '. '. '.:.' . . : -ci.':. ,,' ,..,; : ". ".':" ','. '. . . '..'. '. . ,: ....., . '..<: .' ..... .' ". .,.::.'.... .: ..: . ... '.: ": ...... " . .:.. . .:' "...': . .... ,.' -~::. C....:.' :.'.' .......':.... '.' ,',..' ..' ....'. ' "', .,: i _. .... .:.: '. . ,....,: ',::, . .'," ..,-: ..... ,. ' . . ~. . ' '. ":', , "":' .... :, '., ....',',... '. "'. '. ...... 't :,". '.' .'.:,-:,: '.:: '.-:.. . .:". . .". :., '..'...'..' :....-:... ...' ", :..... ,.... : .,..,' '. ...' .... :. . "'.': ..', " . .'. ..' .'" >";y:,: ............. '. "'. ,..~1:' DEPARTMENT OF RETIREMENT SYSTEMS ...r..I.:...:...!..'..........o:;,;t......:..".....L........ i: .:. PUBLIC EMPLOYEE'S RETIREMENT SYSTEnl SOCIAL SECURITY NUMBER I NOTICE OF SEPARATION .):;' ,'( I/j I; "//.' I:: '},.' , ~,.:,: :;.;3 , 'C. - RB~O.. ;oOC9-IRe.... 8.731 [ r ~~~ -I Covt. Unit Dept. I iL PLt?SYEER I ')) r' () /; / Rerer to your Trnnsmlttnl Report of Deduc- tions, Plut B. Write in department numbers. THE FOLLOWING EMPLOYEE HAS SEPARATED FROM THE PAYROLL OF THIS AGENCY -- LllstName First Name l'.~:ddle Name 1... Separation Date l (. ~/Il ( ., /}~ It. ?~_ / /f(~ I ENTER" GROSS AMOUNTSPAID BELOW ..... o Resigned g"'Retired o Deceased o Ineligible Position o Granted Leave of Absence I1:/ ~./ i c. GROSS PAID FOR: Salary ....1 G ,I.o~~I..I~ ~.. Uonth to be Reported Amount II" /'J J! ] II( ?? /(, without pay untll.................. Date Terminal Leave 1'> 1/. I", ( 1/1 I ':I !. ~.. 5"'I~g:/, ;", ")."...'._~O.~:~~~~n...:~~~:;:.;.'Z,~:;.{;.:::~ ~)I ,),) (:' (J.L.._.....-.- ,..., -' I . /'1" INSTnUCTIONS: Forwllrd while nnd Yl"lIow c;lplrs to netlrt!ml'nt Donrd. Pink' copy f:ot!s ~ AgencY..POlyroll Omcer. ../ The Inst month'" salary nnd the tlIldlllonal deduction (or Tl'rmlnul Len\'t! must be shown s~parately. ,";'-'i" .:;;; ',';-,.,(' , ."';:~.,'?<' ,'. t ~J ",'i".n.:. ';"1.'._'::.' :.~, ,j . . :,,', ,'I," '.',:~'.",' " '1:1,,' y>~:' ,.,~\ i > . ,,' '. ,', ci;'- ", :"'~,(i, ....... .. .', ............... "'.,.. ... ... .;'\: ,'. :':: 'U,;;,)(/:'/:t ,,': '. ;':";':'.., ,"'. .:)~" > ",:',..t:';;; . ,;' ' , , ,".',,;, " ,;'~". ' ;' .'". .', . ,C.,,:. ". ;.,"" '... '. '. ...... .'. . ..... '. ',.:' ,".. ..... ,.'.' ., " 'r' . '" ,'. .., ". .... ,,:,: ..' "..:.,:::.:"'::.'::;:,?? . r:....: :" :"": . ". . . . ' ':.'.-:;:,":: ",,'..., .' ..' ':: <>".: .' . , .....<1.'.: .' :' "....."~ .. , . " , ."'," " ".":~'':/'f:g~;~;i;; .i...., . .;"'.' .::::::... i " ,". .' ..... .,: :':."'.' . '. "., ..:. ;--':'...., <., . .::':.';' . .,:'",'. " .1' ....:..;: ,>: t, .". ".. :' ".' " .' " ..,.... " "::,.':{.' ..... :' :';~:;: ." ", ,'i~~:(.:[:;;., 'I . .. ,':~ I ';. ~ . ., "," !. ,:.' --,.,...,.~. ,..",- " " .... ~~ ,~.. ,_.., - '. -- :- -.. ~~ J5lM ~.Ii:1. ~-_._--"- ~ , .__"..".' ^ 0 .. .., . _0.... .. __ ..__ n ~,---- .~ _""Ull'" .' -- _,M'! ':',_',~, ,",;" ,:.;;..r:. ~-~~~: il~ ~ ... . ...._--- :!! <Il~ :l;tIl Z ~e; 0 ~~ E=: ..", -< is:!! ~ -'" .... ~~Q:; Efll ~ "r!1 en. "'''' ~ ~~ 0 iSS ~ U~ ~o 0 ",a Z Q .. \;\ ";, >- ~ .. ~ tIl :a .. ro o ::l o '" >- 0: .. :I: .. ~ ~ L~ .E ii! <: ~ ~ :g ~ ;; ::J -g ~ ~ ~ R g~~~~'~ .<i) :f CI ;:: C 0 &Jt~~~:i Q _ t:l 'Ei o 000 . ! u; " ~ ... .s 5 ill 0 " ~ 15 . . I c-, '1:\ ~, "\'\ "..1:\ ~0 '~~ C\\'j ~ '.:;::::;:- -:~..- . ..\ . i I -:-- rJ r; .J ,.'J f'\/1 \..1" ((. () ;-- (-, \\) .f) f'..j (I! C,\", Ci ~' 'f) N '. r,',,,! ..:; - \ . '''\ "? fI' ',F, No, ".&-OS-lnev, '067)-5.6. WASHINGTON PUBLIC EMPLO.S' RETIREMENT SYSTEM . EMPLOYEE'S PERMANENT RECORD ITO BE COMPL1!."TED BY EMPLOYER Gov. I SUb. I ~~D= Refer to your Transmtttal Report of DeducUons. Part D. WrIte in depart- ment numbers. To Be Completed Upon Employment by All Employees in All Eligible Positions CLEAVE BLANK) Member No....................................-... Date of entry..........................._........... Orig. member...... New member...... TO THE RETIREMENT BOARD: ,A' a condition of my employment under the requirement' of the Washington Publie Employees' Retirement Act, I submit the following information: (TYPE on PRINT NAME PLAINLY) SECTION A. mSTORY 1. Na;'e-lIe./satY--,- .___L.La,yJ._-,-""--,C.J--,--,,,--- --------,-- (Lnst) . (FfrS"t) (Middle) . (Malden, it rnnrrIed) 2, Mailing address ",..5II/J:!.,1}.e,.;z"i,,"I- ,$50,2, .:J.f.(.~/!;"ea:.e.""_,_,,,_ "',..S"e~p:.<:.:idlv.:. .:,W-As.d.,- (Street) (City) (dounty) (StBte) 3, (a) I began my present employment with_,__.,:G_I=_t:<',Ii:_....(~"t::C____G,u_d~,___,'_""'___,__.:.... (Nllmc/oYdcpllrtment. comml!(Slon, agency, political subdivision) aLtt,'m.4L...t1-.0:2-,.-,-,- on the___RC:_,_day oL"J"...,,,,e---..-,.,-,,----,-, lu~..8 (b) Title of pOsition-2R.u.J:..__..b..lJ.k.::A-,k..L.1...,----",---"-,,,.,--,---,----,-"_.-,-....,..---"-,-,-~ (c) (If applicable) I am also employed by_,__,____,__,_",_,________'__.____"__'_,.,_'_ (Name of department. commission, tlRene)', political subdivision) 4. Present rate of monthly compensation: C..h Agency From Whose Fund. Comp~nsBtlon Is PaId (a) (c) 5. Record of service to present employer and other public agencies since October 1, 1947, to date: Where Serv1ct wu. Rendered PERIOD OF SERVICE Title 01' POlttton Held Declnnlnc \ Endlnr I Len,th of Salllry Paid Name or Deportment PerIod Comml'!llon or ^Kency Mo. Day Yr. Mo. Day Yr. (Month.) 19 I. 19 $ I 19 I 19 $ ~ 19 19 J: 19 19 6. I Dm a member of or receiving benents from the following retirement plan or plans: 7. Social Security No.2.2.:..~.I)- 8, Check by (X)-Marltal status: Slngle__ Married...kWidowed..- Divorced__ 9. Check by (X)-Se,,: Mole_).( Female_ 10. Date 01 blrtJ1-I1.IAr- II I!.:I.IA'_ Place 01 blrtl,rj.hlJJr:/t;~.._.WI.J:Sh..- (Month) (DIl7). (Voat) IClty) (County) (St.to) ~~;~s ...._....J:" .\l~r '_ _."".'. .'\ I -1.'.' :. ._,~., ;- ~ ._~ .~.' -j\-.~_.. ~ '-'~ ' '" ~ , . ~.~ '~.~..: STATE OF . WASHINGTON . (J3<,33 EMPLOYMENT SECURITY DEPARTMENT NOTICE TO BASE YEAR EMPLOYER THIS NOTICE IS INFORMATIONAL r- JEFfERSON CGUNTY COURTHOUSE PURT TOWNSEND WA 983&iJ I PLEASE SEE THE REVEnSE SIDE FOR A DETAILED DESCRIPTION OF THE INFOm"'ATlm~ SHOWN BELOW Employer Account it 9t~5077 LO Date Mailed 04/14/8& ..J 2 3 4 5 1l0URS AND WAGES APPLICMlTS NAME JSC # WBA BASE YEAR REPonTED BY APPLICANTS SSA NUMBER APPLICATION DATE MAP QUARTERS YOUR FIRM MEGONIGLE t1CLOl.;Y A 131 062 1/85 10 534-70-4531 04/06/86 1275 4/iJ5 33.50 6 7 TOTAL REPORTED YOUR % OF [lASE BY ALL EMPLOYERS YEAR WAGES 3,U2Lt-.09 .87% COOE-3! I I I I i I i I I 8 ~~-- ----,-" ,.- ..-., , - 114 - "'---.-----...-...". . -- II"""" 1m-__,.. .,,~. '., !7v----'l_ 1WI!IIII tti.l . _if,_____ ~.~;~:~, ~:"' '. '". \ :.~ , .: .... .'. .' ", .',' ''':.. .'. " . ". ,........ ',. . ""'''','. :.:..' " " , ,.. , ", .'<' ..'.' ",:: ..' : , ' " . r'.:,""""', ,.' ',.,...' :'. '; '". ,.' ........,. ':, '. ,....' . . '.".. . ,. . ,..,.... . '.. ..' ,,'..:-', " ' . >.: .'"," ..,'.... ".' '.' . ..... , :,.... ' . ' '," :. .' : " .'.::.. :.... :" ",....',. ..i' . .. ,'..... . . '.. ". ..' '. ': " "'. '. '..' '... '. , '... '., :<:..,,: .. ,..'...,..,. ':. . ',','. .,' ,.' . " " :'.... '" '...' " '.,'.'., :: "': .' . ....... '. " ".' . ,'. . ," :: '.: '.... .",...:. ..' '" '.' '. ..... ,..... ...' , ".', , " "'..: ....,., ,.... '. ,'. '.' " " :'., , ". ',': ..' : '.. '. '. :., . , . .' ',' " '" .,:-." .:.'... . .' .",' ",' ','" .': "'," .'" '. .". :,.' ,'", '" "'':: . :"" :"" .,"'" "." """." , ,:;,' ;,' :.', " ~"}': 1, ':~(^ '; ',." ::c .. ,j" 1~ 'If HFil:';:in,,' ")'J"r,.e, ,. ." """ I, f I ,'.IIL' I"I! 11,:;' ~Ii " ',r I'.:! <)~ ''^''/'~':lN(.lnrl ': '., OR0U-i /-1 l O'.';:r;c. ,;\! ::.') .~: O'';I~'J(. Cl >\It.~ f()/I ,\~l UI(".\t i RfA Tt\\HJ T ONl Y ~. .- '.,' ',:, .., , . '.,. ! 'I"', 1;;:'~:~-':':'''~(::;~; ) . . "" ,~ .; . ./ .. .. ,'\ 1...(. { , ~_ f, ~ j' i I j' I ,; " . '. 'J ..f~"'. ,':;:'>:,',./:"1 ,,;~;~L,;/',~~;;I~;:/;S.'''~'d:~)~'':I~~~fr~~:i~~;?~~T~\1.~' ,\i" . . t. If fl": ij;(lH~ !."I~' !d:: MADf TO PH flOAkD '/.. ".,'.',! "'.t,:~: !::~'..tF~'~\;~!r'?O~,' It~r D/dE Till"" ()PDF.k IS ','I.':t I.' \ :_;.. ~ t;;:,;';',.: Ir,. i,~;' '. \ l\', ft. "I .' ,.',\ :~ ;;';:: '\ I,:> .',....,0...',.' ....,..'." ,.:.>, .' ....".'. ,', : ..' ":, '.', ,": " , ',': .... ',: . ;'" ,".,:.',' ::'," ,.,. , , '.: '" ":, ',,:' \:..:> ," """ " ',C :, ',' "';'::""""'.. '...' ,'. .':."....;,., ':, ':", . .,... ',:' ,:" > ':: ". .,' .".,' "r.> ,:;.;., ',' :', ",' :."'" "".'. .',.,,'::. :,,"" ,..\ "C ... "',. ...':',:,' .'..',:, ,.,' ,:.< .,' " .'...:, ,'.> ',' "." ......'..', ',. : ''''" ,; ,'" .. ". '. ":':: ~ ',:.,'.,:. ';" ';:" .. " :. ,;, .,::'.'.' " ... ,..."" . :,1.".:., '.' ", ,".,' . ".:: '" , . '.' 'C"".' '" ,0 ./ ',..."... C '.: ... .:. '.,' :..', ". ,.. .'". . ';." ,"'.' , ',';,'1 ','. :,;J,:'.'i .. . '::....'. ..:;,': ," " .. ,'.< '. ' ':':', ,:, .'.1: : ",' ". " " ' . "",:'" :"::",'.:: . ' : .; " I: '. "I:. , . . '. .::,' . " ..:.... ;. " '.:, :.'> ...'i,:: ,. ,',' " .' ",'. . :" , . 'I,':: .':'" .], .::'.... :.,.." ' '.. "'.' . ..'".' ii, i' 'I. .' ','," ,'; ,.'. i .' , . ,. , 'c.; ,.:,:,,: .... ,.," ,,',. : .... " , " ,'.', "\'"'' ." ..' ,'. " " ':,., ..' :.: ."."..,: '. '.": :'." " ... ," . .. "::: ,'. . .' ' , . " ,.; ,"''''',. , ,'. " '. , '..' "". " , ", . ,:.',;';":', "" . .' ',: :'. .'. " , '~ ',; .' ,..', ",; ,;, I..::,...., '..;.~' '.", , "~l"".l' ,\', J" ' ': '.":::'.':"'.' .": : ','. d' , :- \ , .''''',1 . . ':",;,:)'N'.:\"::. I.:~';I,.'< : /f:i:~t , j \ I) ,.,1, "',:,, ~ _ .:. :. > _'_' ~,_ ' , '. " ':' 1 .: _ ,_,~,,' HIGHEST CO~CUTIVE TWENTY-FOUR MONTH9IJOMPENSATION l?lease,indicate compensation by the calendar month (first of the month through, the end of the month) in which it was earned. Month! ~ Hours Worked -..!Z.L.. 11/82 10/82 ~ 09/82 ~ 08/82 ~ 07 182 ~ ~ 176 05/82 ~ 04/82 -..!Z.L.. 03/82 184 '02/82 " ~ '01/82 12181 168 184 Includable Compensation Month/ Year Hours Worked ~ Includable Compensation $ 2,071.87 2,071.87 2,0'11.87 2,041. 87 2,041. 87 2,041.87 2,041'.87 2,041.87 2,041.87 2,041.87 2,041.87 1,820.00 -----------------:~~::-~:-~~~~:~::~~~~-~~:~:~-~~~~:__~~~~~:Yl_____ Yes No $ 2,240.01 2,240.01 2,240.01 2,240.01 2,240.01 2,240.01 2.240.01 2,240.01 2,240.01 2,240.01 2,240',01 2,071.87 ~ ~~ ~~ ~~ ~~ ~ 176 ~~ ~~ ~ 184 02/81 160 ~ 12/80 168 184 l. Does your agency report on a calendar month? ..L- '2. Does 'your agency use lag pay? .x.. 3. "Does your agency use pay periods? .x.. 4. If other than above, please explain. . * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Return to: Department of Retirement Systems 1025 East Union Olympia, WA 98504 Phone No. (206) 753-5283 ~i"1\N "',1-[;,?R1 Certified by Agency ...JEFFERSON COUNTY DEPARTMENT OF PUIlLl C ~IORKS .' _ . ~_+ ~::, ., ." < \ " ,: ,r~.'. \, \ .H!'I~..~" ~,JlllllIIlIIHn'n= . tl" .~ ~ -. ., - """" - , - .~.,.,.....t.""...-:;~:''' , ..- . DEPAIlTMENT OF RETlnEl\1ENT SYSTEMS I-VULlO EMPLOYEE'S ltE'1'IREMENT SYSTEM NOTICE OF SEPARA'I'ION First Nnme Middle Name Sepll~atlon Dille: o Resigned iiJ Retired o Deceased o Ineligible PosfUon o Granted Leave ot Absence, wIthout pay until...................... Date MARGGRAF FRED NOVEMBER 30 1982 ENTER GROSS AMOUNTS PAID BELOW Amount Month to be Reported Snlnry $ 2,240.01 NOVEMBER TennJnal Leave $ 2,151.14 NOVEMBER Sick Leave 2 41 40 NOVEMBER Other JEFFERSON COUNTY DEPT. OF PUBLIC WORKS .....................................E~pioyi:.r...ii.geiicy...............".................... .............sjgn3ijjre.oTpej.~o;;n~Tor.p.3Y~~ii.o.iiicer............. INSTRUCTlONS: Forward white and yellow copies to Retirement Board. Pink copy goes to Agency Payroll Officer. The last month's salary nnd the additional deduction Cor Tllrmlnal Leave musl be shown sl:PDrately, ~~ ........--...-..-... ~-_...__.__._--_._-----_.._.._......._...."_.. ------ ---------.-.-.-.---..---.-. IIP."'- ~/\ ~'"e ~_..." '" ",. " ~ H,,' "'''',.~_, ~~. ........ _.-.a~A"IJDHl'" "~ii;1!1lll!\Rl>_~__"_' -: "". . ,.'. , ,;: :, ',,' . .~ , .. ......... :, ,':. . ,,' ",,',' '.:i'-' " ",",J' , " ':'. ", ,'; , ,.' ','.: '.' .,..' , , :" ';'" ... '." ' ...... .. '. .. ' :\, " '. .,",.'" "...",. ':"" .' , ','," '", ." , . , ,'" ,'.,' " .',,' '.:<:, ,: " ;.... >',"::: "";...,,, ,':,', ,'..".,"'" ,'.' ',"'..:, ,'" ".,;: ',"', ".' :,' ,'. ';:'" : ,::' , , :":'.' L' :. ': : ' , ' > <.'" ...:.... ',":"::'" '," ,'.' : :". ", .. '.", " ',' ',: '. : .::..',::, , ',' , ", ,.'., . ,.,.'" .. '" , ,,,' ....'.'., '.. " ,'....:', ,,", ",'" ,: '; ,., :'. "",'. " ", ' " " ,.'.' ':"",'" ..,.. 8 . I/. ~. <i' /'G:/'.Jl ,J/Cd c',:. /.2-, nJ' 7'/2 t : , IJ 7'?", 1?:J.r/)n, ,... -i, ~~ )76,06 j .,' " ,.? /0 7). ;)'7;(0(/ '" ' .?/".C) '(o:;-').. .)'11'0:1 " I J, .:)'icfoi I-P :) 'if. tJt /h. ..tz~ ,< ._.-J--- ;f ;2 / c2 /. 3';;, / t /:;. 7? ;/../' ~~ -~-?=-'" U;. " " (JIJ / / l 10)/ 1(11,.0 f'~" '.'.' ( IlI/ t/ /'-tC, d"l.. ------ .' ,,' V 09 /J ,A.,"? '1/): ',' ,') uS' ~ /) ;( ? J:;;',; /7.;' ;'0 ~ '1;), 'I~:J.. h-, .J.; /5/.; 'I ').~)\ " ~~ '; 0" '. ;;;-/16 ~ .;( '/~ '1~ 1') ~~\) ," ..'00...,..... "';~ " , '. ,.',' ','i.'.'." .,:-:"'?::;7r.'I:, .' :> .,:,,:.: " " " . . ,'. :. "" ".:' ":.,' ':'" :, ',''-,'''.'''', . .' ,,', .,'. ". : . ".. ,.,', .- .'.' '" ""', '.il .,..,' .,',,',' .'.' .' " . ", ". .. ,.,' '..' ; . ", . " " . . ."'" ,i~;: ~".. ':',:' " ." " , " '.','" :':.::::";"" ":',', ' "':' ", .:,: .";, : .-,.' :' .....:" . " '. :;" . , '" " ' , . . "....,. ..': .'. .,.' . ": ::".':".; ',;:', ;. . "".."., ,', '"... ,'" " . " " .",,;'. ", ' '::':'::".>: .. . ,.,",: ' .', '..: , .' : " ,; ., " ';":,. ':. ' :.: . ,: . '. ':", . , ',' . ,. ",,:.,', "":':: :.:: .. . ';, ',,:' '. ,,' .' ',;, ,'.' :. ":. ,'. " ' " ' . " ':, : .;,; :, ;'.,' .\, i. .;,,' ," . ,',' , ',', .' ,,' " .' .. .. ",:( '" ", . t',. ,;' .':" .. :':' ,:".', .. ", , .: "" :': .:' " ".:, "'", " , , '" :,' .", ,V.::(:;:",;," >:,d':,:".: :,','<:,'! ,~,">/.~\~{,:,f)'~, . ',,"'., ' ' .i . , " I, /3' 7-1 7S '10 1"7 ?f 71 ffu g:/ . /) I ' ~I j:;~f// ;sJo /.3 ;/0 .25/0 ;2~/0 .:~ .. ?,;;;?J ...2-;;, /'0 );j'j, JS/u ,iJ . fi" I d.. '/.J..I'<', '" (~;;L '..;~ V / " -),~) ;T-.?J ;0 , I '::.\' ,;;" \1'-1.' .'~~ ,.; '" ,i .... ';.r .:<~: ' ',: '. / ~. . ",' .' ' , ........... .'.'.... ,.c',. ,'. t., .: ';1 " >I ': 'I" .' r- .~ACCIDENT REPORT !""""""'" .,,-,-oyer Mutl Compl.t. Thb R.po,1 by Filling In Gnd Signing Empl' Seellon B"low. The" Mllil Report ot On(. 10 Department 01 Lobor Gnd Indutl",," Olympia, Walklnglcm 98504, AIfAClllHIIRlf MOR( 5f'ACE NUOW ' '-"~'-"-,;,wli~'AOO'~-~SS -.-..-.... '_._._-'-'-'---"--'_.-"wy&i1A~rf-'--- .---,._~ .."-... ,--,,<,_u-iift(~i"':~~~ Jefferson County Highws;y Dept., Courtho~se, .... .. PortTOlIllsend, WlI.lIbiJigtOri 98368 :if.:i~~~:~::~~::;:;;'~;:;"]:~~.:;:,:::'.iU. ':"'.:.'.:~~. -~...]~~~~..."':~U''':~".:'::.i. '1;'~~-.':,:;:~~;,._;.":::.:J~I~l.;~~~~.'H.O~:;'~:~ ~~~~KNliAfION @) _ - _ t!~ f)) L ZFred Mar rat Jr" _ __ _ _ i 536-26-0511 _ ~~'iOYff ,t2i Xi> ~~~E~~~~~~~~~~J,_,~~~'~'-~:~'~O.G~EiOTl~.:~:t~~;~~~~~~~".l:~ir~~f~~:~~~:]~~r<<~f~~:~~~;~= "___~J_IJ'oP.1QYl:~..fl1\'=~~YJQ 1f::!~Y'I.I.lIW !2.f!?A~rl!-~!.!.I1.".'-_fADOl/f5S 01/ lOCAIION. INCLUDING (OUNI'( WliEI/E A(CIOEtlf OCCURl/fD r SIAIE WHU( 1r.:i~,Y~~ S JOB SI.If . OHlfll CONST~~CTJONJ_OPf~):j_:~5L[~_N~~~gr.e060A~. _~~.._~~~_~..Le~~feX:~~~_~~~~____"___~_n~\~1l .~~J~' "_.,-...::~"__$~; WASIHISACCIOENT V.IS .NO.. IEVES ""ACtt fi)Af[.,0. FACOO HH : liME. . OAIEREPORrEOTGYOU. : II~E . .," :...' .CHECKHERE '.' -'"," TIME. lOSSOlJffOIN1URY'" CAUSfD8YSOMEONE.v;,\ X'," . 14 4 6 '2.00';'A.M. .4.14.'7.6...... .'. . 230 A,M. tFACCIDEtlT fl.,,!! . .. NOJEM!LOYfOIlYYOU?Y ::iI. EXPlANATION, _~l._~.1__..;_~L_~_..!~. _':__"_____1-2._. ~ N~O .~ _~~ lASTOAlEWORJ(EO . '. . '10 oAA1'~E~lIeruRNfD'owORK --r~.~SEJo.'.PlOYEEEtlGAOmIN' .yes NO l!.Htf'Ho.uI/S 4 ] 00 YOU QUESIlON ns NO lFVES.WHY? 4...14-7~~14-~__~~~~~~.~~E'~~0~~._._~j ~~~~~.~_ :~. ~~~~CIAtM? (Z; .~ ~~fnoNl_ Wlll YOU PAY THIS EMPLOYEE . YES NO tEYES.EXPLAIN TENIEIIEMPLOYEE'S, . CItIC.. ""Pl!Of'il"'ll CIKll b~~~~!:~~~~~31i11l11ll~? _ ~ ~.____ ____.._.~___J~~~~I~_ $ 6~ 12' >~."~~.-i)II, ~i ~)K . ~J~~ ~EWAGE . J ~.OWMANYOAVS ! NAMESCHEOUIEODAYSOFF . 'W^,,'M'lOm "~IF'''N'''",O.' YES NO ~~:c~~6~_~_ 'mpt'J::ft~MPLOVED~._~._~~~~~~~~~~____~~€I~::~g;Y_.~1{1_.~JE~~:Nf? __~~~_ Walldng down' bank, tripped on vines end brush - cl11n struck chain saw. DATE NonCE SENT fll1M NUMBEII CLA5S '. N.l.MEOFINJUI!EDfMl'l. . onE ". FIIIST MICOlE. LAS. T 'jElEPHONENUMIlEII lSOCIAL SCCUkJTV NUM.8EI1 LC'lg-,,\,.P;rJ__....-=-li~::.(__,__.___j!:.~~'29~.P~2i ?!<r5__~!!".~?::.-,,<?;){,, - 261 -os/ /._. . 1-~~~~~'T~~~~~~":~f~sI015f~~~~~.l?~?-q~~7T~dt~ ~ t9;'O'" .."wo."o:-J GMO""',"',",010WO",IFSO f W""OUDO'NG'OU' YES .NO t "AT!W"'" ''II/grw JO",,,, 0,," \i....j"~.."."J!l.,..=,_Z. ..If...!"..._,_...- ..... ..,.___. ._.. _. . .._..j?~~~~.~.~.:::'.:~,...__X__.~~_LA.:~~~~~~~.u~e_~_~,___ ('Zl'-".-2Sl.,.-- ~.:t).. 1h'~AA(;OHM""O"'fR"!/. . ....... '. '. .~l~[U...Ol:".[M .., ..... '_ ClT.76": '. . ".l"lI"COD~IOWlONG'IAVf/~ ",..~;;i~,;-,g~;;;~d*:::-fu~ - ~2tt(c;ft~,t;;~O~~N~~W~~f,f~~,f<C~-,~0J!;!!?~,~_2'~::S_. ~ 1,.2f/?1 c(j/':~!i.!!./lc.~_,_.__.___L~~~___.,-~~_c!..,~1~-7!'.-o'--0-.:._~.m!!~ V~ c/ o CE5CIIIBEACClOWff .STATING.FYOufHlOI!W[I!~MIrUCJ( /. ..;./- _. 1-. f- -L' If ~':;s~~~76~ .l~~P~~L\I~~~~~I~~~~~:~~~-1'djA:!.&'-!..:...(/_._~~71-__~~.~~.~./_~!...,ls.!'~~C(' .'6i~."'<.....;..I.' _ c; ING? FALLS ESCIlIUD AS INOCX)JlS OR 00'0001/$ /.. . .,..;:,. ". w .~~:~___~r-::~~:~~-":~2::~~~:':!:fE_qJ!..ri._.k!J::!:E.!L-=-___q!'=:!_:2_...rrrc-/. etL i!ji tV /1-- S-c<-..t.-U '1. ~~~\~~i:~(~~~;\"iiiF~.'.'Yi;-~"fDA";;:'.'7;"';:"Dipo;oU~zyi.-.._..'...'I-~o5io"~---.: ;''''' & TJij~,c::~-:;- !121f~~~~E~ 1l::OU~ fMPLOYUl'. __.,~._.S?..~ )j::._L...,.._____,~_ ~~._-,-_.- ...:::_,.~_._,._ ____,._____t'< '''-'1- ~:y'-L~~ t-I<(!}~g:!:L::~,t."If:!..lj/Jt:._ un_ WO<l_JAn Of 'A, ,. .'".'eA_II .0. .no.... DO .OT'.C~UIlI 0.11..",.. 'UIl. NAAU".. Of 'if'l OILHUW,ND At tJMiOf"j;';il.iRV.'-- ,u'.'_._"._. .,. ..-.r;Fo;;O;C';;O;;'F'N"oii;;;-D;ii-'...'..I.;;ii,;;o;C,~;7;!I.~~~~;I;::~~-[-~,:~:-= f)vrt;'I:.!!~'elt1..1 ~!?g!2~i'u_._L____~__.~__~__."___--L~.~~,:~:[~~~~~~!~J3!~~~hC~!~:~u~OOI~.~. ~.' ',..;.;L-:-~._~~,r~.~~.!.~~.!'~Dr~.I.~.!~~~!~_~~.I~.~~!lI~.n_._~~~,,~,~~,!..~,,~.~~!!~~!.~!',~.":~~.~- ~_.".~,.-.~ ~~I~TrgR~~~:~~~~fE~~$o A~~I~;Uf J~rJ:~~ . ! O"~l! 0. .:,"," ." NAME . f Ilt~fIOtI9j(f' AG'. r~"Mf I PE\ATIONSHIP I AG[ ST...~m TU'" ANY MISR[PRfSWIATlON IlV Mf:~ e. ~7-':'-'-'~'-.'~;""'" ~.,.. -... '....r.. ..~,.- . ...."........ "'r-,1" .--"...--..... --"........ ...._...._,,- .....'1..' "_._~"-'-"-'-+"'''''"i MAV PI'SIIlf IN CIVIL 011 (PIM1NAl PH/...trlES ,~/ ~ '.'~. ". ,;1U"" /c.- . (t/-.<-" , ~ . : ;:';;;~;~;~J::::'I~~=~'~:...~~ =.:,:::..:~~~=:==J=:~-:::I=~-31-i~~B~: ,_.:~.~:~_~?~.,' .___ .__w.~!k.~!!glidi~'.'l1tb.c:JI1~ L 1:h!'f pp_e~L,o".. ~i!1,!t.lI..al1(L,brlJ.a]h. .~~'.~~~~_.._' .!.":.~A~..._IJ.~.'. j}.._8 C':OM"lMltSANOI'UY~""Olt.c.'5INOU""t ens ruc~ C Q1n saw. I'HHU[At~YI't{f)C15T1tK.l. YES,' NO .J_~~~~~~.~~~~~.~.(~:..). ..~",.~,._'._.-- .~. .""-'-." .--~~..... _..~ --~,..~'.-_......., ._~._..,,".."- '---~"-I".''''~ .~~~~~.~f.~~~~~~~~~_.x~. 'OIAG~ ." WILL fHI50'AN'I'OTli(I' . YlS .'. NO r~~-!!!.~~~~,:,~~"~,~.~.~~.~,~~~-~.,....~,.I!!,~ .~,.." . -.. .."" .-......... '.'''.'-"---..,._.',,-,,, ._.....I~c.;;~;;,(.Ji~{~i:~i?!~;f'1~Jfi~::o,~;~ {' DIAGtKlMD II[ 'tif '15OLI ~1'!'tJ ",""'" or~ ~\~., ro;~-iCI.iAi~~('~ii"u~o'- Ex(imi.-na't'lon"~' ."t'ro'atm'e nt'I'. "w'o'u"'d "w.o"8 f'-o'(f~.- s.u-.fur=-a~;':~.~~~~'~!~r!~l;~.;;;~~;;,;~~"6(-;;i;%ir-~. !A . ff.~~i'<O~;:'~ ~!,G~J. i,!1. J, .1?T..~,o()ll~,er., ... """'.'1 ESTh~~ ~j~:~~:~~~~~:~~7E?, :~ g 1;;;:;'';';;0;''.''"; ..,".. .,.". ..,..,..',,o',..,;',,i.;,,,,;. .-... ,.,. . ...,."...1 T;;;:;;.;;;;;..;;.~,;;,----'-;;~CUNo'.iT..M;;;;.,; ~' _~~~T!!~.~,;~~~~~~,l',...,..^ ..~~~..,...~'. ....... t:.~~~.~~~I~~T,O'I.~,~,~~;~~..5~.."r:it...".,".!fL_.."~ II. . If tAW 'UUIl10 '0 APlQlllUCXX10l, (,.lVI NAMI ",...,0 "()(!lit~~, ::!, ='r'~'-';"~"~";'jo&.i'I'At'iil)""<' """}" ;j"'Y:,oiP;';,,ii ~I .c I. ~~;~'~__, .. ,~';':f~' i ~I~;;;3~:P..;;~;.:"~::';:;;'~~~6"~~~~~ ,(lrGO~ )}J2t ;;:~lIl1nd, WA . . ~1("'i,l'U~f {~ r1 ~ r,..." , __ ,4-15-76 II f""'IOVU wAi NOI ' \ 1.0'lrl(0 Ulf SA.Mf o'-ll ~ . A~ T~f "(~IIl(NI GIVI UAION . . 'CllY~ .-., ." .'-~'.~"'-r'i'jP'(06f--'~"--~'- pll'i,r~l ....,. >'ritli',;~jiiiiJM~;'--'~-'.. : 98368. .,.. 385-1300,.,... ! f-AYII,lCt.;OU11I"')I.lRIf 11113648 'U\![lI"'I'....lfM,(OI.tiIr.UMI\I'..'AMI'1 !MPlOYU; C;OMPHH flA~II, (MPlO't'(P' 5 R(POIH. IMMEDIATElY AND MAIL THE O~lGINAl TO HiE OfflAIHMft.lT or lAbOll" INOUSHltrs. OlYMPIA. WASH 9850,", W[ HfFElllO U^vE EM, PlOVfP St.'[POIH f1[fOPf TAKING ACT10NONClAIM. MOE 2 " ., '~ (l:" u :rIOIJOltt'V1fnl .. 4i ",' .Y'. .j' "',(,:!7IJ/::}".. ..:~.i/;..Ii-\;:i\:??::'\';.;.:y:' ,....('.1....,; ,.. 'p'" I:',~ ,',..:j';' . .'~ 'i :1 ::.;\)::-:;;;~! .'.' ;~;,{i.' :""!'.',,/"~ Ji ,\:{.~;, ':. , ........ .. ;'.::;';" ,'.:.'...., "::,,', _".~-r:;I ,.~" _ _ ~. "1 1111 ~ IIl1l1l_JJ1~.. __nn_ .,~__.....~_IIL m...". r--- , I I" ,I . I ' \ . 'I', '\ " I " ,-I..: ,.. I \ I ~ . J-J., ' , ,I iIIII __,..,.'M-.,..,..,.........,._.",..... _ - -- ~ lti~_ _. '.JiB , '"I STATE OF WASHINGTON" R E PORT 0 F Ace I ~ EMPLOYER'S COPY Deportmont,.:!r . (Nol Claim Numberl . Labor and len, Chlm No..__..._..........._......... 4/_ Employot Must Complele this RDport by FIJllno In and Slanina Employe,', Sodlcm Bo ow. Thon Moll Report at One. to ~ ~ Dopartmont of labor ~nd Industrlos, DI,t,ld OffiCi, (S-. rovon. tide for addrnl,) 5~ FJrm number "I CmP10YOL___!!.J~g,:=!-_~___________Tol0phono NQ'.?~?..:?~~~___"_____I .. . I log (Numbor lIul9nod by DOP<l;rIJIUtn! at Labor "'o\I..d IlIdulItrlosl.. Socldl SoCunl'1 No. 01 workman~___._..._..__..,__..__~_.. =.il Jeff. Co. Ll3pt. 01' Highways Port 'rownsenu wasn. ~8.l68 '~~ Firm namo 01 omployot.._,;.______.,__~-_------------------------------------------e5Addroa/J------------.--------~---1-;;-1---------------- Have this workman'. hounJ been Included In payrolls reporlud to thll dopartmont'l____':l_____________. If 10, In what dass? -------------------------- If ~ot Included, gIve reason__ ___ _ _ -- ------------ -----.'----------- -----,------ ------ ------- - --- -- - -,.;----------------- -- -------- - ---- - ---- --- How'long b!'\8 wo~1cman been omployed by yOu?_______~i.Y~~&lJ___.._..Occupallon when InJured?_~_~~_~_~!l_f!~_~_~_~?E_________________ ~g: Bualnoll8 01, emPIOyer_~!__~~__~__c:~t..1~~!Location oj plant or place of work whore accIdent occurred__________________________________ f:c.. ' (II ouqll.qed I,n conlltructlon work Glo110 pullculllr kind) . :!~ Check in whIch dopa~ent workman was employed: ConslructIon [% OporroUon 0 Rep~ 0 On launched boat 0 .::~ :i:::f workman __~~__!.:f!~_~~~!I__~~!____,___________________..~~r~: ~~YI~~b~c~~osS? ____~______.~~~n:~n~~~oraht olllcor?_______. ~~ WUllbls'workmim bo kept on aal~ry during his period of dlsablllty?_______________If so, 'attach an oxplanatfOn___~Q__~~~_~~_~_______________ .'cil!:! 2-2-681 ~130 ,,~ " .c. c, ~~ :: :~:::~ :~:::::~::-~:-;:~:~:;~:::.:-:~-~~:::~lo~::n:':h::'~:I~'~d~~.~_-~.-~~i~_~~~.-~~~:~~::~~:::~_~: ~:Ik-:::,:]_:_.:~Ji~.~~~~~~ ~L,.: Old accident occur on your premlseo?______Z~l!__________U not, whore?___________________________________________~____n_---------------- ..:1; DA~O and hour accident reported 10 yOU___?~:?_~_~~~:~_____________:J:.. To whom repor1edJ.A-~~__________po.U1on_~~ID!'----- .,,~~ No",o and .dd.... olullondlnq Phy.lclaa..P.!;:.__!jQ~~_~!'.tl_~;:.::._!'_~~_!.'~E~E~.L~!!l!!~!_2~l~,!L______._m__________.___' '. no Do !OU ~0esuon Dllowance 01 claim? ~(;tt~~~gOC~P;;f~tiona-a---ehUiik--ofr--a--tree~new--fii6o-:raCe------------ How did accJdent happen? _..___________.__.., ------------------ ------------------ ---------------------------------- --------- --~-~---------~ _____~__~___________________________________r______________________.________________________________________.--------------------------- tOfllll:rlbe the accident fully, .taUnq whether tho injured pOrion fell or wu IItruck, elc., and lI,U tho faclorll contrlbullno;r 10 tho accldenl., If necelllllrY wdlo a .uppl.. mentary lottor.) . t~eclare',~aU1io.'fOregolngstal~monls are true to'thebosl of my knowledge a~eUof',1,':'5~~ . . S;...'.. d. 1h1i__:t~.--!t---. d.y OL~. _J.:!3E.!-________. ,.~~~.[~4'~--/...~!-... BY~~.~.. g. p.-.1Jll. _., _. !;.Y... __~!lP"'!'!~__.__. --------- , . ." :"" . .... ' 'r '.' .... .' ....... .mployur) (<"'.: r{~~"",~;"":7 . (OJflclal poslUon) . r ~/.,',,';',AditJ1ged ,!o1J.~ompenr.fb/e except./qr. (TO B~ USEp BY DE,fA~~MEN"LONLY~ t? ~ r ..<'...,.".,;~,:.:,.,:..H ~ '. .'1 ) ~ . ,.M. ed.eol Aid D.Il.r, allotvable. by law, ." Dy_.....~._...-.,',..,~ . ~ .....!/;/j?,..,' ClaIm No__ ;. ,.'...".. .>:. .... '..". ,'Clalm..&xamlner ,{~, 71' ~ .. ~'.,>_,A//owe~for a~'lh~rizcd treatment By________,.;..__._...______l.f} " Finn No.__~... _':anJ ~CtJO,I.~,as uuilcated.. ". .. . Clalmll.'Examlner SUP(l~VI50.r'~f Indu:iti~ Inllu~anco . Class MEDICAL AID AWARDS DlI.leNotico Sent Cont_ , 'EMPLOYER'S COPY /.. \\ 1I.'."'.o.ol mju,od wO,kmUl..FMII-.--...-----------4.A. -fI.~,fii:.;>~..:rr-l?-; Sod,I Security No,,__ ~~- 1:;'--0- fl- .......... ' . .,...... .-111 (1'I.CA.:'~~IL.NrO..TYI';;'--~',~~,:.\..-,:,~~l:';i:".)~:>,7'TolophonoNo.___.. ,____ ... - --'-- Add.... (t~ which all m.lllo bo .dd'e..od)-ll().u.:r-E-OJ...-.f?all--r:~w-}l~i4J6Iy ,od SI"o--W;f-5"lrr--~-,~L---~- PI,co . of bhlh._/!.o_RJ:-_74.J,U-.JV~-E.I/..j)----Sox--M--;"""A9~,;://f!;I~~-d;,;;'),';;hj.-.---Hof9hl5'-=fr:>---- WOIghl/'i';j=-' , ',' ...DateacddIJllt. o(C\I'r.d--€-J:=./J..~:;.~T~-;.f9fl------ll \Ie ho~~,:.;~.t l!occidfJnt~~:JtJ---P_I1:-------~-ShUt bours__~-__----~_..;--------~ : _.;,;:" ?~vo~at& laat.'Ylo.r.kCJd--':"-:---~_---~----.;..------:------- -----If.'.yolI hove rOlurno~,lo work glvo doIO_____________~--__------~-----------:-' . ...... '... Nam. of.mp!oy"~P;.jE:.Eli9(1.Jt--e.Utl",..T:Y.-ll#)1W.'!Y---t~j...dd,..~.fu~-:r:.-+-cr{4.L#5'-E-W/}-rW,4-Y? ,. ,'.... Woro you doing your regular work alUme of aCddO'f1I?___~-E-S'l:.':'::'-.--------..-...,..,!4---on omployors promees?--J-c:-SI'---,~~-------------- S2 O.oa1I>o accldoot In fUIL'O.f-.;;:/?.A.t:/-/l6~---~-t/-1.L-j)(j:z~E_If~~'.Gh-(;rN.K_-'--tTP----1;trQ7J-17-.---------.,.-~ .' . .. ~ ~ .c---FL/%-w---.I/-p-----A--f'/-p----!f-/-'F----M-e------------..----.---.,-----'---"'---'-7-'-"::,,::::-~:,:::" ';;'.';,/;',,~~ ~~th~' accident lnyouroplnloD caunedtn any way 'bY' ~m.eone not employed by yout omPloyor?______M.o.____' . "..... .. : ;~ iiO"IO~g.bavo .YOU. wO,~hd 'for this omP1OY. or? ---1-7..,-. _ f-1':U:/JI:ths... ..jl---------.---~------~:.:~~~~- W.go por d.YL.&.-f-.--/G'---' ~~ Da,~Q,!OU re~rtod ~cddent to omPloyor____:Y-E-5-~~:~-------.~.:-:.:..:.:-)t whom rer:;rted-~-~fJ-lF~f)'--S-~fi,JfI(,.1iN-ir=/V'/)~---~-...,~ g ~ N.",. of Auondlng Phy.lelan-.-I1--()-hel?-:t--(if/'lf1s.FR-.---n..----n~-------Add....fl1/frrow1d-5'-e.N-j)jlj~ = . FuUnamo cl:wlfe orhusband.IJ."5--I'r'.J.~~l'S;/~ff.i'I....I.1 '!">&;tl1-F-!l.dlVO"Od glvo Ilnal d....o d.IO.___c_~_.~_.____.________m_,r.~..:.;;1 5=. Ii divorced and you have .ntlnor, ~m1rOl'. lIub'ml.t A copy of the court ordor showing 10gal custodian of luchch11dren. ~t; , .. Al.o,g!~~~~o8ont address 01 such custodian. , ~ GIVE 'NAMES AND BIRTH DAfE~;?F YOUR CHILDREN UNDER 18 SUPPORTED IV YOU NAMr. n~i)"f~n.b1P M~.lIlcp~~BIQ~u NAMr. (Not Cllllm Number) nfllll.!lon.hlp DlI,lll 01 Blnh Mo. Day Year . :J =-5-T=-S:-Y-. E-M~.' ----:::- .,~!/- .7;~--F- e~ --j}-(;;I-A /rI-f?:-' ... -r--j ) '.I ' :''is'':'' declaro th~i1h. forogolnq atatOJQ(lrit"~.ro Iru 0 I II 01 of my lmowlod'Jo And bollof. . . Jl SI:"'od___./-~__. d.y Ol~,:~~';-~~~V;~~~~~~~~~ ::;;--:_~-_-_~_---~-_-_~:_~_~~~_-_-:~_~:::::~_=~=~~=~~~~~~~~~~=~~~ , . 4C- .(/, , ': PHYSICIAN~S .REPORT' ;" ~::.1:r;R:;;:~~~W~~~:.r~~~~~~--~~~~JC~~ -;;;..~-1:f:&>~ E~PIOY..r--~~.,c.ff.-<;.-t)"-+-.-.f-+tI-N/."7---~-,-Add..ufot+-~'w-fl/-~~(./; . . 7'. I 0.1. lolurod___~eb-_?-_____",_t;.? .,?~~~___~,Oa" 11", troatm..t--..&.-lr.o<""---------------- Wo,k"'..'. A.. .#A---------------~- , . ..--r-.. ..--:. ... rVj 1''-"' IOlved.l.oIDlrthy'" . ;' m'lety ollnJuty__""""'~#/___'-A~--l-., '-. -"2?7,;n'-7--..:r--?I--c:.-----'--m~------.---~-----------~--~~------:' ... ;h::t..2~:.-'--~1r?" 71j----;t'(7'{C.<1-~~~-L-F~~----r'/a:;j7.~r~'j---~~-.?AZ-Zr?6iry;27i;-------:. 2 f:l' , if;:;' "-:;:'/170 .-c.-V'.''/'r;-,r..rr:-r---npa-<Cr,~.m'=--.--?'.;..y;'-(:1 -----;H;,-.r)b/f!--~-~---...---;, !i~~~i~.t~;~~~'~;~~:;:~~J~,~~~~! ~:3 l~. workman hAd f1rntoua lnlury 10 ar.duo../\Ttt~...-.-/-;,;'{I.lJ~..c.:..~~<(::~.:.....-./,-~~~~"UA;::.".,.,-J.f'-(.-/::7\-.j-.-----."-~..--;.~. :l ~ II.. _kmon .." bo.nUuted hy .nyon. 10' p.....I.' .1.(;1101 "'odlllonl,..,_~"'/O.-------.lI y.., ..plaln._u._m______.___..___'._.________ . ... !:-~;:; '::~.~.~:~.~:~- ~:.:':.:' ~ 'I~:' :;:: 'I:;~;~;_~~~::: : :..: :;: ;;:...,._-_-.._-,:: ::::: :::,' ::: ~::::::::::::: ~:::::::: ::~:::: ::::::::: :::::= Will thla or an, oth., pr...xi.t1r\lJ condItion complicate tro&tmonl or 1Clllld locov.ryl. n'---71"/'{:r __ ~~ ._,.~_.~.'."_' ..... '.MO'_~__.~-P~' ....~~-._.. 11 condtnon dlaqJ\()..d lh. u'lull 01 accld.nl d..crlliCl'd? YIlI 0 '. Probably 0 .. Po..lbly 0 No 0 ~;~;~I;;;:.;;~.~;~;~~~:I~I~,--~:~:.TO'--. ,..'.'-..:~:, _.Add~"___=:~' ,...,~~:~---:-.--.,~= AU.lldlllt 'hr,u:t.a: M.... I"lnl Of lTP~tTN.~nJ 4Id'du,e: 0"""'" ... ..-~~vtA;.i';4f,,;::;r,-.;..J,." ~,-n<.'I"~Il"l~lI'lh. N.m':;:'?c.'b..,..f'-'/~--[ A. fJ...rFt.:.c.:." .~() S 'uAdd,....;I'Ii?' '--,1/1"-'-" ---..-. .,~;-' ("-I/;.~plrAA;;,:i,;:-'ra;i--:l_ SI .hu :~ _0" .".. ~.. . P"'6,_I1't-:r::~~.._.P.y.~~~eo,;'nlfl~~~'o.. ....__Tfll,No..." _,.._0'.- -....~--. (M'tOrU-fUMovr UHH ywo.. rlNI( (.'or1"-.TIlu 1\ 'tQUIt COPY ...("~~ . ~Il p~~~_-" ~ <,'" ..,- TIlIIiI _ ~" .lJ:a_ l~~ ~~; ~.~ 'Ii!:" tJ~-- w 5 Cl CI) m Cl C) 0') Cl 0 Cl 0') Cl'l CD (:11m Q ell C') 0'110) m c:r:. 0')1(1) C'I C'I U > ~ ~ - - - - - - - - - - - - - - - - - - - - - - - 5: ~~ gj '"~ : tl I ' o ' g ~ ffi ~ ',,: o 0. " .' t:", Q 'i~ ~ ,"~" ='.c CJ'r:-" ~'~ . tJ'~ ;;:.,' : ~i~ 00':"8 ' ."~ :,tj 00 ;:.3 Po4:.~ 5 ~:'i:: ~~i 0- Q., &:2:a ~::~ ~~~ : ~':,',',g- ~ 1;::., ".e- <ll <II t.) ,'C) ::s" :a "",, " ~ ~ i:l\.'.l(l ~l I;:: 'g ~p: l/'~ '" '~ : ~b oS ~g ~ ~ ~ ~ oS ~ j ~ 50 B tl ~ ~ Ji ~ ~ J~ i.1 fl. IIII I I - ~~I~I~I~I~I~121=!~!~I=I~I~~~I~I"I1J-lnIMI~ J ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ \b-. . ; t3 ~ I > : !:. ; lllTmlTmmm ! I ~ '<.J , ::l "' ::> '" r.. o Z o t ::> 0:: 0:: '" ~ r.. o '" o ~ " is >" 0 .c 6 ~ ] ~ ~.c 1tii ~ . lll::: .c-g ~ ~ S >. c . ~ .~ ~ -;;.c > . ~'E 13 ~ ~'a :E~ 's 8 ~ . o . ~ !$ ~ ~ .cia' ~;:J. . . ~l.' ~ ~ '~ -5 :S ~~ ~ 0 '~ ~ e'g. ~ . ~j .g, ~ ~ ~~ 0 s il il ~ . a -.--. ,"' ~n. W~ ~u,_.,,,,, ."...... mlJ!llI '''' >~ H~ ~-~__'~ ..'~.. ',', c ,'.' ,". ~,~:.' - III , . '1',_'1;'" i,'i',c~'" . 'PRE-EMPl..O~ N'PLlCAfPON LAN.DFILL PosLllon AppLLed For "effcr..on County ls an Equal Opportunlty Employer and encourages ~ppllca _ tlons, 'rom ell persons regardless of race. creed. color. seK, natlonal orlaln. ",arltal ..tatus. ege or phy.lcal, aensorr Or "'"ntal d...bUlty un- l... ba.ed upon a bo.... 'lde occup.Uo....l quaLLf caUon. (St..te Law: Chapter 49.60 RCW ..nd "'AC 162). IMPORTANT: Complete ..ll ....ctlon.. LEVY (Last) Pl.... use lnl<. Frlnt name only. ". ARTHI./R :B (ftr.t) ~mtddl.) Pert 7O/..<J1JSl:f1d) '1 d'..36d' Celty) (at.te) (IlLp) , Soclal Secuo::l,_:~y N~.. 05'8 38 6 '1st... D.t. of IIlrth 6 30 53 ' " . - '. . .,,=<<~. ",lll not be u..d to dl.crl...l~ Cd>'i*ut- Ihe. by , fforne/Me....ge phon.. I/oteo lJ~tlSe ' e. lIluslne.. phone.' . 'I. Name: 1-11 (streeU WitTER .Sr: 2. Addr... z 3. " .' ,6. " i; 7. IEcl.Icatlon - Total year. of ......-unlv.r.lty achoolln,:. CLrcl. y.ar compl.hdz "I a 3 -4 . G 7 e .' '0 ,,@ "'v. you p....d the Gen.r.l Ed.catlon Oevatopm.nt (CEO) T..t In I.loau c ...tah School eractuatlonz Ve. ~o Vaar . ,... e. '. . .. ,,(:OUeg.. Att.nded I>a&".. ".ar. "rom To 'J . " STI97C (/. OF 1Y.y. AT A/..iY1IVY NY Q2. 9/71 '_, 1fT OIVEolVT1f IVy ./ 9/7? ',,:"\':"10. UFERENCES. (Pl.... do ftDt ".t ...tattv..) , , , lIIam. Addr... _,. NI?, ROb IRwIN CbMJ'flllVny SHF/.l /ll/DLCCk 5/7] s- I>> 2. I't~, I?oss /l!t:CIfI.l 430 W;f7EfI. sr- . Pr. 3. I'tRS . V/c~/ IRWIN kEAIAJFPY I/b. HIl~' OCk .IUS- - '" 74.5 . :"~ oJ;..,RS ' PeQO:I1!?t JUSffr 81.:1. JJvt:/<LIN IIIll. Rb. 8'42 -/176 ;U;,/lJBRIl)& eo ISLAIIJJ:) 91'110 S. 1"11'1. , fl,()8 1 Vti?RsolII l. r+lJllr:,<ftl. ReS7. . 3!S" - 5.9/4- t...';';"~.qo. --'.-' ". ,... ,-- - ., .., _ii__ _ C'fi! _...II . . 22. A. Special qualifications ana skIlls /S.II/5 Willi maCllines: pa/lfnr! Dr i"venr,ons: your most Important PUO/lcatlons (rfll nor subm,(ccPIU unless requestea}: your puolle speaklftl} and publica. tlons uper,ence: memDtfShlp In ",aleS$/Dnal or SClMldlC soc/tlles; ele,} PLEJlSE SEE 7'HE ATTACHED SHEETS B. KinG 131 license or cerlllical/! Ipllor, f~ISleftdnu'St. /;/wytr. fadlO opera/or, CPA. etc,) C.laleSl'icenst!orcelllliCiJle o ApprOXImate number 131 WOllis per mmute Year SliJteor olherJicenslOgiJUfhOrlly TYPing Shoflllan:t 1. I 23. A. Dill you !lrolOualelromnlllnschoololwlllyauqraOUJleWllhlntneneAlnlOe I S. Name and lociJlIon (City and St.J/elat lalul high sCheol attended monlhs, orao youha~e aGED tllllnscnooteQllIV;llencYCerllliciJte? ", Manlhano rUt " l1'O'tsl Qf~de(nmlllelea XX June 1971 I I I Lafayette High School Brooklyn New York c. N~ml! anlllocallon fClly. Stille. ilnd ZIP Cod~. If knownl 01 college Olllnivl!'Slly. D~les AlIended YunComllleletl No 0' Cre1lIlSComoleled Tyoeol YUlol (If you Uptct to t)raduale wlllllff nlfft monthf.lIlveMONTH and rEAR YOUt;fPec/ From T. D., NlgM SemeSter Qu~r1er Deglee Deglee 10rtctlveyourdtgree. Hour, Hours leg"B,AJ Sta te University of New York at Albany 9/71 5/73 2 60 90 State Uni versi ty of New York at Oneonta 9/73 5/74 1 30 45 D.Chlclundergf3du.11eCollegesuOJeClS No, 01 CledllS Comoleled E. Chler \1r.1dll.1le coH~ge suojeClS No,olCaollsCcmolelell StmUler Qualler SemeSler OUJrler HlIurs Hours Hnurs 110url Biol'<'BL - Chemis t:01L - PhYSics Geol(Lq~ - _Math - CQJ!IPuter 60 90 HistoXl/ - Art 30 45 F, Mdlor rllHd olSlulIy .II nlgneSflever 01 College wO/ll; Training to become a high school BiOlogy Teacher G. Olher ~cnooll 01 Iramlng IIor eumDle. Iraoe, VOCJ/ton"I. Armed Forces or tJUSIMUJ. Give 101 ucn Ihe name anlllocallon IClty. Sldlednd llPeode. If Anown/ 01 SChool. dales al1endeO, sub. jects SludleO. nurnDer 01 cJuS/oom hours ollnslrucUon JW wee~. cerllllcare, and any olhel pefllnenl dala PLEJlSE SeE THE ATTACHED SHEETS 2~ Honors. .lI*.I11:lS.dnd lellolunlPI rectrved ~ tJrl(j1u~ou OUlt' ln~n Engll.h lllllnt langudOeS /o/he, l/loln En~/ISIl, In WhiCh YOU .Ire ll/oltclen, ano IndlcJre vou, lhel OllllOllCltncy Ov llullln", J c~eck ,"Jrll; t ....,llll~e f11111IQ:!lI,'t columnl C.UlclJltllor PellW1lI1 UQlIlflng unnrutlonlllbllJr, III ~ rJnqUJg. OUll' thJn [nQJlIIlIIIl, II. alv'll.nlnltfvlnr conclijCI.1t "'ot, Illlnll rlnguJao. OelCflOe tlfllem 3-4 naw vou !lJlned yo~r lanllu':\lJt Skirt, ~nd III~ .1mounr 01 tllleflellCe you n,)v, n.:ld Ie 11, comDlettd .7hourJ ,f classroom "oI,nml). spa., l,lfItJu.H}e.:l1 home fo, 18 VUII, stll".luahl tIC I PROFICIENCY Can Prrll~I' ~nd Call CO/l~tIU Hh.r'ClhlvlOrl~/I,IJleAlhclu Can lieU All.tlM T"Mlc~1 N.lmtalt.1nquJOfnl Oth"lKl\>ln It,nnIC.lII,lIl"I~II, lie l.4alll'lall,ltt.loI0.nUu fk,rnUv WllllDlrhculty Flu.nuy '''''011 InlllEngh\tl FfOmE~IIUI r'llly WllnOllhC~lly ~"6 R,rt'f1'ICf\ t." 'tilt. gtllOllS "'''0 .lIt hOr "I.lled III IOU JlhfJ ..no n.ave Glllnl" kfla..ltOljt 01 ~ou, lIu.IlIICJ'lons oInd "'heu IO! rnt pOslllOn ror wnlcn you .II.1Plllylhll, OonOI 'tpUI n~mn olsUII"."S4f''''"edundt, Ittmll:f'PIII.nct ___.____._ I 2135 Ocean Avonue 718 I/.S. Office l&.- n- .1u ,"I Drooklyn; N.Y. l1229 645 - 3073 Prsnl. Mgt. I ,,2. , OUCIU.,,., JIII.l. 'lo, '::0<. King Coun ty Ns. .'largarot Mi tcholl ao")~"'d9~ 1!:4"&/r> "'''''0 81-2- 1938 Parks - Dept. I Post; Offico Box 206 Nt. Rainier I Hr. Gerald Sandors Ashford, Wa. 98304 56",'=. 2211 N'l!:.. Park Attach Supplemental Sheets or Forms Here ...:..._"~ J " :~' ...: ~,.... '.,.. " ' '" .,','. :., , . '.' .TERVIEW REPORT . NAM~" ~F APPLICANT; "..,.,~..~..,"",..,..,",.."......,...," PN~l~~~';;~~~,.....""_",....,.....,.."..,......,,.. ADDRESS ,......,. "',.."""......,..,..",........".."..,.."", PHONE ",...."..",.."..'"", "",'....' CANDIDATE FOR; , ................_....."............"..........iJ~b.Tjij;i'.....,........... THIS IS, 1.1 INTERVIEW 0 2nd INTERVIEW 0 3,d INTERVIEW 0 ~~~:~~~:~~.:;:: :'~::::'~::..:"""'.."....".."""""...""'..""."'"",......,, '."""",....,..""" ,.. PLEASE REPORT YOUR'INTERVIEW IMPRESSIONS BY CHECKING THE ONE MOST APPROPRIATE BOX IN EACH AREA. i:-AP'EARANCE o V.rr ,,/lIid.,; pOOl t.d.;n dr.... o Som._h.. c.,.r.1I .bou' plllon"l .pp..,.nc.. S.'i,f.dol1 pluon.1 .ppe.r.ncI. Q'" Good ,,,.. ;, du.., 0 b.tt., th." 'Yor.g. __~.eP."f.nc.. o Unl.llu.lIy w.lIlJroom.d; . "'ry nul; ..ull.n' hi'. In dr'lI. "i,- fR'tE-NDiINESS o Appro.ch.bl.; f.~11 fri~!'~!'t. o W.rm:rri.ndIYi ,~~i.bJ.. ri V.''Iloci.bl. end ~""9ojnlJ~ o e.lr.m;ly M.ndl, .nd lodobl.. o _~:f:i~:!:"'t. d.i~~:~ 'i-POISE:STABIUTY o m.t 0.1,.: i, "jwmpy" .nd !OPp'..,!!"'''OIlI. Som.wh.t I.",.: is ...iI, i"it.,.d. o Aboll' ., poi,.d ., the u.,.g. .. plic.nt. N CI 0 Slu.ofhim..lr: Edt.m.l)' woll compeud: .pP"" '0 m. "i,.. .pp...ntl, thrh'" "!or. Ih.n ....t.!J. p.non. IlH,d.r pr.nll'.. ~ 0 0 V.,., d.,i,.bl. Ollhl.nding (ot lor thi. 'ob. fhi, job. 'm 0 0 T.U. w.lI.nd ue.llont .,p'hlion: "tl:' the poi",." IIIJ.lnm.l., fl"."I: lornlul. 4. PERSONALITY Un,.,;,f.<t"y I.. 0 Q...,;...bl. I" !~!'J~~'. ._ _ thi. job. 5. CONVERSATIONAL ABILITY o o S.ti.r.ctor.,/or this 'ob. T.U. ".rv li'*I.: E'fr.".. him..1f poolly. T,i.. to ..p'.u him"Jf 0 bill do.. I.i, job .t bill". A"".g. "".ney .nd .'p,.nion. 6. ALERTNESS Slow to "catch 00." o K.lh., .10..; ,.qllir., mo,. Ih_" ...,.g. lup'.n.tion. o G,..p, id.., ",ith ....."9. .bilily. o Qllick to \,lnd.nl.ndi p.rui".. ".rr ",.11. ri E'Clption.II'f l..n .nd .I.n. o 7. INFORMATION ABOUT GENERAL WORK FIELD 000 roor Ino..l.dg. f.ir Ino.l.dg. II .. inform,,' ., of li.ld. 01 (i.ld. Ih. ev.r.g. .pplic.n'. []I" f.i,l,. ",.11 inlo,m.d; know, mal. th." .".'.ljI. .ppliunl. o Hili, .,c.Uenllnowl.dg. or Ih. li.ld. B. EXPI:RIENCE o No ,.I.tion.."ip 1..,..." ..ppliunl', b.dg,ollnd _,!!!~j.~~,~qwi,"m,,"!!:. w o F.i, ,.I.,ion.hip b.'...n .ppli,.nt', b.dgrownd ..nd 'ob '.~r.m..nl'. IT A"".g. .mollnt 0' m..nin9(..1 b.dljlround .nd "e.!ri...~~.. o Bu19fownd ".''1 good; con,id.,,,bl. ..plti.ne.. Eleell.nt b.d9rownd .nd ..p.,ienc.. o o H.. pOll' I., d.fin.d 90.1. .nd .pp.." 10 ." . _~~hw!.~.!.p~,.... ;o.-OVERALL o Appun 'A ,.1 90.h '00 _ _.~ro:,"tQ ':ct~.~O~~~~~I"" B' App.." to h.... ...r.g. go..I.: puh forlh .".r.g. .Hor' tg ~..ch Ih.,!: App.." 10 ..,i\.. h.,d.O hu high d.,i,. to ~ch!.!.. o App.." 10 ,.t hi9h 90,,15 .nd 10 .hi... ine.".nllJ' 10 .chiev. th..!~ o 0 O~~!liI.!t II"..t:-,!..cf~~,.:.. Sub!.t.lld.,d. o O,~;~~~o.._~!... ~ Ollhl.ndinq. o /1.."..9.. S APPLICANT SHOULD BE HIRED: YES C NO 0 IF NO, STATE REASON: ..;......................................................................................:..........,...................................-...........-..........-................ ....-.. .......--.. ....... .......... .......".................. ....,..,...........~., .-.. ........ .... .......... ......... ...... ........... ....... .............. .... .:......... .... 0, WOULD YOU RECOMMEND CONSIDERATION AT FUTURE DATE FOR THIS OR ANY OTHER ITlON? YES 0 NO 0 REMARKS ..................,.......,..'..........,...................................................... OIT/ONAL COMMENTS: ............','....,..........,..'..'..... "",'.....,....'..','.,..,'." ......,..,..,.,..,............".........."...,....,...... R'~1IiIG 5T::~;~:~~ii~:.ON REPORT OF ACCIIlfaNII ClalmNo...._'m'_.m..~m...:.n . Implore, Mus.t'_Compl.'. fbI, R.port by FnUng!n and S'gnlng Employer.Settlon Below, Th... Mall .eport at OAe. '0 ~j , . . D.parim..' .f L.ba, ond l.d.",I... "".<tOffl... (5.. IOvon. dd. 10, .dd,...,) , ' !Y Firm number of em?JoYlt'n~__.g.'-~g::~____________Tet.Phone No.~~2:~.2.C!~____~n._ Social SeCW'i1y No. oJ wOlkman_,.;.~__":_n___._.___;"__ IE (Numb."..I,..d by "p"'m...., Lab.".. "'''b'..) . 't, 9 3 :~ Finn. ..m. of.omPloy.ut~_U,..519..__J?!l.p!l..__l?!._~~__________.______Add,",._l'~~---~'!!!~.1...~8 Zip 5", d. ____...'------- <1.2 Hav. thl. wod".an'. hou," bo.a included la p_olla '.po"" 10 thl. '.porim.o" ,____~__.._____, 11'0, in who' ola..? _______::____._,_----,______ ~~ ::;:~::~::::::i~:~~~~t~~~~;~~~~:~~~;=~~~:::.~:::~:::::~l:~S~~~~~:~:::::;:::::::::::: 3: a.. - -, ,'" -, -.: - (If enq4qed In eon.lluetlon work .141e p4rllcul41 kind) ~::: Ch.o.k in whlch'dop.""'.nl wo,Ion.. w... .mploy.d, Co'.lru.llo. 0 Oper.noa 0 R.paIr IJt On I.unched boal 0 ...' Nllma of ',LoU A Lnraen, , HaJJ he any fmandal, no _ _ Sole owner? .. ~ Injured workmAn --------------~----.----------.-------------_________Inloreat In the bualnesl? :-_~----------.PQrtnllr? Corporate oHlcorL;.,'':';.:.._____ ~~ WllI'hla wo,Ion.. bo hpl o. ..I"y dUll.. hI. p.nod 01 dlaalllllly?__m___.._____lf so, .tt.cll .. .apla..lloa.-----!!.q_~~._~~"____:_____c Ii 0.10 and hou, a.' .ccJd..~~~~~_~~_~Q9_______~ wi d.y wo,hd ----.-----~S----------O.,. ,.IUlnod 10 wO,k---------irioo-:.;-lii30 :; Was, workman engaged In the regular COUIIII of hi. employment when Injured? ___:2..____________________________ Sh1ft houra________________.---- a..: DJd accident occur on your premises? -------I'~.l.t_._______lf Dot, wherll? _"-__..________________________________________.___.--------;....;.----..;--_'_:- ~:;; 0.1. ..d hou, aceldo.. '.pon.d 10 you--4~17~~"_,___________m___.a: To whom ,"poried---W...-}!OJ(1M!L_.m_.Poallloa_~1J.1rt;....:__., ~ :::o;,;u::::::."::;:::~_:l~!~__~;:~_;:'~~:~~:~~.~~~~~~~~;:::~~:::~:~::::~~~::::::~~::~~~:~:~:~~~:~~:~ 193~~;~~f~;'~~~~~:~~7~;'~~8 "C"'ildj;;gt 7;oi;;";cn7aii. ~;p; j;, - ;;O~'-";;;;-;;-';A;M~-.,-;:r~l_- -...: V;~'-~ -_J."~~~~!=:'~;r'-T Medical Aid Billr a.lluwahle by law. By--............................,;...,;;if ,n., ~. : Claim NO._.._.~....:::..::L,..'.n Allowed for a'u/horized Irea,men: ,Clahn. E.amlner pr~. ~OKEY" , Firm NO~~~~.'..~.~~nn.'.~.:.~~,;_...~'.. and aclion as indica'ed, By--..ci;;;;,;.;;;;;;;;i,;~;"......,' :,0 ".... C!ass,.._.._._......._..._n....... EMPLOYER'S COPY R 21611.6 !Nol Claim Number) MEDICAL AID AWARDS Dale NoU~ ...1 ConL.,~...n:'. Nmo.oI injured worlr:man.~--~bE..L.L_________/:h:~.)J..ddT,. "IIISf' {J . I"LC.,,:I::~~ Oil no Addre.. (to which all mall to be addle~ed}__..h3L1fC-_c:..6.::Z_h__..<.,.~, LC-_______:..Cl1y and State _ _:-.___ ._.._::Zip ~d~ "_~~,~~__. :/ d. '_k J, . '- d,"<""",,- /fj 1-.-/<; -If' ./.'"'2" /.L v , Your Job tllIe whonlnlured.._... t."'1..t..<..Lt..tJ..J;~7/:;,~_..iJ.t... ~ ..::...::~.. Sex /_:.t...._.. AVe .'-...._........._...Hoight....J.._... ~._ Welght,._ :a_~. b ...._,...~-_-'i"-~._=M,<__::_l___...;;... "....:;~~~~~',. .1~:=-:::S7.ft:.:__::':.:.~~:~~~.;~;~:;:;n;~__."_.____....___ __c?:~-:2~~;~~~:=:~~::~~:~~:~:?:~~C=:::::::: ;~ Was tho acclde.1 I. you, oplnIan c.....d in any w.y by somoon. 'a' .mp)oy.d by YOUl "mployo,?___.~2-.______ - . -:------" / -117-6<;, If.. / I. oJ/./..;I . (Y.aM,old . .: iii Oal... YOU'r.. po. ri",. ac". deal '0 ".mPIOY .r.....:........_....'.",. '.. r.p~'rted ,-.-.-t_t....ci..-D...!./",. ~c..~.!.!.!.~;/.k..=_. /.:d.~.:~'..:Q..,..w a. '. ...... , d. a.F.' .'.'.-..'. _ .'.. _.'..~ .. l' . _I 'J ///- (If.....ttO.1 ....// ,Z'..1 Z II .".)0'.' ,,:,ao aol a,~n.d th...... ~al. GO tho _ . ',.-{~,L(.a..ldf.."...~:z.u::.".L..-'-",f}iZC<..:..c.J.=.:;.;;.L;"U.t4.q::-,." 1= ~:=:'~~"l'~~~:.:;~..--=~=:-:'=:-======= II dl..orced cmct rOil hcno. minor children .ubmll a copy O~:lh~:,~ourf Ord.uho",lnq I.qat CWllodlcm of .uch children. .Ilho vi... pr.'.h' octclr".. of .ucb aullodlan. ,: . , OIV;I~:N:4M.ES AND "SlIt'rH DArES Of YOUP CHilDREN UNDER II SUPPORTED BY YOU ,.' " "AME: / ~X ">"". """.""',,~ Da,.01 lIlrlh R.l~tf?n.hlp'lP' Mo, D.y Y...r NAME R.lallon.hlp D.fe olBlrlh Mo. Day y..,. "'\, .,',:;'\,~'.,....:."..~ R216116 Hot aalm Humbtor) H.m. of "IUIOd ...,Ianu_~J:t_b__~.JII>>_____________________________._ _._________________________ Add,... ..1Jo.r..5'1-________.______ .____0.. --------______Clty Qutl.ofIM.... Zip Cod. ___0._____________ EmploF.'_ oT"fj'1R'4on..-CountV.H~.41pt.--------- Add......"PQrl-:J'_B1Idy-1ft>8h.,__ d.'. Inlu~._;fj1616!l__.__._._____.__ -________,001. Ilnllr.a.....,.___4/l.'1/.fi9.___________. __.Wa,.....'. A.. ,l/2fl.!.8...i;oiiiit;.j--'--' RIololT of'~nJulJ',OI.at"''''d''la..lYOd. ".. rl,blor '.IU --r.tftlng-1Jf1d-tJut-"Of-d'toh-4r~./R11;j'----_-,----C------h.- '...~~-.... .-~--.---~~_."_."__4 -.....-..-.~~~...~~___4_.. .__ ~_._.._ ~4 _.... ~.. __,~4~~~4 _...~~. .__~..___..._..___.~~~........_.....~.._.~.~.______~.__...~..~~. .. 3'" !le ;~ i1;l if ~:i ~~ .. ...w..~~~..... ~.."~.1 ~~....-.. ..~~.. ~....--...~..... .~_~ .~w... _~._ ..._ ..__~.... ...~_.'__..__ ._..~_.w_____ -..------~.~~.-...-w-.-w..._....~~._w..__w...._.....w~_.~_ .-~-.-.. .'~~--.~~ .-,.". -~~..~~'...... ~ "4~.. ._4. -.. .... ...._~~-...~ _~..~ ...~.. ~..~ ~".'~.4~ ..._~_ _~_.. __.__.w~_~.__.._~__._ ~..._.__._~_~... w.._._ww.._w~..._...~~. "')'d<<lI. fllllcllll" I" detail (U .IltnNlU.. hn'olyecl, vi.. "vht or 1,'1). ..---.-.....--..~-....~--~---~~-...------__..__~._u~____.__~-~......____u~:_...._~ OIa.....I.__y<U7'- ..trr,d.--r.tght- .tngutnaJ .1_A''''___.___ _____..__..________ _._._________._____._______________________________, 01.. . ....1..... 1laod.---~-liJI'---..tO'.7'..~-_rgtoo:lll1-1lO0II----.-----.____._____ .----.----________m_~_____.__. X'''r lind'-________..EQI:l4_.tcUn._.__ _..... ______no. _ _____ .___.____...., _.__ _...___ _:______ ______ ____________.___.____._.___________ If.. workman had pr."'-SOU' inJury to ar...?~..NO.._~.....~.~...__......___...__........ .~..__....~._...~..~....__..__~......._..;_...._..._.._...._..._._......... Hu. JI'Ofkman '..r*n tr.sl-.:l b, upon. for p"..nl or slmlJ'r C'ODdJnoo?.......~..NO".....n~..u_U ,.... .aplaIA_..._u........___..........______.___..;.... >._. 1 ..~~.... ...~~...... ......... _ ...~._. ._~ _. ~._. _'" _~......... .... _ _~~ ~.. _.. _. .._.... .__._~~. ..___..._._........__...._._.._.._......~.._......~., ,. "._,,___.... .......... "',",. -..~.-...... .--~.. -.~..~ -:"-~ ~- ... .... -'.~ _M'_. ..~...... ~ .~. ._.~ __4 ..... ~...... _... _. ...... ~...__ .____..... ....~........ ~~....._..........._..__..._....... _ .....__.,..._. I. Ih.r. Dr p......I.tlnV dl..... 01111. ..r...lalwlod?~_No....~......_:~.........._~__.._..._....._.~_.._..._............_..._.........._.....___~_.........._....,,_...._.._.... WlIJ 1hJ. or aa, oth.r Pl'Hlhtlnq condlUon complkat. tre.lm.ftl or ..lard rteo't'.rr?~..l{o~.....uu_~.....u....__...u....u....u~..;__..._......u...u__. II COI'IdlCSoa dlaqDOMd Ih. ...ult 01 .edd.nl d.acrtbed? V.. 13: Probl.bJ,'D PouIbJ, 0 No 0 If hotpltall.aaUon r~. lI..m. boapU.J.,,~.. --.. .....-.......... ........ ... ~;......... __ ~___.. '''~.''. '.... Addr...__.... _.."4 _ ..~.._._....._1 ._............._........__...__... uUm"led I1me 10000a due 10 In y1 ' . ~ 'ow ..... ud"dd~' ---".;.. r'PHIT... It. "1iiiTf7'ift~ii." !oJ' 1"........."'.1"." ,-,J/.}IJ.O;-9.- -.., Add'..~:lIed..1I1dg.l..1lJ6...at",..st;,-J'o1't~O~'Ifd;.....--~' lure.. ~~~ . "...,,",.. _.~,~.... _"""..P. ..ActounINO.._.n......__u_...... ~~_^._".._.._...~_ I),lP\,O'ffll'-.lIrMovr SHflr 'WO._ rINK COPY-flUS IS YOUIt COpy :, .;; ::!r::~G!:JI.,:i[~)lY:;111"\~7.1li\~li:;'f:;;~~,i:X?: ~~;.~:~i.~ t;"li;'J.i(:~!!;,\'i,;.:,;.::::i:~".\~!::i';~ti;.~I::;~;.X{,i;;ii.~:i;:;1:r,:";,;:y::~::,;'::::;,)1$i:(~;;i:i:~\.,~:,: X~:;;;,i;:~;::i::;,;y:i/;:il(H~i)'f:i~iPti'i:~;!n~:,t,;...:.. ',l,:':':/'~,l;'- 'i."r,' ;,"',1' '" ~\ " " i.-;""";''- 'II;" (U,. 0.", ".y.. Au.u", NUMt.er I'a...p) F,_J1~i' F-- J .jl,~ ---'-'.-"--'-- .... .. -, .- T___ <- iiil[ -.. - JI w .. __.~i," ..' --. "'.., ". . rran - -.. 11 -_...~.,,_. ,,,, ..,..... 1'1 _ --jj1Y" WASIIINGTON p. EMPLOYEIl'S ItETIRE~lENT SYSTE~l. NOTICE OF SEPARATION A'o 1-31.-79 ENTER GROSS AMOUNTS PAID BELOW Amount Month to be Reported Salary 1,748.00 1-31-79 Terminal Leave 59l.5/3 1-31-19 830;32 1-31.79 Lc11' THE FOLLOWING EMPLOYEE HAS SEPARATED FROM THE PAYROLL OF THIS AGENCY First Name Middle Name Sepuratlon Date o Resigned mtRetired o Deceased o Ineligible Position o Granted Leave of Absence without pay ur.tl1...................... Dote ..-_"._...".. ___.llf__.._,.... J!f.~ r..-...'....'..--'--.-. ""'~~~~,~"~..~,~"..,"',...,'" Emplo)'cr Adeney ~':'~.~ ~~::~h.:n~IlI~~IO~l~~~'pd~lt\~~\U~eJ~~f~~~tn ~;~r<fer~l~n~ ~~loi.~\O b~g~~~~lfnl:;l~lI?eT:.cr. .............signaturc.o"i"per.60.nnc"i"iir.pay.r;;ii"o.iiicer.............. .'. , !Oept of1& tcopy ',',0,,'lR; Bol<>o'e comple',ng ,eclion below ,hoded area, READ lEGAL WARNiNG on reverse 'ide of ,hi, pClge, : Top po'''o.. 'ubm,".d PHYSICIAN; Camplelo Physician's Roportfl"'ch lop portion of Originol where designo~ndsubmillaDeparl_i by phy,,,;on menl of lobar & Indusfries, Allen'ion; Accldenl Reporl, Claims Seclion, Olympia, Wa, %"04, Delach Ihe PhYSi-: BO"om po<ho.. 'vbrn"l"d cion's Copy (3rd copy) far your files and promplly maillho balance of Ihe form 10 Ihe empiayer ('his includes i by urnp'oyo. the ballom porlion o~ the Original and 011 of the 2nd copy.) I :EMPlOYE-R~SCCjpy- TYPE OR PRINT IN INK _ REPORT Will BE MiCROFilMED, . 9. F. No. 764~-ttl-10M. 28001. . (LEAVE BLANK) WASHINGTON STATE EMPLOYEES' RETffiEMENX SYSTEM Member No........._................................. Date ot entry...................................... Orlg. mcmbe~...... New member...... PRIOR'SERVICE Date DPpro,":cd by Board EMPLOYEE'S PERMANENT RECORD To Be Completed DurIng the First 30 days ot Employment by All Employees in All Eligible Positions Certification NO......;......_..............._..... Date issued.....................;..................... TO THE RETIREMENT BOARD: ~s a condition of my employment under the requirements of the State Employees' Retirement Act I submit the following information: SECTION A, HISTORY 1. Name~_ -LeU~- ~ 2, Permanent addres5-llox..3OSI('st;;;.)_____ --QlI1lclffi&;- ~ --ill\llll;;;;- 3. (a) I began my present employment with,.....Jet,feli'SOljN~.PW1.~ ~W"Ml~~- at "-__,____ on the.--llth._,__day oL-HllT----'---:--, 19'~j-', ' (b) Title of position__fmck-Dr1.ver-_,____,..__,._"__,_,_;_---,-:.:........:..:.:...:..~,..:..__,___ (c) (If applicable) I am also employed bY-"'-"---mameo'd.."tment,comml,,'on,a.,ncy) 4. Present rate of monthly compensation: , , , .' , .', Cash Maintenance Allowance Total ,(aJ (C) llO.....-- ,Record of service to present employer and other public agencies since October 1, 1947, to date: Whom Service \Val Rendered Name ot Department. Commlulon or Agency TIllo ot POllltlon Held PERIOD OF SERVICE Deglnnlng Ending LenKth ot Salary Paid Period Mo. Day Yr. Mo. Day Yr. (Monthl) 10 19 $ 10 19 $ 10 19 $ 10 19 $ 6, I am a member of or receiving benellts from the following retirement plan or plans: '___W_W_,_,_,ti_, _____w______ti______... 7, Social Security No,532-'"...J.4..-a603_'_ 8, Check by (X)-Marltal status: Singlc..___ Marrleej__ Wldowed___ D1vorced....___ 9, Check by' (X)-Sex: Malol_ Female,_,_" 10. Date of birth..JIIllIAJ7....29..->>18--_ Place of b1rtlJ>ou1abo-;;::;;-ntUiIn (MonthT (Dll)') (Year) (Clt)') 'II'" ICoJ(IJ!IlWl:g('QIi;;i;)'" ~:~ 0;' ',','" It-..--." . "(,.-'<... ; OJ ':3 'tl " ~ 'Ol E " ~ '2 " ~ o " "" .5 " o ::l oS " -E " o g. ~ m r.l Ol ~ ,.Q t.l ...- ~. ~ 1> -- ~ 1;1 r.l',.Q rn ~ ~ 0 . f~'~ ~, "R f<<' $ '~ ~ ~. ~ ~ 2 i>< S . ~ ~ ,.Ill :(j ~.~ E:; ] t.l ~ f}j " 'E ill .. oS ~ ~ .. oS "~ G ::l g; Ol " ~ E ... ,.Q " lil '" .... -- -----, ".-- .-. II , ..." ..," ~~--.. ,'," '.; ',.' ~., ....,. tIE ia:[ ~~. DiE :i!s~ ~~3 li~- ~II It~ I ~ ~~., ~ I _1l I.c .~ 1:<: ~ ~~~~~~~~~~~~~~~00~~~~~~00 'C:.. 0 jl~~ ~ ~~~ ~ ...' "'~ ~ 8 ~.8 ~ ~ "'~ t;~ tJ E~ :> .... 0: 'p ~ 5l ~ ~ 7J~ ~ ~~ ~ ~'~ ~H Ol 0" en 11lf: ~ ~'~ ~ ~ R a ~ ~ z "~i .~ ~~ P:: a'O ~ 'g,~ ~ ~ ~ ~ "~:8 ~ fj 1'1 ai ~ 9 ~~ &3 gj -a '. of o.l-r-:1j . o o 'I a ... . " o -t-~ ~ o E tl s: f5 ~ .. o " e ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~ ~ ... ,-j ~il ..-{ t ~ <r. J. .~ ~ ~ ~ ~ ~ ~ ~ ::l ::l ~ '" ~ ::l ~ ~ ::l ::l ::l ~ ~ ~ '" '" ::l b .; <lid .; II ~ " !~ 'lI" . " 1< .. o .g o-'l ~" ~f L <~ j, .. " " .c: Ol .", " '" " o ~ Po. .. !E ~O i <- C ~ ~~ ~~ 'lI< 1I Il ~ e ~ j l'z ~ f t tl S '" IE ../I I~ ~ j5 lo ~ : I ~ i In: 'lI ! . ~ " It. il I 11 1I Il MOI>>1tN9. ... N ,., .... It) \('I ~ co CPt 2 ::: C'I ~ :: ~ :e ~ ~ ~ f: l'J fj ~ ~ .... .. .. il. o " 8 _,,'--'_!;lI""I.~ '.,,';.,::',"'; :f"' . ',;''-<:."..,'.f .; !l s ~ g . . -~-- .-. ". ~"h ...-- ~ '" - ,., ,-,.,. , ., ".~."\ , I' 1"',.', I, " " , ' ' ' . ,.' " ',,'" , 1 . . I" , ,I' . ',I", --_... .I. ,._".,.. '1711 v~' 1 f1-=~ .l~ I'"'''' ."".. n ! -,~..~.' ..,:>.~ lu,--,,~.:..t.__ -... ~.' _.......,~- .' ,-'-"-- ~\ I,~ _: ~~,,~. _ '~', I " \. ".\_' \' .';- I. ~". ~:~ 11. EHPJ,OYHENT HISTORY .ginning with latest employment. A. Company Name: Phone: Address: City State Zip Immediated Supervisor: Salary: Job Title: Dates Employed: From To Beginning Final (Honthly) Specific Duties: ************************************************************************************** B. Company Name: Address: Phone: City State Zip Immediate Supervisor: Salary: Job Title: Dates Employed: From To Beginning Final (Honthly) Specific Duties: ************************************************************************************** C. Company Name: Address: Phone: City State Zip Immediate Supervisor: Salary: Job Title: Date Employed: From To Beginning Final (Monthly) Specific Duties: *~**h********************************************************************************* D. Company Name: Phone: Address: City S ta te Zip Job Title: Immediate Supervisor: Date Employed Salary: From To Beginning Fina 1 (llonthly) Specific Duties: Form 100, V,P.C,C., Rev Dee 1974 ----'..',.. ,.. ". --->-..-.,~--...-..:-..-...,.;.......~_.. ~-;-':....~.:.-....:..---.......-;..,......:.- t'""'rr-.:..,}.;).... ,"--:...:-... ~--.- ".,.-S!r;au"_~........,.,~1JIl r . -,--,..~---~.- '" y ""'- " " '.. ~,....,......,-,":~...,---:".-'.-- ',,', :.,~."-',,,"....~ ~~- ",: " r,,-'.;\ ',,'~~ '~:'~"?;, _~,_....~..JD.._~ ---...~-~ ......"" ,'1;-. ~.'-.,' -,-' '1~ ~.,'" 1~\ I \~-_:~~'" :......,..-~. r-" :,.. "'.,,', "I::' ;', " '. ., ,) ,,' '.,,',: ,.. ;,j.> ;::~ :', I', ~:';I ;.(,' " , :,.',";'1, ,!,':"~C: '. ,C.:::, . ,'.,,',' r-- ",.::,/,:.'i' "'.,,,'1. ..~ HI! -.-- ~,- " . . - --. -~- _..____W(...,~~ ':i~\t,;:: . .', ~.... .1 . :,.... : ,,~. ">,< . ",.".",..":,:,,,,', ',,;.' ..'.':, "" ',,',;" .'" : ";' ",,:';. .; ,", " ' . '. " , " ': '.:':':'! ;"',' :.,:,:.~ ',' ..'.',. .", .," ',..,,:.<. " .' ';', ..' :', .' "", " . ,:. .. '" ' ,,' ,,:. ,;,:: " ',:":, n:.',':: ',. ".: ,,','.' ':< ,.",' ,', ',,:',' " " :. ", ""'," '.. . , '", ';"," ,." :. , .. ", ' ';.:, :,':,.... \ "''"., '. " ," ..."." "".. ,.!,' ," ,,', ,':; ":,' .' '" C"':"'" ,'.: , ',' ,': ."-; ': , ;' .: ',.',' '..,. ~ ',', ", '..... .'.., ..' , '" . " ."' . .,' ..' '.""" " " '., ,,",". , , " :, , :- .' .',. ;:",:. , ",', ,,' , .".' , , . " . '. '" . '>:';"-~.~.' ,:. " ~ II"".'.,' .......J.~t..I.!.~.......:-ii~.ir/".:.{..:..c5.'.......,.."... ".';' ~ - " R8 No. 7649-IRev. _'~?31 .. -ron-',..... Govt. Unit Dept. I EM- PL8lJ'R;<:~ (: 71 (: / Refer to your Transmittal Report of Deduc- tions, Part B. Write In department numbers. DEPARTMENT OF RETIREMENT SYSTEMS P'AIC EMPLOYEE'S RETIREMENT SYSTEM. ""NOTICE OF SEPARATION I SOCIAL SECURITY NUMBER I .)",1,'( lu I'LLII THE FOLLOWING EMPLOYEE HAS SEPARATED FROM TilE PAYROLL OF THIS AGENCY .,- Last Name First Name Middle Name I Separation Date /) /Jj, ,:/ ~ /"./,. TiJ / ENTER GROSS AMOUNTS PAID BELOW ,( o Resigned l1}--Retired o Deceascd o Ineligible Position o Granted Leave of Absence ~~,; CROSS PAID FOR: Month to be Reported Amount Salary ---) I. '// '/'-/ without pay untiL................... Date Tennlnal Leave / ,/., / , '/ "r., " Sick Leave (' ..., ..,t,:::,~,':,:::~j;:;2:1~p.,:~y,~;'~::~:::':::':,',: . ../)' / ,J INSTRUCTIONS: Forward white and yellow t"oplt"s tu Retirement Board. Pink copy goes to Mceney Pa{..oll om~r. The last month's salary and the additional deduction for Terminal Leave must be shown separately. /: ,', }, _. Othcr ~J ~ ,..\;. '., ..' ,', :..:,' ",'>< '., ....... ..... ~:,!, ...:'.... .', ' ". ",': " ,,,':.:' .<'::. ", ...;. , ."', ",::. ," ..: " . -: '.. ..' . :' '. ',: ....: .', '. ",., ", ;,' .' .,,' . ,."......,: ': :.:"", ". ", '.' ',':';', :" ':,.' ., ..' , . :',' .." :.. ' .. .' . ":. '.'." " ' ':;,,< ,'''':. . ' ',' .': .:. ' '. " ")" " ....... .i,:'<' ..' ". ..... ...,...., , '.' '.: ....,..:. ',';. .', ,'. .:' . . '. .. '.":\'.., , \ ';, '::',',;::;::".:.' ,.,~, :, ..j,,', :~':,",',:" ,:; ,- '",,',' ....... ..';, . .' ,:.'" " ': ....... . ....:,., .' , .' ":'.: ". ' ., '. :. .,:' . " . :: .: ." '.',>,: . ,:' ,', . ',' ,'.:,:";:"..: ,. :',:", , . ." '. ", .':' ;,:' ...... ,... ' :'.; :i. ' ",.:', ' , ,'..> .' ',". ' ";'.'c. ,; :.' , , ." ....". , '.. ' '. ',' ..,',".,,:'.'. ,', .' , .....,.",.. :"., , "'., '." '. " " . '. .'............. . ;. : :. :".' " " . " .: ':' '. :: ' : '::,,' .... :'.' ';:,," , ,::" .::,'." :"",,,::. ."',: ' .' ..' ", ,.' :..C..::, ': ",' :i. ,.,' I" J~ '. ::. ..c. ,'" ,'.: .,'" ,~;;j!i! : I, i ,,::.... i,: .ji/:\ :" ".; ..' ....~ . ... , ' '" , .'::"'; DftARTMENT OF RETIREMENT SYSTA' Public Employees' Retirement System Final Compensation Report "compensation Earnable" in Final Two Years of Employment NAHE: JOHNSON.,JAMES M SSAN: 538-36_2041 DEPT: 220901 RUN DATE: 06/30/86 . TERMINATION DATE: / / I J *STATEMENT OF WRITTEN LABOR AGREEMENT COVERING THIS '.,..' EMPLOYEE: DATE SIGNED EXPIRATION DATE CERTIFI,ED BY 1. Amount of accrued vacation time , .' paid at retirement. .,2. Amount of adcrued sick leave paid at retirement., ~ Dollars }.JY..t!O ' /t.J?n0 \" { ~ ?'/. .a..11 .~ ' , '3. . ,Amount of other earnable compensation "paid at retirement, i.e., retroactive pay, severance pay, overtime pay, clothing allowance, ho~sing allowance, e,t~:, ' ~ ".NOTE: .,We can use only that ,annual leave, sick -;leave" '. etc., e'frned in .the ."f:I,nal two.years of employment for the Average Final"Compensation', purposes., \YOU must,nevertheless,transmit contributions on the total amount paid at "retirement. Sick leave cash outs are not to be reported for state, school "district, or nigher education employeeS:- ' ' ' J",' , "',:' ,', ",",' ,,', ' " "', ',' ,', ,," ~''', " ,,' ,:', '. I I' I ..... _~~_.!!!l!'"IT1.-~~"'n~~~., _ ,-..,. -'"- - -.... -- .....ll;,(-~ ", ,,', 'I, ., I ' '., I. I \' , """',, ' , I , " .: " " 1/". ..,' '. ..- ~ .. - "",~.~."""'~ .~ "-_.' - ,,"'!ll. ~" [ -- -- ~...'1 .11 ~---- .~-,~_. ,,_."' - -...~- ._ .~"'..; ; JiIi,,"C:<'ii'l, .~....... .~~,/~.wil- 3 :a ;: ... :gg '" ~ z " - '" '" z Z 0 <( ~ ~ ~ ~ ~ ~, ~ c{ 'I ~ ~ 0.; ffi ~ ~ ~ :;; 0 <( ~. . -" "' ",..'" .~ , _. n _ "r"" .:::zrr::. ----'. ----~ IMPiOYU, ~, HH>tf\l' "11' - ~.,,~._"'--,..,.....-- - "" Iln_ llfUUII ~ ..JliIlli!., l~_ ~ r-:?';:;:~ll -.,---.,",' ""."" to ",., __ .. !lII,", 1......'II.~~.__~1Ii ~ ACCIDENT REPORT j""""UM'" ~ ~-,: ~;i;:i.:>:'; _,j> oyerMI,l11 Cpmpt.,.Thlt Rcpell' by filling In Gnd SignIng Emp " SwlonBclow. Then Mail Report 01 Once III \ Departmenl of Labor and IndI,l11r1... Olympia, Wo,hlnglon 98504. Al Aell UmR If MO~f SPACE N[fOW ---i"-',--'"~" .",-'-" ....-- '~-ADO~fSS-' -... .__.._~'.m_~. .~. "-'---'-'"'-"-'-"--""H-cIN-i.sl;'i~'''--'*---'~-'''''- '-'zifcoiii"---" Je1'f'ereon County Highway Dept. Courthouse' Port Townsend. Waeh*, 98368 . b~;:~"~,:~,~"r^lfT:~~~~::::~i:=P-:~~coieo'~I~~~=:~::::;~:~:;,~':~-=:-=:~=--===~~::;::;:::';~':"-.::~' l"O~~~~~AhON'" ) (j i'('1' ....:....' .,l':"....:;.(,t.:e;:..:n;..;:"HUnt~tord.' ..-.. ". ,.. . i; "534'-1~.9667 'S'NJU~El)fM;;LOYfE- - - -y[S-:!;Q- ~:,fYES 5rAI~-WIH6;ANDGIVEllil-i r- --.-~ lE.MPlcrrER~slA9&iNoFI~MNUM9l:~ -- - -!INWIiAT ClA!.SWlll . t: ~~~O~~:A~:~m~(R? ~'~'. ~x / n~:~:~~[:.b:HD? 2 rF:. "-=-(MPlOvtE~E~l9itDIN"'!.H!CHDE~JtT~~Nf?- ~ -1 ADD~~~SOJtlOCAT~ON INClUOINGcciuNIV wHmACclotNTOcCU~~H) -- - -I srAH.../;iEFE 1~~t~\S JOllSllE ~ (C~S'~r~o~:l ::A;~IO~J~l=J:::U~Ct~E: llO~T l__~lrlmac:~, W~~h1ngt~n .~_ _ _ _ _ _ ~ _1~~~~_, . _ _ x_ ffi ~A'lM~I~:;g~~~~( YES NO IF YES A""CH IOAIEOFACCIDEtlT ,liME AM: DATE REPOllltD TO VOU 'TIME AM] ~1~~~I~~~(r >- NOIEMPtOvfOllY'l'OU? 1./ "x EXptANAfION 2/28/73 : ll:OOpl(l ~3/1/73 ll:15xxl NOrmORlfO 9 lASTClAlE wooeD--~E JifiURNfOlowoiK 1 WA-;-EMPlOYfEENGAGfO ,N' vis NO -II SfflflltOulis -1- 00 V~QC;;';~~-- -vis -NO' -- IFYES .Wlty? .-- ~ _~L~L?i__~_1'-~_ t~_~!!__. ~~E~~~~~~~rc~~~n'~~~~~D' ~ ~ 8:":.4~30 _~. L~~Y~~~~~?__:!.~:~ _ tE~~~~~~O~[_ . r Will YOU PAY litiS EMPlOvEE YES NO IF YES EXPLAIN 1 (NIH EMPlOVEE S OIICK"Pf'II'OnlAlfCltCt(,.. _ FUll5ALA~YO~WAGES j RAfEOFPAv. 4 84 HOUR DAY WUK MO~TH ~ ~~~~~_.~ :JJ1______ ____ _~_~ ~~~~~T~M~~-.-:_-:_~~~1_~#____€.L_-,._:0~__ ~ ~E~E~~~~rAGE ~~m~rDAYS flAMESCHEDUlEDDAYSOfF ~~~ $ EMPlOYEEE~.1.._ satur~_~~undaY 'f 11 .>~::'" -' ~ :'::::::.:: :~: ::':'" r~~t':~- ,:-: ~\ .--.----------- , ~\I;.-;S i\i> ~- --- ~(if'~\\'~:~.::~" ;'-~-: ~ -0:- ..... ---::-.-- ---=---::- '" ^ .~~~~ -.;; -'!"(------------~.---------- -- ~ ~~?~~-----.-.-- -i,:'"";......:if;;r'(::;:.L~;~:::.'i:!23~~Z~ke~~ ! ,:c~ty.-gnit1~i~:~-;~T1~~;~~.~- ~~ ,~ (,~ ,", ,:~:,~y; < ~,AMEOfINJU~fDEMPlOYfE . FIRST MIDDLE, lAST ...' IIE~EPHONENUMBER (~\;"j~~"') Ch,,/.~.6 or,. /_LE:"''':''-:/ f'7r"2:::6-LZ 12-' - '-f { M^tr60~"'2 ,/3 0 X 8.3 (: J g d<.L Fl. ~ e tV e, IV-.4'Lj.' ~'_ OATEOf~c(jO[NT .;, j HOU~A~CloENt,occUiiifo-1 SHIFJHOU~~QijiJOllT.lrlEw.tH.E~.It~J.UR~O-:-_A . : SEX ~ r.:t-:l..8-'7;3-" 1/' ~ .-L01"<,,-/ifoll'- ./'/, r~o^,' .'^J;';;O,,,o GoY' "" RHU'''," rowOiii:;Fso~-r;:;;;rn;;;oo'NG 'OU.--,,, '"Nol;;;;;, WH'''' 01.'1' ....: :J..-y,... 7... __~._.~___~F~2~1~~:~~~~__~~2~~~URHD S(9 (J I~ a:: NAMEOHMPlOYEll ' ,- , STIlHTA['lORf!.S CHY llPCOOE HOW lONG HAVE ~ .:JlfI:;~O' /1//1-/. .19 ':L!::.. ______c.I:i.!:lf.~Y_~"L__ lii!tr...~~~~I,O' !..244. Ill: EMPlOVU So 8IJSl~IESS ~~ OR N"tUIlE OFI 1 ADDRESS OR lOCATION. tNGUOINGCOUNTY. Wl-fERE ^CCIDENT OCCURRED ~ J!..1_!1I" 1'" "'/1)' w, C ptJ.5 T. _.__L__~./i ;'1-fAr(3._(:!..L#."A- 1..i:..---JYJ. CeJ ' \~~\-<_____. ~.r0,C,,, u,."^"NG:~~:&~~~:~~__L~:;!?~C~i_.(~L<: T ~__.'-:_I I.e .,/ !.,~V J' II!~!~,-~_ :::,' ~~tc~~.~r~~~~[. IDlllNAMlO"NAMECHEMICApV.A/.J... e /)I-'.t..//lv"f- {"~vT ~11~)'rr:,I.r /;)/;t! ~ '---;::;-.61" d4 rr: '. T;' A-~7r';----4f.~-;:1-:'--'~~~- L);'; (" r ------------- ';''-M~COOitn IN YOUR Of'iNi~-:---Y7S-No-[O"TE yciJplPOiiEO;cCiOENi-iOYOli!iI:MPtOY[;--- TO WHOM IlfPORUO" (NAME & TlnEl ,~~~1t,;<ri:;~'l:.m~t8;:'" _~__~ _'?_=_?:_l__.~_.1_:!:!.!._ J!llf~/.'-)' 11.~.!.,:!!...'1!!y.}..[,'~-:!~1}:~ ., " f rl.e'(.u () UIUlOU..."Gl',n"..,"UUlUlO.lnow DOllOflll(lIIDIQ'o'U""'. . '. . '..!!'!.:-P~'~.~I'::f..~_.:-!_~.~_~.~.__,_<.,t!)-.!I:~__-.j/~t:L~';.1Cifr;d~~~"- _re;:'~~~~,,~:_:~2!."~~~-~/L.--c-"- ooy~~roG'~'r'''''o:c'''~~'.....__ j~~~0~~J~~~ti1;fJ.~~~~~~~i~_~~~~~~_.....__ _.,_.~".. ._,.. ~,~~~.~,~~l.~~.O. ~.~~'.t:t,~~!~s_or ':?~.~ C.t:tI~~~~NUN"Dn 1~ $UP"o~'~DI~~_~o~,... '''., . ____j ~~l~/g:~~~;";~~l~nll~~~':~:l;~d:~( .1 DAn u........ ~1I..rlON...ut' ""I OlAMI ~ItAT'(JN""HP I "r.r ~I"'NO TlIAI ..NY MI~ilf/'~'.INrAlION fW ME :&E;J~~-:=:: i.Jf;;i;:l :==----.---.--...t-.........:.-~-~.-==:_'~.:;:'~.~:. ~"'j';;;"tf^TNoJ,.,r HIS'OtY ____.l_.~_~.~--l- /../-~- :._:.c.. "I"'~;,;'1"1___L__.......Piece.-o!:..metaL.!J.ow.-.1ntO--loi't.-oyG-whllo-dr;\. v.1na-Oui;..mllBtel'-p. in .--'---" COW'IAltifr,ll,NO,..lrllCAtflNOINGo\INOfIM t part d J.~!~~.~.~.:~~NVOl.(tJ'_:l___..._~~~,-~~~~_.~.__..._~~-~~.~~~~~-~~------~ ~..:;;:;n . ~----~..- DI"O"O~5, - , A;::,l'ft:'" ... ' , GiV1~~;.e..I~. }lody...Lo!t-~lI----:.--'--------'---]-'iiV"iiP;NG'-----.'---'----'~:' ,'--J![;~~~ -.---- E::i Jr~'V' "~,, ~=~I'~an._~;~Il~j1~i~;?:~t~ody--romo~d.~---,;,i;(iiiAiN.-.-.-.-- .. _~t\.\~~iL - '.i-"-- !~:~~~,~,~~~.~~~. __..~~~ ..:.~~~~~~~~~!~~l~~~~~___._~,~ ...,~,_.~~i:~_._._~._...._~,_.",_,_....___.__~__".. _7 _~ '-':~'''_ " :j..,_....... I'CA$l tU(ttfDTOAuorHl.DOC10i'.c:.tvtNAMl,lNO^OOttss. .~ -..~t..~~.:-.:.~.._~.~~.7.,..:.~.~.;.~.r.-.~-.;.~.'..~.[:'~~.'. .':.~..~.~.'-.'. ....,~."..,.~l. i.~.'~.-.r..~.!L.~OI.r.~.f.~~'tf.~:~~.~~~;;~~:,~~'::~~:":;:l~~r.~~~I!f.!~' -.-...'X Z': vI}) _ f;o! _ _ '.' ".,~",'."'-~,;,..-'.-. . .. ,.,,-- 00 ".......,.....,...." '."'.'."'1 "".\(',;,:;Ql...1~" .c1; - .. y~';. ,~ ..1 EST..I.MA.'T.E.'O TI.'M.E..LO. .S.S......~.. ... .~,.~ 1 :::~;~,~;~"~..fY: .-"..",' ~ lli~~iU'tii:JM.. .'.'?;.'-. ..: ".' '-'.' .. i_WOt<< DUE TO'~'iNlU'H ._ ~~) DUE TO ..,.lJu,,~. ...~ _~~' ._.....-,...-_.-^oow~s ~ -' - ,,- ',- 1""001 - '''. <,,!"'i'i:'~l;:I~j;1l(-iff?!;i!JI '<"..,.. "',Ui(;o,~~.utiM,.i'irp;;;fOtllriYC;;!.N"M,,,,~,,,uC!.I"\1 . i,\ "'. d" "'no: .. r"l/Jt ..... ,.-~g?-1300,._..- . . I.. t./ t i3 ~oot l'ort .l.O\.alt10n ,'1 . ,~~r.r.c)IJNT'~ I II jf;C"oJ n Dr , :1'1<11 . -\,(.., hI ~"'l...'."Jf ( I J \., .' ...... '~., - Jl]!l~rt \.\ ~.).,- ~~__.,________~____'J-S-7- Ill'of Dlfj""jr(Y\i:"'A (OUl4lrm....ftl'ST...M" --,-- 2 ,~ro<-"" ,'" ~"., ~;~~',;:,; ';' ~ \ 'I ", , ' ' YJ.;",<., .'i',. 'y;:,:::",~ ;"', ,: ,',i". .,/;.; t ~l:i "2]'::'.':;'<'</' """":,(",, (1", '.' "~" "':' ," " . --..,.... ....., _. -, ~ ... .... "Y' ""I1IPlI I ~\,+.....,_.:"",,,,,,:,,,,,.,..,~ ".~.+. "r. -,!""-,,,,,,~,,',,,:,,,,~;,,,-;...L-, ' :!III1l - "" " ., .-, ~"1 -:-:.. _ll iJ' .._.IlL...,........, ~ Ifll": JIIlI .....' , ._ ". ..~." ~'. "~~.~L 4~ 1 .-- ____ iliii ill ." .1' . .'. I. ..~. . . :.'.: . "1 '_',:. .; ". ..'. ". , '.,. ,:. ',:, ,'~ I <-;i" ", r-~"""-"----'._- ..': .,' , "". ,:"' , ',: .' 'I,. ',.' ..:.; ;.. '" .,,' ..., ..... '.... '.' . ,'", .... '.. . . ,''':':.\ '.;..,,;, '; ";.':.'"" ',"'.:.:. ..... .,,;.:' "J I: ' : "",,',:"', ,'.":",:. . : ." , .' .' '. , \. '" .... :',," . ..'i:!;': , ':; ".,.. ..,...... .. . . .:, , ;., :..::. ..,':. "'. , ", . ""..:" . . " ..,.i : .'.' '." " .... . . . ."., '. ,': . , .'. .': " ..' "",' '. ": .'..... '.'. . ,. .' ','- "". . .,': , . "'," ,.'.' ...... ,"". "".' " ,", ' . .',: '. ..,: ': ,". '." .' ..... . '.' '. '. ,.".... ,: ,\: . '.,: .,': ,.,.' ..", <,': . '" '. '.:, ." '." . .." . '. .....'.... . '.' ..>'" '.... .,.... ,':: ..; .:, ,," ,. '..' """"""':" '. ,. " ..,,". ""',::'. . ..... '. :.... . .,.: . ;.. ,...' ';'. ..". ." '.' .. , ", ' " ' , ~, ',;, , ',', :,' '" , .. '. ,', . ., ". ..: .. '. ..,. "., . : ....,'.: / .'. , . ." " STATE OF WASHINGTON a DEPARTMENT OF LABOR & IND~IES OLYMPIA, WASHINGTON 98S04 -e~~;~f~ ft ~ EMPLOYER CHARLES R HUNrlNGFORU I CL~'''' "'0 "'1M NO ('L.~5 G407721 4,3bU- 1 l~-l I JEFFERSON COUNTY HIGHWAY DEPT i COURTHOUSE PORT TOWNSEND WASH ~~3b8 PATE '''JUIH P n"f1 ',OTlC( ~I 'H 11'''','''11 Of' 10 L-2d-73 7-U9-73 BREMERrON I ~l. n.'J~'.'_1I'I":.I..;t 4~.1:' \lIel: ;, '';, ;: "" :.... '< '" :.; ".' " . c.> . , '". i '" , . :'. :"1 ,;, ': . ,/' .' , ," , ' .'," .. '::' .,..' .,:, , f' , --- ~~ . .: '.' ,...'. :", ,:.8: "" ,.~:f~;l~t:;{~1,'L:' '., ,,', 1 d 'I ----...... "'.,,,.'.' ,~ ~""",~.~ -.. -~- .,~ r ::rl~ '-- 4...- _ _ __II ~ (.i' :;'/:1 '~ i>'l ~=~ w__...._~ .."~... fT.,." ...,-.'~nl\llll. 1 PlII[ _:\i(" ..We .11 __~"-' ____,__,__ '. .ST~TfOfW""ING10N ~ 'A CCIDENT REPORT J"^'M"UM'" ,..,....Lot?o~PoO~~i~d~~IV .. ...~. " '. .1 ~'MU'1 Complel. Thl, R.port by Filling In and Slgnl?9 Emplo~ :. IIGn lIelow, Th.n Moll bPOft 011 Once 10 Deportment 01 LQbof and Ind""III.., OlympIa, Wa,hlnglon 98504, Al J<l,:H IETTUlI' MOllE !.flAc~y!mfO ----...-~.,..,--.---MAii:iNGADOiiE$S-'-.~---~--.--,.--,.--~----'-Ciiy 'iSWEh_~~ ~._._-.'- < ,-<. -----iip.cooi'-."- !!.rr~_~_~_.~~unt~ Hi~!!':'~__~~...~~~!t~~"=r~~.!~~!!.d._~1..~S}:'!!!_~.c>.'!_ =r:!- ___211~__ 'M.P.lO,YE.lrs LOCA"O"4lfOlffERENT froM M. AILING "DDIlESS. .' .... EMPLOnll'S BUSINESS. ISIAlE tVPE OR IlAt. URE Of. ' . . .... EMPlOVEn. IflfPHONE NUM!lEIl . .' ", ., 38$::-3$0$ ~~C:"\;~;t.'''O~U^~.p~.:~t:,j~';:~~l~~~~i~~..;'~:;;~J~~~~;;~i~~-;.~~t:i~~~~;~tt~~-:J~Mv;;___;i "'[ IS~';;.OEMPL07Ei- -YES ~- NO . IF ns, STATE WHICH ArmClVll!llE-. lEMPlOVEIl.S LA6. & IND, fiRM NO'[IN WHAI CLASS Will J DIV. ~RDEPr. WHERE .~~~?!~:~~~~_~__~_~~~___._.,_~_ _<__< __~..._..._._.__<__J:_4 ~.~_~1-_,"~,,~____ ~~~~~~~~I.~_~!.-._~-:~~ ..M.~~~~~=-..l!-C?_~_~._. . (MP1Q)'~E,{MPLQ.\.EC IN WH.I~~j (JfPARfM(N,T~._1 AD.DRE.SSOlIlO..CA.'..ION' INC...'.UO.ltlCCOUNlV' WflfREAC.C. 10. fNT.OC..CUI1.I1[::> 1 STAff WHEllf h\.(..~.. III~ J06 S....ITE. . OTHEIl ~~~O'ION].:~~:r~JON-l/:~~:~~~: ..._~~~~~~~,-.!'!~~_~nWQtl~~9f~~~~911__.~___1 ~~~?~-1~~$ _xL~_Y~~ WAS THIS ACCIDfNT Vf. S NO IF YES ATTACH 1 DArE OF ACCIDENT : liME xx: lOATEl1fP.OIlIED 10 YOU : liME . . fCHECKHERE .:TjlMELOSSDUE T.O.INNIlV ~~~~~p~b~~i~~bu?~ ~fXPLA'NAIION. LJ.-21-76 , ,r L 1.00 .,p.M~l,1-21~76 ,.j, ,.' ~.l~~TC;~~~:ED' ~~:.L.~..:~ ',:'W~IlKDAY$ '''STDAIEW.OI1KED' -TDATERETUIlNEDTOWOI1K-Dw",;; -;;;~~rne~';:GE;-.IN --VES-"""'N[]- S;i;;rH~@.DOYOU.. ;um.loN VES.;:m- ".lfYE5.WH_Y? . '. ,'. '., 6" . I. "6' 6' THE REGUtAR COUIlSf OF HIS .-, ,-",~ 8 4 l'?-1I. ( _ ATTACH...\ J.-2l.::7__~...:.L___. ~~~~~!~~~R~!-~? _ clJ) _lQ..QM1:.:: ..;.)Q ~~~~:L~~._~_~._-,-\!~I~_ WILlVOUPAVIHISEMPLOYEE n.' ".0. .IFVES.EXPLAIN.. [ElHfREMPlOYEE.s . (:"'fQl."'P~ ~1"".lC.I~Ql' Fl)Ll SAlARV 011 WAGES " RAIEOF PAV. 6 I1Q,!!! DAY. . WHK },\ONtH OUIlI~!~~~BllII~-r I~) ~_,___~~_________._I~_?~~~.__!~ ..3~~ ~ (l'J __~~_~rt~ A"ERAGEWAGE. J HOW MANY DAYS ] NAMESCHEDUlWDAVSOff ~"5EMPlOYEf HS NO If TIl"NSFfI!fO, YES NO rEkDAYlf ..', PERWHlCIS. TR"NSFEIlEDTO ~;'. r Will IT BE '~,'~" PIEUW~_.l..____~~:.:::~~~!.._~_~.. _~~~~_~y_~_.~_~.!l~._~____ ~~_!.~~__ VJ.I \~ PEIlMA_N~~ ~'" .,__~:r,:lI:t_~g_gJ!il......:_SJ!.isJ~_,1::t.~lL~!J'LI!J;.:r,:y!'_\(..!L<>r.~.:r,:B_:t.!!~~~.._ i~~~~~~~;ii;~.'~~-~'~N~~;t:':~~t~~~~~=&;~.~:~~.;:;;~;=;;;~to,;';~:;~--"--- - DAlE NOTICE SENT ClA5$ Ie:. ~~~.~:;~~OEMm>t'h..4. /"J.es ":lr~~f.,.T:ftvJVf" ~&r- tJ JJ3";rM': ~(~ z.ls:fi:';;;:' b'..6Z r M^,.'''CAOO'', e.:l {3 (I X g"3? 9'1.-' I J... r!.. '{' (I/ e C;:::d-~?.' lIPa'77t OAl,o,-lf.CENi-----T..oo. ^Co~Ni.occu."o . :-1~"';;OO',-Too';6B;"" W;'"'''JU''O--n,x .1 O^,'Of"RiH--FGH~r= t:Tt9/l1-'--4.L--Z.r~-~.-~~L.-::.-. ~h~________j?j"2(' ":78-rA.{-,Jl:L_f:2 ~ ~~L~.ilZ~/j GIVEDAlflASTWO~KEO ~1..GIVED"TElletUIlNEDTOWOP.K.IFSO JWUeYOUOOINGYOUR YES. NO II SWeWHm l'tR~rJ:P ,J06SltE.' OTHER" ~ .. L-~?::~?L_I_=_.~_.c._~_~ZC_~_ ~~~~~H~~~~~:~__.'~'._~-l~~~~OCC~~~__~?P!~_ ." _fl4':, ,:,;_ S N.:"MEOCEMPlOYEIl'_ . '. . .". . . 5IReETAODO:ESS. I. . .' CITV . '. ZIP CODe HOWLONGHAVE...... /,~ fll. LIi.rEL~J.2JL4-o'~-Y~/..!-J!Ielz;--J!..lt.!IJ'- /) M___~3.!:.2=- J;"'f~!W" ) t!_~ r.{ Gl: eMPlO'f'[/l5 8USlt~rSS (STATE TVPE OR NA1UIlE 0;.(""', Z"- 10001'[5$ OR lOCAtiON. INOUDING COUNIV, W.iUE ACCIDENT OCCURRfO ....... . ~.t'"@IP.~_..L~d//I!.L~/'/{:'-:f:.~?'e. _._7.~!&_1~~~1:,'lL.,i:!ft:C!::.!.:!_.('!:__--~O ~__ >, ~, '. " . .. o DfSOlBE ACC!C1ENT flJllY. 5TATINGo IF YOIJ flllORWEPEsnUCK - t r; ~... . :~5jC,~~~~ ~~ ~'&,VPt~~PN6~~t~I~DOO~~~If,~~~g:RI~~ __a~ ~_,-e.!'::.A-~!!:::f.<__. ~?~__1.,_.__. m~;t..._~.,_.~~__._~ __ ,.__.~..-~!.i-_f!r:_,~_,_ __. _.:~_ INu? AllS 5HQIJlD a DE5018ED AS IN 11'5 OR OUTDOOllS ,.- '/..-. .. .' . "NO LASt OBJECT STQ\JCK SHOUIO liE NAMeo_ NAME OiEMI(JI,l E ~YO"'~..~~:~~__________'_____'___._.r-!-Lp~_._'t.,__._~C!:..~_f'.J{_.)t~___Z.lr!..__._6..~L--:__'Lc:._ ~SJ~~i~~.~~~~~~p-_._'_.'_.:~;..-~~'roAIiYOU;fPO-R'[DA}C'~OEr~T-TO~;MPl.OYf~'---".-~-l]O~HoM~POmo~:-~TN,:;u TIT&:; --~--- l!2!E_M_~?V.~D,"a~,Y~~~M_~I?Ym._,~_~_._~_~__L...,..l.:~_?:__-~-=-.~--~ -----,..~<-,-<-'-~~- '~-~~[ ~~;~~~~~~~~~:;;t~~[:;~(~U~~~..' '. . '....' '..... '.. '.. _____.... _...__.,._._...,_____.. ...._._._....'_.....-..'....._..'____._____.].___.__. _ .~C~~]~:;z:tL;l.~~'c9.[I2m.'=-11 '<.V:i..-----..~.":.... f.~._...2~-.:.~..:.~:..O.~~.:~:..~.!...:....:.'~..~. :.~.:...~..~.",_. ~..~~:~,,~_:. '~..:+....'~~. ~=!~~.-~i~\':~:'.:J.~.'~~.~-.~....~.:~-. ....- ...~~~~.f~(.~,?~W~WA~i~i~1~}~.r.-\1f1f.~~~~;.~~.. '-:'_. . _\.'~:'"..' . .~' GIV'NA~' AND.'.lH DA'UO" YOUI CltllOlfN UNDU 18 SUI'''C?~UD.Y Y~U . it.! mW;OlrlO ~T"'!fM'W5 ...~c HIl)f 10 Hir :0,4.11'. . . ~~=;l2=11~~~~3~~elt ;F."'i'~~~~ .:c.:::.c_~:::~.=-?:~.. __~:!;i.c:JLg!lJLal1.cLs:truc:~ patiollt!-.S ..1. o.f.:t:__.oYlu,hi l"~~~::NJU~ mAl ~.. fl! COYJ'l.A1NT$ANDI'HV5ItALFlt~l>1"lG5INDnAII operating ','0 cat . I I!. . --:-. "'" "y(;-;-NO~ I,J-~~l'!.~'I\\l rJ!!~.Oj_.:__..u___,_.c __ .. ___,'__.,.____ ". ,_.:.. ..___, ___,_.. ... __. __.___.._~__.,_--- ,.._ ~~~~~~7{{;:,~~~~~~~_~_)(~ .' "~$ jWllluuSOIlANVOTHEI! .' '. 'YlS 'NO. r.!!~-c:-()~j yl.!.c.~,i,vJ,.!1.LJlODlorrhalll:Ju,l.IIf.:\:lIyo .---.---- .---,,-. .----......-..T,'cOO~;~Ei~~:'~~~~r~:~~:~~~~~y;~!v.-~ I; t. _ _~_ ,< .. ~ _ . _ .^_ _ _. ~ g~A~i~7o';~:~~~~i('o'~; (~ (;}; . ';~ o l GM tInA1W.N'IJ~D Examination ,- treatlllont ".-L-....'''-.,..~'-..:''.-._.[.-.;;;I~.,;~~~c;;U;;O'-;-Y($7.NO. ml_. .. _.._~ . WOt':PiJETOflllSIlWIIY?~~@ ~ 10m,,,,,,..,, '''[Esi'iMATEO-Y'MiLOSS---.^-'-- o ,..;..,i'...."O;lf I~U "Ut. ~1O ---.--...-"'- Uh .._.,-..~.Lr.,~.-~~,~,,!~.,I_f:'~~.~!~_,3._._..~J.' _ t '''''''0'. A'f1'Ct.f lOll' I Wilt hf"l fIl At.., H~ NO Ut~OfTUMIMO ~ 1_r.~,~.~.t~~~~~~~~?"~"'~?I.~ (X ,11'1~MM'II~'OI'>AMlIV7 Go i I' (ASf '1'1"10 IO"'j('Il.U[l()(I~if. (.;III! 'lAM' "'lOAt'JOi'f\1. . , 5 ThoDl06 CaGO,,,,. D;".Port T,own $ond, Wcfshington, 98366. ~ =- ,~,...,,,I~.H{.'V.11"lIl1f~JI'0""'" ,: OJ''.''''C-''''..''.I,,I'''1 (II, ~ ;.'5i"_,.."n:~,, _', ,.., ",," ",_, ! Afll'ft'l'I(~ '1''I)lU",. ,1'\110\( rV"11 ()II hI" 10llv Ij"~1 -"Il(J Ar.(~~I\~' "1)(.'1\\ ~-"'~~..t:' '.'l~i;;;.c6fli I ...1... .. 98368 .. . J"u;~,~:~;OO , "A'" A((OU""MM~U William ~ ~l~M1z''p"p6t., ~rt _ : ,. t/q~~ ~'?t16Vi4"~ EMPLOYER'S COPY Townsllnd, HA ll.o.rf 2-5dL-iJ;~_ 'U'.I r"-~I ~"'tl "(((JWI' Ijl)""lIf~ ~1""'1'1 r~G! 2 IM'lonl1 COMfllfTf PAIn" '(MPLQYEJ/' S "(fiCin, IMMEOtAHlV ,.NO MAil THf ORIGINAL TO THE OfPAIlTMHH Of lABOIl f.INOUS''''f[5. OlVMPIA, WASi~ ?fl!.104, WE PP(tf.1l' TO HAV[ .EM. NOvrlt S R(POPf" f1ErOQ( TAl(ING ACTlOr~ ONClMM LI."o.l)')IH'V,IPl) I,::";', ",<(L,;:'::--:;~I "';--';'(V;" , ~ '\ ;'!, ',",/' _:':' ,,1, ;',;;::}\, ";1':'::;'1::'." ,)} ,.. ::'. " ':" "., .', . :." " . '" . . '. '.' .' ".':, , . ". '. ...... ',.- ' ,':.. .. ", ":"..:: ' : , . .,~.~I . . .. II . ',. .'. .'.,' :. , ,,'. '. :'.", .: '.'::., . . --- , ....... '::'".:.:' .: --. ' " ,:. . ">'-'. ' '. '. ,"',',.'" ...:." " , '. <, .'.',,',., ' /;;)~',\c ",' " ," ....: . ". ': ". " ','.' :,">,,:,," .... , , .. . , .,::" (. ' .' ". .,..,'" .., '....' . . . '. ::..' ':.' ' . .... '. ',;' i5' '. :' I, , . ", c' :' ..',' ,..:: ,..,'.:.' .' ., ,',',.:" '. .. .' .' . " " '. \~. .' ;',.n-"J\ r:'<l ,i I~./S.I.J'-E I ; ",. .'"! r; i ' ,f. i " i ~ . r \, i " ! ,.: i ' '; -, ,-,1; II ,'.1(, ,,,I~.'-,IOfJ ',,' '. ;. '. . :..'.':: :' J . .' ;'.' OR()t.r,,:. ~(!::I~;(, I','il)'-\C,' ;\ ),,!'.'rn:l-..\llRF,\TMHITONlY L "" : ( .. .' \ '" ~ I";' j ",."d,'''' Viti!':'! ., ,] "" ,', ,. ,~ I' . , ", . : : : .:: ( ,.,: i i . , .. - " ,~ .~~ [~;~:~\I~"ll..~~\~ll '-',~' '\:,\':', ','. Ii; f / , ~ ,'. lIll dJ~' ~i f, I I" " (.'~.').\ \,,~. I' r,] i I ".\ '. '" , A', ~ _ j . " " . " I ;.: t,\IJ",! jlf ......."r)f Ir. WRITING TO THE ,1 -" ,,' I,' : -:: : 1\ I ;,\, f(';~": :.'/' I I. ".'111/1: ~,' r,!, .,':':[ :' ;~I(.I~;.I ~f i..:~~ ~_~~f~10 Al~i[f ~~)A^R:6 'r.~"I,\ ,'.llHI'~ >/1 l"_i, ~~or.~ fHE DAIf THtS OPDfR I~ , .., "!",,, \ " , i ., ': 0, ~, " I ~ I 'P.': \,", \ ' ,.,'" " ..,..... . '.' .n,. ..> . .'. ...., '< .' , .' ..\:~ , '. ....,... .... '.' : .....'....; ,:" ' , . . . ....." ....'.... ,.........:.".- ,..:..:...., '.. .'.., . , '. . . '" .. '., './: . '.' . .' '. ,', . "". . . : ".:: ...: '.:' , '. . ,.", .:. '.. .... ......,.,..,':' '.. :, ....... ::. ."."'':''. ..... '. "..; ',.... . "':.", ".-'>, '." ,. ",.'","::,:" ...... ,...... :" ,':'. ':.' , , ". .- ",... :..:'.". . ..,. :.,:." ;'. .,\ " '.". . , ': '. \'.: : . .... \'" I"~ ,".' ". "''. :; ...,:.,. ',:., .', : ." " ' . .' """ ..; ..' '.", " ., '. .. ..,.' ,," '.: ','.' " . . . .:: .:": 'c ....'.' " ~:'; '::,';~!~,;, :: ....-::' "'.:,: <": " .' , ,," ...." ',:. '.' , . .,'.., . .....:' . .:' " '. ". "" " ,<::' ',. .'. ,... :," :":.,',:' ,.....:' ....:..'.., , :'; <:..",:,.,"":' ',' . "..,. ',:.' ~"::.': " ,',':". ""'. '. .. . ,,"'. C ,..... ... ' . ", " '. :", ..,:... . . " '., ','.: .' ".': .' '..,' ,'" :::'.,'" . n. '. ....: .... ":..:' . " , '.,'., .".-., ., ' " .: .,'; ,'.,'; " ...,.. :... : ',1 '. . ,,'" ,:i'" . ,:' ..' c 'C: ' ,., . ',C" ':.' . .:. ':' I/':!:j"'::';:";"':'" ". " . i;:::'./(". , : '. .:.,' ::.,.. ' , ' ,:::. .' .'. ':::,.'",," ' 0"::';",. ,. .,{';>",...::,:';',.,.....::'..., ',', ,.' . '1',', ''';,:,<:' ;"" t-- ..:;: '" .:' , ; ,I,,>:,', " I, '\:'.(~'t,;\ti F~!': I' !, I' I " \ " " ., '., " " .. "" " ":',. , ' '" _. ..,. . .-, ,,~.>-~~."""'" 1MIIi. w .,= _t=::li~~ IIfii,. "", -,-,..._-,..., -.... \' " "I, ' '.,' ',' , " , " ": ' """',,':,, " " ,~ ~...."."..';'" .. ---. -- .......-.......-- ...,. ~- ~ -"....... .,_. ",,".u S.F.No.7646-{Rev.9.54)-s.rs~r. 4rl714. .. .. .. . WASHINGTON STATE EMPLO~' RETffiEMENT SYSTEM EMPWYEE'S PERMANENT RECORD (LEAVE BLANK) Member No......................._...._.._......; Date of entry........................................ Ortg-, member...... New member...... TO THE RETIREMENT BOARD: 'As a condition of my employment under the requirements of the State Employees' Retirement Act I submit the following infonnation: SECTION A. 1. NamJ.-IVMrIlV'lfdJ!:..tJ_tfll./"J.( ~ _ . (Laltf. . (First) 2. . Present address _,__.-13J::&_~:t.f_"7:- _ (Street) mSTORY R IJb efV-r (Middle) . (Malden, if mlU'rled) -$.J,U..h-~'!..~.kfL:- tt/A/". (City) (County) . (State) (a) Ibegan my present employment with~..fEf{'l' ZP~~ tJl J/; f,a /(1 A)'" L_ , ' , " " (Name ot department, commisJr'oI1. 8gen.!y) . at..lM.t/lfIf' C (J 1'1 , ' W/ 4/. on the "1/\(.:C day oLPLIJ.J!._ . 19.612: (b) Title.ofpositiol1-__ ,(c) (If applicable) I am also employed by 4, ,Pr~sEintrate of monthly compensation: (Nama ot department, comm1ulon, agency) c..h Malntenanee AUowanco Total Agency From Whose Funds Compensation 1:1 Paid (a) (c) 5. Where Servtco ~aI Rendered PERIOD OF SERVIC!: Name ot Department Commlsllon or Aa:enC)" 'nUe ot poalUon Held Bea:lnnlnl' Endlnl Mo. Day: Yr. Mo. Day Yr. 19 19 19 19 19 19 19 19 \ 6, I am a member of or receiving benefits from the following retirement plan or plana!, 'j ~/V eo. __, _ i\ ) 7. SoclalSecurtty No~t: --'9t:tf'7 " ., 8. Check by (X)-Marltal status: Slngi<,_ MarrJectX__ Widowed_ Divorce<L-_ 9, Check by (X)-Sex: Male4_ Female__ .' 10. Date of blrtLL1td,L ~ /22:!Z.- Place ot blrt"--.c~(.f r- __L(.EL__IYIJ/_ (Month) (Day) (Y..:) (City. (County) " (8hte) ~. n ~ II __ .........II..~ r'i W-i"l' , '\",~:;; ,.,',;< -_................~"""'..;.=-~ ~ .-g ] 'Ol E OJ ~ ~ ]- o OJ b/J .5 ~ ~ .s 0:: o t: !3' ~ 1 t.l .a I'l ,: t.l m ~ ... ~ !il '" .g ~ 1:> 00 ~ s ... ~ 0 ~ '[ lj ~. ~ ~]- t.l '" ~ ~ ~! lli .:g 11 '" 8 .~ .t:~_ iljl~ ~~,Q =l"" "~3 5~- 3~ al'" 4~ '}','r,< "j. "\ .~ ::':::;', l~ 000~0000~0~00~000000M00~0 os~~ ~~. ~..~ tl ~ '" .. o g ~ ~ ~~~~~~~ ,i;;.- Il' ~ '" '" ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ '" '" ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~'~ ~ ~ ~ ~ ~ ~ ~ ~ 0 Q ~ ~ ~ ~ ~ ~ , ~ ~ . o ~" .... ~tI: " ;:: ~" d ~~ is :<0 ... ~ ~b "0 ::1- ~ ~ ; I I ~ b ... oS 6 :;1 11 ::l a. a. ., '" ~ Ei i '" ... ... II i~ os ~ : ~ ~ .~ ~ i~ ~ i:I{l .... S 8 ~ 'a'~ Il= ~ ~ 0:: n ~ ,g 0- t3 ~: :;: ~" ~d ~ :<J &i i~ ~ ~ a ~ U'A ~ ~ - li1 0-4 I .h!l -~:!!l or ~ :!!l r-. t; ., o.b 8 Cl~. !l ~ ~i '~ Pf (i< ~ ~ ~ '" .. 8 _I- 0 g J ~ ~ 8. 'a 8 ~ 0 Q ~ --1 ",.'" ~ ~ ~ ~ . . -~ ~ ~-.- _~_____.>o~J,_."\~~.__; '., '"",, JII - . , ,. I. ~ _I " ._ _!'.< J.:.. . . llEI'AH'l'ML.:N'l' Ul" H.I::.'1'1 i{.l:;M.J,::i-l'l' S'i.S'l'BM~ Public !::mpluYlJ'.:::.; J l<ctirement System F'ioi..l.l COlllpL.!Jl.5J.tion Report "ClJlIll)WO;.;illioll !::i.1rn..:.tblc" in Fil\..!l 'l'Wo 'fcars of Brnployment /-.~ r) :,.' (!~. S~ f:! .5 :;; / _ - :5U"-~:S 0" /i'l./'/ (.1;.4(. ').3 n ..5"$' fu,tl./- ,? :J 0 'I Hours 0011ar5_ 1. Amount or accrued vacat.ion tim~ pnid at rutircmcn~. o o 2. AllLount of accrued sick leave paid at re t.i r~lnen t. o o 3. Amount. of other earnable compensa- t.ion puid at retirement, 'i.e., cctroactlVe pay, severance pay, overtime lJclY, clothing al.lowance, h()usln<J allowdnce, ~ tc. o o NU'!'!::: \-J~ can use only that annual leave, sick leave, etc., earned In-th~ final tWO years of employment for the Average Final Compensa- tiau puq)05~$. You must, nevertheless, transmit contributions on the l;..otal amount paid at retirement. Sick leave cash-outs are not to pe reported for st.ate, school dist.rict, or higher educaj:ion em=- plOY~C5. Hours Dollars % Payoff 4. NnuUI) t ot Vdca tion lime accrued in final tWO yeurs and paid at fL'tlrement 240 0 100% -- ... Accrua.l rat~ per month "19 hrs. lJ. lIourly race of pay 8,46 ---- 50 ^l1lount ot Hick leilvc accru~d 111 f lna 1 twO years dnd paid dC rc Li romen t:.. 48 0 25% ..I. Accrual rate per month II hrno ...--..--- U. lIou rl y rate of p.1y _~4_<!.-_ 6. Amount. of other earnable componsu- LtO" .Jccrul.od in final twO ycar~ lUHJ p..ti.d .at rcejrcmcnt (SL~e number I l-lLJove) . 0 0 0 ..--- -- I~_.~,-_':~,....,' ", ,k~ :'", - ',':~ .~. ~".l.",~, :':., . . hIGIlES'!' CONSBCU'rIVI: ']'Wl,N'!'Y-FOUR MON'I'HS COMPENSATION Pll!ase indicate compensation by the calendar monlh (first of the Ulon lit through the end 0 f the man th) in which i t Wil~ earned. Includable Compensatiof! S 1,310~ 1,539.26 ~~~ 1,681 .62 Monthl 'f.~~_ Hours Work_e~ 168 Includable Compensation S 1,331,22-_ 1,298.75 ~~- __~20___ _1. 54!LJ!l__ Monthl ~~-~-~. Hours WorkeE, 170 04/83 05/~ 06/83 _ 04/lJ2 176 _q5/83, _~lB2 _OI/H.?_ JlIWl2 '175 1lJ4 '16; 175 1t;~__ n2~ 1.875.6~_ J,flL-_ ..:!lLtL_ 08/-1\3-. 0_2LlrL 10/83 ~~ 12183 ~ J.fi8___. .liQ,___ 1 , 968 ,71 __ 1 1i02 ~~ 1,341.16 ~L-5.l- __126_ 168 .09/132 10/82 .-L_s&O_..7...!J. __ __~__Q8-_ ?fl7 OIL- :11 {!L2 .12.1.112 O'1/1l3 02/lJ~ -91/lJ3 ..HtL, .1.4S- 1 ~7S nO 1, 494. 56 -- ~l1iIL- '176 'l?1i qli <l.l.LBA- .:L.1S-- '1,600.56 ---1....5L:L2L... ~ -1..!ill- .1ZIi- 02.,LlL:l- Q;lj~ 1.350.00 -1iO.-- 71i? 1\0-. Total of Compensation Listed Above S35,22~ ------------------------------------------------------------------ r~ No DO~5 your agency report on a calendar month? .11- Doc~ your ayency use lag pay? x. DCl~S yom agency use pay periods? x 1. 2. ) . 4. If ether th"? ,g""8, pleas., explain. ,tf(f!1efg_'ft?t:! wl'h'S 0..1 11- _U:t.l.<I.~__O,c _(ti2~~~,<#... _L'~__I?!!-P_.J!?A_~L:i...:J1-1,#.. "<.1_<;/1 -- A(LG~'r.._3-?-Lq 3:y::__s.t:/.LL~Q~_21}::(~ ,..~~~...fl8 :::!.-!:?':L litlit.._..'" *...",.**********.Ir.. /It PLI';A::.H: IU;'l'URN ,\$ SOON ..\5 P0SS1UU:: " . II: . lit .. * lit . . . I; * !II '1'0 8XI'EPITE MEMUER' S RETIREMENT _.*...*..",.".. Certifiod 1-- ~L. ^ll..,ney.j{f,er~ 7v tH-ic. ~ u......r .... /d (To l'i'rho'n,'- 'l{ulnilur'(P?o~'t,,.r HClUfl\ to: l)l!p~lrtJnont of Rccir0ment l02r, E<HiC Union {,lYI1lpi.l, \-JA 9H~;O.1 l'lHlHL' No. (206) 7SJ-528J SCf,N 2 H-52~J Sys tllnw ",--_,_~, :~'-'-'"-i, ,1":: l, ,".', '. ~ '..~l~" , . . DJ;PAl('1'MEN'l' 0[' lill'1' 1,lillMEN'l' S'iSTEI1S Public l::lIIploy~e~ I Retirement System Final comptH1.sation Report IlCOlllpt;!l1.sation l::arnable" in Final Two Years of Employment /I- tJwt!... '-""#-~ ' ~: ~ :-/- 3o-L,-::) 0 (" .'w",<JA~: :;"3o''?y D-yzt, 2;)0"1 Hours Dollars 1. Amount of accrued vacation tim~ paid at retirement. ....B-- er 2. Amount of accrued sick leave paid atret.irement. :9- -e- 3. Amount of other earnable compensa- tion paid at retirement, i.e., retroactive pay, severance pay, overtime pay, clothing allowance, housing allowance, etc. -& -er NOTE: We can use only that annual leave, sick leave, etc., earned rn-the final two years of employment for the Average Final Compensa- tion purposes. YOU must, nevertheless, transmit contrib~t~onS on the total amount paid at retirement. Sick leave cash-oute are not to be reported for state, school district, or higher educa~ion ~ ployces. Hours Dollars % Payoff 4. Amount of vdcation time accrued ~ ,;r.. Ie" .,<, in final tWO years and paid at cJ.(-!O ,e- jOO% r(!tirement .-- ... Accrual rate per month /IJ~ b. Hourly rate of pay gc-&- 5. Amount of sick leave accrued ~_~ "fl._ in final twO years and paid at I./~ ~~ retirement. J!iLd ~- il. Accrual rate per mon th U. Hourly rate of pay -~- '& 6. Al1\ount of other oarnilble compensa- tion dccrued in f i na 1 tWO years ilnd paid at retirement (See number .-(:::r 3 ilbove) . ~ e;r fit . HIGHEST CONSECUTIVE 1'WENTY-FOUR MONTHS COMPENSATION Please indicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Monthl Hours Includable Monthl Hours Includable Year Worked Compensation Year Work~~ Compensation o~ ~ $ ~ 33/ ;1,</ ~<lk.$. 1&,(_ ~3jo.3J 6:;~~ 17S' I .z ',,/Y,7S' ~5 1/(,. ~~ ;~~ Irl (.)7~.ocf ~ /75' ~t:tt'.3?' ~ .LW- ~?:<o ~ It.r (, {,frl, /,.:<. 6 lib -?$~&KL ()~3...L2~ ~%?~{"S- -;;i;. ~ ~ {,o,J S~!!'fln B~ ~<1".T.7/ ~4=-~ J!eY_ ~,3'7'/ j(, L~ ~ .-+6a2.~_'i LiL?z,,_ L?5' / l/;n,Si iJ~J ~ _~-,oJ' /,2./;2 ~ / ~'7s;c.D 12iL I'I'S ?;!1.'?'l.Ob ~..ilL ~ '1'7'<;% ",IN ~ ~3;u'. 96 ~ 19'1 <(,00.570 o,JJ.! 17(, 1S-?:l.7;2, ~ ~ /.3SD,Qu ~ ~ /7Cx::?YO ----------------_:~:~:_~:_:~~~:~:~:~~~-~~:::~-~~~~:--~~~~~~ Yes ~'? 1. Does your agency report on a calendar month? /' 2. Does your agency use lag pay? V 3. Does your agency use pay periodz? ,..-/ 4. If other than above, please explain. . * . * * * * * * * * * . . * . * * * * * * * * * . . * * * . * * PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S lillTIREMENT * . . * . * . . . . * . . . . . . * . * * . . * * * * * * * * * * Return to: Department of Retirement Systems 1025 Ellst Union Olympia. WA 98504 Phone No. (206) 753-52B3 SCAN 234-5283 Ccrti Ciod by Agency Frc-i e ph 011'0""17 UiiiborT (1J~ltcT r' l ,', ~ ~'" 'c.."...,. :: '. ',: . , " ", , ':'i ..' '.', ':', ': '. . . .. \ ..:." ',',.," ",'. '... ,.........,'. ......... .... ,.... __. ,', :'.' :.' '....... . .' .",' ..'. ...."... " .' ,.' "" ". i :\;'IK~!~I~ '. ........ TO: PAYROLL DEPARTMENT :': ;', ,,;.. .. '.' ,:. I" '., . '." , "', , ~~, .. :.'.' , ' . ....' ' ... :. '" .'.,..,.... \ " ...:. . '.. :.:, ". ':, :. .' , . ':. '.' . ' . "" .'. . '" , ..' .... '. ~.... :: ',< " ., :, "'::'>";""" .,:". ." . " '.,'.. ''-'" ....': " .' "",.:.., :.,' . ":"'.<',:'..:':".' '. ',..'." '.;...."..... , ,'.,',', "....'.:, .... ,.... .': :;. . .' ..' ", .,'".:.'.,:, :'",> : '" ",,' ",,,:. .....,.., ,',' ". ",;' ,,; , :' '..' ":':"" ,".:.- : , ',', " '. .". "':." '; i ,;' . ...... ,":, '," .;;,... " . <' .. "LEASE ENTeR THE FOl.I.OWING Cf<ANGEI~IIN V8ECOADS TO TAKE ". : '," August 31, 1984 Midnight Floyd D. Howe :. SOCIAl-SECURITY NO, 531-30-4506 DEPf. Public Works .:' " :.' .' : :.. . ." " THE CHANGEIS) ....CHECK ALL APPLICABLE DOXIES I'AOM (] DEPARTMEI"H OJOB ; o SHIFT lJRATE 1'1 REASON FOR THE CHANGEIS) lJl-llRED o PRDO...TIDNARY PERIClD C~MPLETED OLENGTH OF SERVICE INCREASE ;. l]RE.HIREO [] PROMono,.. o fiE. EVALUATION OF EXISTING JOB l )OEMOTlON XJ RESIGNATION I jTRANSFER [I RETlRE"'IONT LI MERIT INCREASE [!L.AYOF" ;'.', U UNION SCALI! o DISCHARGE l J LEAVE OF ABSENCE FROM. : I jOntER 1I'l'lll.., Resignation due to physical disability ;", I :< '-"'. iC: ' ":';. "...' "..', ,:' <"'"D. Aun.o.,,,"", Jii.e~ c&}::A' OAHr Z 8 - 84 ~T.W~AL/OEPT HEAD CriANCir A,.,."O...,o ""~h,~.""l-l,,../' _DATI: 2~A:,L BOARD cr Lb COMMISSIONERS ' .'-'..,.:', :'..,i' '.:. ",.'.' '..' . :........ .," ,,"',.' ," .':... ... ;, ,,' '. . ': ' , ..'.,. ''''. .'. ".' ;', ' " < '. .' ..: " :' ,'. " ":';":'::"':: ',':.' ,': "':."', ." /.', ' '. ';.' ,",,': '. ,- ':,'-,' ,:" " ". :- :"'::' . ...... .' .' . '.... , " "',:' '" '. ".,\ ',' " - , ...... , '. ..i' , ...,...;.. ...... . ::" >:':.1 ',. :... ,.. ',,.' '.. ," , "'. . : ..:. "::.- :, :: ,:' .. ; ", '.', i..: ~--"""~' ."p" ... _Ii lll~ _~17 _llfr-.w*JU ~1ii_'IIIlII - .--....- -..IIIIIIII, ... .., ,L.. - ,- ill "",. l .- __.:,c,,': ~- . ., . I ,_ ,~~. ~' '. <! ..,'1 ~ I ~-" ..,,,.,, .', "~,, -"..,".. ~ -. .~. - ~_ .lllr. " "l" l 1l'III ~ ---- - nil! r----'~- C> ~ ... '" c c , ': ... 0 ': .. c ... .. ... ~ N ... C ~ '" Z '" '" Ii z " '" C ~ ~ C> .., .. ... ~ 0 0 .. ~ ... c ': C> . ... ~ ~ '" ... ~ 0 ~ '" ::t '" .. " ~ :: ... ... '" ~ C> ~ v, ... '" = ... '" .., C N .. ~ ... .. .. ~ .., ., ... ~ '" '" : :::: C> '" .. ::: '" " U on ~ .., 'r .., :::: " ~ on '" i - C> .. ~ ~ ::: '" " " ~ '" ~ '" ,. '" .. : ~ ~ ~ ~ ... '" .. .., 3 ~ S 'r a i ~ ~ :a .. '" N .. ~ 0 " z :;: '" .. " ... :;: 0 0 .. l: ;; 1 . ~. . """..._.__IiL.,,. ~ _.__.,1111 .. rr ~_. " ..'., :: ~ "", ... 1 '<,.__ '_~"')- II' . ~;: , ,:,~;(~~:";,' ' . " .,.'.'.: I ..; , .' ,;.:'<,", "'. ' ",' . .......'. . . :; . ,'> :{i':;{~}:\\' '. . .' ",.> ','.,:.',.....:.,.:,;..;,:,/:/;C.:... ,,; ,.:.:.~'~.,:.:~~' ". .....,. .......'., ,.." ;, > ,1 . . .. " . . .. '. . . . . "," , ' 1 .',: ~~ WIlUA....SCHEYER, M.D. -; .. . . ' .:d'" .... _t-l_J D-w.4- "I ~..: ...'. ".'",. '. ~ y'fz,~_ ......,.~......'.....,. ,.,:.n .' n -." " '. I (..IJ.,'<: I ,~. ~ ~..f4{ ..' . 1 ~I "'"'' ". - ' · ""'''\ ~. ..", .~ ..".. :k~1II PHONE3B5'5~" "'1" - ,0, ;".."";..,. '.,.,'" c ""'~.'"'."- . .. , . .'. .', .,' ...: '. ' .~~., ..'. . .,':':: :., . '".' , ' .,' ;,:i, .'.',' "....';, ' ,. , . ' . ; '," "';." :,' . ..... , ...... ' ' ,:'" " . ' " ' , . ' , ;' :. ..' ,.',,: ",' ..:.,...: .:'C.' :>, , ' ':" . ' ;" '.,' '.',.'.' '.'" , . '.... ;"'; , ' ,.; ,.:'" ' "".. ' " " ' '. :' ", ., . : " . ,...: ." " '.. "'., .:, . . " .. ." '... . ,,: .. ' .',',.". '..,..'...... ' ":'.::.::: '. :.:.:,',. ','" ..:,'" "':,'" ,,:"',..'.." .. ' . .' , ,. ", . .: " .' ., ,,:' , ' ",'-";" ',: . .".' ,'" \, I" :" I..>: " '.' . ..' ",' ,.".' ,', .' ,', " : ., . ,I ," ,.', ", .:'\, " .':'" :" .':. "; ,.;.., . ,:,.:. '. .'. .,.,.' }, ....' -.' '.::: : : ".:", :' '. .', ':., ' :'. : .., : " '.,' .... ':". :.'::' ,: .' . ;: ,:;~l::>'" ". . >,i..,:,: . '. . '., ,:.".,...:.,. .... ,:::," " .; :'. . ..,. . " . ' . "17' . ",:: " c.';' " ,'. ' . .: " " . i' :'"i,iJ: , : ,,:,> .'., , . . '. . ....;. ::,'.',. ':,', ..':.' <., " .:.,. '.'. ,'C: '... r ---- .n ,~." ': I,':, . " '.'-.'. ,....,.. .:/ .... ',', ,', ....',' :', '.. : ., " ':" :' .,.;.. :,:; < '.:' . "', :',: . .._-, - -- ". .... ~ iii .. -" ~",,~,I, .'~ "_'," ".i' ;' ~:;; - 'I: ';~;', '. ~.:'.'" If . ..-,.........--. '-'-" .-- '" ~ ~. . . , ,". .... ~""q' . -" :-~~ ''''''' _.. . ,,:; ,', ,. I ~ : -: "'" ,,', ::) .. ,.''';',:i , , '.,-f' '.:"J'.': ,~.;: CLMT flOYD 0 HOWE 813 PARKSIDE DR PORT TOWNSEND, WA 98368 . STA~F WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES DIVISION OF INDUSTRIAL INSURANCE OLYMPIA, WA. 98504 PHY SCHEYER WILLIAM J MD MEDICAL BUILDING PORT TOWNSEND WASH 98368 CLAIM NUMBER H962677 TYPE KS CH ECK DIGIT ADJ 6C MAILING DATE 08-03-82 UNIT INJURY DATE 12-09-81 SERVICE LOCATION: BREMER TON EMPLOYER ACCT NO: 4,360-01-2 CLASS: 15-1 EMP JEFFERSON COUNTY HIGHWAY DEPT COURTHOUSE PORT TOWNSEND WASH 98368 ORDER AND .NOTICE **************************************************************************** * ANY PROTEST OR REQUEST FOR RECONSIDERATION OF THIS ORDER MUST BE MADE * * IN WRITING TO THE DEPARTMENT OF LABOR AND INDUSTRIES IN OLYMPIA WITHIN * * 60 DAYS. A FURTHER APPEALABLE ORDER WILL FOLLOW SUCH A REQUEST. ANY * * APPEAL FROM THIS ORDER MUST BE MADE TO THE BOARD OF INDUSTRIAL * * INSURANCE APPEALS, OLYMPIA, WITHIN 60 DAYS FROM THE DATE THIS ORDER * * IS COMMUNICATED TO THE PARTIES, OR THE SAME SHALL BECOME FINAL. * **************************************************************************** WHEREAS, THE ABOVE NAMED WORKER SUSTAINED AN INJURY DURING THE COURSE OF EMPLOYMENT AND UNDER CIRCUMSTANCES ENTITLING THE WORKER TO BENEFITS OF THE INDUSTRIAL INSURANCE LAWS, AND WHEREAS, THE CLAIMANT WAS RETAINED ON THE EMPLOYER'S PAYROLL AT HIS/HER USUAL WAGE OR SALARY DURING THE PERIOD OF DISABILITY CAUSED BY THE INJURY, AND THERE BEING NO PERMANENT PARTIAL DISABILITY DUE TO THE INJURY; THEREFORE, IT IS ORDERED THAT THIS CLAIM BE ALLOWED AND ADJUDGED NON-COMPENSABLE EXCEPT FOR MEDICAL TREATMENT. THIS CLAIM IS HEREBY CLOSED. SUPERVISOR OF INDUSTRIAL INSURANCE BY TERRY A SJOBLOM ADJUDICATOR EMPLOYER COPY RECEiVED AUG ',: 1982 JE;;;:j::E::R"'0 ENGIN':>"'~ ,,!, <:':':.JUrv' \, -""'':;' Cf-'f.i:':'1:. 17_.._..IIr."., ".. .. '1lf -~I5f_ TO WHOM PAID INJUflVDATE 1.10 VA 15-1 HO'. E R SO,'I GENERAL 12 81 H962077 69.00 53-6 SANSTROM M RSON ROGER MD 10 09 81 H'I67539 28.80 15-1 HENDERSON K A DOUGLAS r" D 02 24 82 H988033 22.00 119.80 JEFFERSON COUNTY H:GH.AY D~PT COURTHOUSE PORT TO~NSEND .ASH 96368 G'~""'''.\ ~ : ~ ~'" ,...~,! DEPARTMENT OF LABOR 8< INDUSTRIES Ot. YMPIA, WASHINGTON 98504 THIS DEPARTMENT MADE AWARDS AS SHOWN ABOVE FROM THE MEDICAL AID FUND. NOTIFY THIS DEPARTMENT AT ONCE IF FOR ANY REASON IN YOUR OPINION AWARD IS IN ERROR OR CHARGED TO THE WRONG CLASS, IlIJJ j UIIL .R'.Ill -....- --~,' .. -II!I~~"'I ~ .. [ i 1i - ~~ _ _ _Tilj;~__. -.-. ,... .'''''.' .~. -- _, .""_. ___._--I!a -'IlIIIl "} n.. '''~'''l '" U...I'.I[..... ('1l1!'r"'""~] ~f..'CH~~'1 De I 0'''' "-t~.,~ an:,,'J, ....tJ\LJ ltt..::r"l""",A~f'III'!'.;, cn r0'1('r::" ~!('tn "'f '~,": TVl']'" llop pOll'un ~ul.Jmj!lL'd PHYSICIAN: Complele Physlcrorl's Ropo.tach top portio~ofOrjg~nol where .df;'sign~andsubmrt loDepon-j h, pl""':".H' Il~enl of labor 8. Industries, Allenlion: Ac....,dunl Report, C!OUIlS St..~ctlon, OlympIa, Wu. Y'J;04. Detach the Phys,-: Bol!orn portIOn svbm,ltcd CIOr.'SCOPV (3rd copy) for your files and promptly moillhe balonce of Ihe form 10 the employer (Ihis includes I by QHlploycr the bottom portion ot the Original and all of the 2nd copy.) I 1--------------- i EMPLOYER'S COPY - .. r--- .~ . - -., L~~( .....-RlfliUlll!U ~ :,',r , .' ,'....<"'21 " ""',' " : '. . " i>', ..":' , '.' . . .'. ,. , :,.' . . ,. " <. . ,'," :..., '--., .'. . .. . :. , :-', ..... , ." ...."" .- :. ,.".;. ,,',: . , . '. ' . ", '.. :" ',.',.,..' .', ,," .' .....,'..., . ." ..:., ".'.., ,>'> , ',,': ." ", , .' '," ' '.."...,..,...,.,., .:: ." ',. . ,.' ' ." ,'...: ,. .'. "... ::" .::: ." ...'. . ..;,.,.. ":'. ;. ",,'. '.'" : .> ....'.' , .... .... ,." '," ...., . ......,' :..'." '.. ,',.", ," '.. " ;'..., '. : " .... ,. : .' ,'. .'. '. ". ,.'." '. .,'., ::, .: ," ,:' . :: : '. ......':.,:: .- ;, ",'; . .,',:'., , .', . , :" , . , ..' '::',. , . ,.'.., . " ,','. .': ,', '",.,., ,...,' ',: ," .'" C' :"" ,"':~', , .:., .... ....... ,',,' ;'" .-, ': . . .. ,'" . c.:.. CLASS EMPLOYEE NAME TO WHOM PAID INJURYOATE CLAIM NO. AMOUNT 15-1 BUCHILLO L ilIFFERSON GENERAL HOSP O~~ 77 H226B12 74~43 15-1 BUCHILLO L JEFFERSON GENERAL HOSP OB 15 77 H226812 83.29 15-1 AU S TI N K OICKERSON ROGER MD 11 01 79 H608457 12~64 I, 15-1 AUSTIN K OICKERSDN ROGER MD 11 01 79 H60B457 14.00 i184~36 . ;, I " , i JEFFERSON COUNTY HIGHWAY COURTHOUSE PORT TOWNSEND WASH EMPLOYER'S NOTICE of DEPMEDICAL,:.,~YMENTS 1;1 2B 9B36B 8 Bol FIRM NUMBER 1 4.360-011 DEPARTMENT OF LABOR & INDUSTRIES GENERAL ADMINISTRATION BLDG. OLYMPIA, WASHINGTON '1S04 ll.210.81IlEV. sm THIS DEPARTMENT MADE AWARDS AS SHOWN ABOVE FROM THE MEDICAL AID FUND. NOTIFY THIS DEPARTMENT Employ.r', NOliu.Med. 'o~m...1I AT ONCE IF FOR ANY REASON IN YOUR OPINION AWARD IS IN ERROR OR CHARGED TO THE WRONG CLASS. ":" '.' . "'. ,:,.' , , ." " . . . ,'. ". ,:. ',: , ..', 'C'" . "" : : ',' . '.. ';. .;': ',' :'~i::::~\d"" ' \,,:::1,; :ii.fti;:\? ',' . ,,;' ':., "': "::;; '; ::, '., .',.:,,',:.'.':......,,, . " ",." " .' '. ,"", C., " " .. '" ,:: ' ".' , . ,'" ",':',..':: ,'.;: . .," . ':,', .': 'j' .' " '" , " ','" ',.' ", .:,': '.. .:.:,.":,':' ., ,. ,.:'..",.",' '''. 'i' ,i, ::, ','i}: :',:" . ,,' " ';-,'. ..,.,:,., .' ,:,,> '. '., d.:'::"":,...... '. , ......,. '" ;" :' ", " " ." '. ;' '!" .,:,: ", . :,; '. '. : ',," :,1, '. ":', >.,. ,....... ,i . .' , ". ". ','. ",,,:,,,..\ ..'.:' ,........ . ' '. ' ,,' .' 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'., '; .. . i'. > ... ,'. . .:' . . .,.' ...... ., . ". ',.' .", -. ~. ~. - :.ii, -'. . . ...' . " . ..,'..... '., .':, <' ..:.... . . .... '.:'. ': '.: ' , .... ". " . '., .., . .' '. -.:. ..,'. .' . .... :',':: !..,- . ..... .... '... '., ... CLASS EMPLOYEE NAME 15-1 FRAKER E 15-1 AUSTIN K TO WHOM PAID II)YMPIC PHCY DICKERSON ROGER MD INJUNY DAn CLAIM NO. o~~ 78 H2b444S 05 is 78 H337784 AMOUNT 1.39 40.85 149.S6 .. 1111087 FOHn No!'(OI MOld A,d 0"" FIRM NUMBER '1 lor 24 78 I 4,360-011 STATE OF WASHINGTON DEPARTMENT OF LABOR & INDUSTRIES OLYMPIA, WASHINGTON 99504 THIS DEPARTMENT MADE AWARDS AS SHOWN ABOVE FROM THE MEDICAL AID FUND NonrY tHIS DePARTMENT AT ONCE IF FOR AfH REASON IN YOUR OPlrllON AWARD IS IN ERROR OR CHARGED TO THE WPONG CLASS JEFFERSON COUNTY HIGHWAY DEDT COURTHOUSE POqT TO~NSEND WASH 9~36B ,". c. , :-".'. .. '" '.' '. .:.' ;.. ..: . . .: .' :,/ri:~!'?;.;:,,~~":. . ..,":.:,:..., . '.. ;::. . ..':: ,.::" '., .::"...... ...""' ". . ..:/. .....; ". i' : ...:. i" '. 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Before complellng seclion bel oWe oded area, READ LEGAL WARNING on reverse ,side of this poge. IT' b' d _ . I op porllon SlJ rntt:c , PHYSICIAN: Complete Physician's Report,,:,,'j._ Ich lOp portion of Original where designat ,~" ldsubmilloDeparl.: by physicion ment of labor & Industries, Allenlion: Accident Report, Claims Section, Olympia, Wo. 98 . Detach the Physi-I Bit' b' d cian's Copy (3rd copy) for your files and promplly moil tho balance of the form 10 the employer (this includes l b~ o~:p~:::I;n sv mUlu Il1e ballam portion ot the Original and all of the 2nd copy.) : ......-------------- i EMPLO'lER'S COPY r..'" " '. -..,.....,.-- ".- ",c"i,',':l;,: :;\':;,:'~/:~~:~.'~~~'..." t' __..,_... 'n,. "",,' .'. ~ ~ ',' ;:'i,::/.',., ; "'i.. '. .'..........,':...,. :"" " " " /lc< .,.' '.. ":;-::,.' '..'. ,...... '....:' ,:,. .: ..' . '" , '~- ~ '.'...'.',. , ''',. ...,,: .'. ',.:".' .. ." .' ,c., : '.;' , "; .,'. ",':::' .... ...,.'., ," .:'. ......, '. :- . .',:' ,':' " ...... .:: , ,.",. ::,: ' . : ' .:. . ;'.:' . , ',;,..", . "" ..' '.,.:' .".,' '. ,..,." " " . ,"'> ;' .,..... .,....':.;. . '....... . .' . '.; , '..' ',' . ..'.....:. . ,.:'".' '. ..,":..'" .:: ; , "' '.-'. ..' .:' ,:' '....... :.. ",. . . ";.: : '"'.. .:, ", .' '.' ,,:: ,.........'... :'. . . . " ' ", ,','.,... ..:',:, '. ...' .'. ., , .'"' . ",:. '..-.,.... ... ~~)_:" .', ....., .,. ,." ..... ...".....:...,;. RICHARD LYNN, M, D., '.' ' -.. . - . 0 ,,8- - ~r.~ ~~:!~;;~:~_li~;;~L:'~:;.:' 8 i:" :''.::::'/:/'.: 15' ;tcUlfl<;,J i4.t "C~J7 . . 0", ::) 6. ~Jq -L)t (/ tI /- 1- / ! .....,. ,', ',:'. > ~~ /l-,~ <7~0-Jl--p-<..f ! 'd U --L-- UA ' .: "" c~~ ~c-CL1~ ,A"-a-c~~.~ ;l; ~t '. .,..'.....,::.: " .' c-t<-~'<A_ ~,r~C. q..-~e /h_.Q-e..l!-oL.k ,". ::,; c~:,,:.J ILccL, --'7~cu- ' .,,', ," /'M~;2,-&~ , .; " ,...' '" '. ,., ..'.' ", ,,' [, [;,... ( ~- .. ~ M [) :: ,,'. ,'" if" h'1 T ( 1,\ r hI. ~.1 r-.~ fl ~ : I, ...'; L, , \, ! 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'.':'" ~f;iy;\,,:,,',' ,.','.' ." ,,~,,!,-"\"",';" ": :< ... ,:'; r---- 1II1<!lrllll1"1 ._,--""'..-.". - i ---,. ,j_Oii.ll__ """"",17'l'IIlIlII ~ .... .; '. ....'..,. , " .- .' . ."'." .....c.:.... .,:.'" . "; ":c' ", . ::, ....,. /" ,"C'.>' ;,". :',:. >,: ,., " '~ /:,1 ,l' ;[1 ,J!, :y, , j~ ,C .'. ,j' :~i: ":,: ('.: ':' .... .':.: j\' '.,:, " , ~ ::~;;H~~ ~17" ~- ----- ., .", JIl,,.,.,- v m: ~ ..... C" ....~',~,,;\~...~ ,~"..' -..:"', ';'-', " ;';,"." ~ ... .' ...~.._............, _____.."_,,.w, ... "" -- r~ ~L -- .,------ ,",[;.. "[ACGI D.ENT;i'~ERORT' ~~~~l:.~ ~:~~:~~~O:~~~f..~~~t(~~:;I~RBI~'~ri~:~~C~~~I(~~~~rl 0100,.10 . ... .. ._-,-,_._.,_m'__"--'(jIY&SrAU."-'---~'--'---~-V;cOOr--' ,.---. --~-. """". ., .. _.~ ""...', ,i' " ._. _. Ilt""-r YT , , '11 iF = ~'F lJI~ . "C' .,. """ ',. . . ,: .' ",,'.,' ",' . ,.';' " :".,.' ,".,' '.' ; .. {I ,':.', (lftS<' 15-1 15-1 15-1 15-1 15-1 FRAKER FRAKER F RAKE R FRAKER FRAKER : .', . "..' ':'" K ; ,':: ,____;,:,),:::.:...,_),,'''~''~'' :.,:,',::'.:'.~;. 'i ';, :\ -~ , "". . , '. ". " ..,: ,'.' .',' ,..... " .,..' .' " : ,:. ..... '.' .: '': . ....' ..... '." ", ~. ..., ..':' . '. "",', ,': ,:.' " , , . , '. , . '.','. ' ". '-, "'.' ;. ":.'.:"'. :<'. . '. '. ".' .......'., .". '. c', "" 'c. ':." ":..' ',: '. , ,':>', ....,.., . ", , . ,<, ". ; ...... '.', '. " , ',' ". '" ., ' ..; ',.': . '. . " .,.. ", ...: -'" " .., ':,".,. ..... ....-, :;: :'" :,' .': ,... , .,:: " .'. ' , ':'," '.' ,,'c,: """>:'" " ",.",,:' . 'C":' ':i '. '.i.:,'. ... .:. .: ..,:. .:...':- ". ........ ....:' "':'. >,. :.'.' ,,"c'. ' .'.' . '. ,'.:.:. .. '. ,:.:.i.,' ". 'c .c,..... ... . ..' ..:".' ..', '. :"" :', ',. . .', '" '.. ,. ., . '.,-. :' ....,....:. . ..-' : ". '....., '..,. ,.'. '."'. " '..:: ."',' ,... .' ".'., .' ,,' ..:' ."..,. ",.,"'. :,< . .'::,' .. i'~ ..'. ~ .:" . '.":. .... EMPlOy(r fl'\/,\! EV -~'YMPIC 1",~j~NHOMP^'I) Jv CLALLAM CO GV LEIBOLD E F E NOVAK J C E NOVAK J 4B9.30 18.00 11.40 30.00 2.00 550.10* ,r' . '~y UAll 11"Cll\f4 12 11 14 12 11 14 12 11 14 12 11 14 12 ClAIM NO AMOUNT G31012B G31012B G310128 G310128 G310128 JEFFERSON COUNTY HIGHWAY DEPT COURHIOUSE PO~T TOWNSEND WASH 98368 ',') ~~;~ FIRM NUM[l[R "') 104 23 131 4.360-011 STATE OF WASHINGTON DEPARTMENT Of LABOR & INDUSTRIES l OLYMPIA, WASHINGTON 98504 THIS DIPARIML~T MADE AWAR[,,, A"; ~HOWN AIlO'lL fROM THl Mllll(Al AID FUND NOTifY THIS D(PARTMENT AT ON(( Ir rOil ANY REA',OtJ IN 'Y~)l!R OPIIIIO/I AWAIlt> IS IN ERROR OJ< OtAR(jfD 10 THf W~0NG (lASS ". ; ',',::.: ,. .... . '.., ,. : '. . "".':.' '.:: . , ,:'," ,," ' ',: ,\ :,' i' . ,: '" ',: ',': :: " ':'.. ,.:' :', ")""'. '"~ :: ;'. " " ":,"'C '." ... ....,' ':',:, j~ '. ,::..' '.i , .,,',' .: ". ,.',,::. :':. :," ,.:', ," ...'.., ......",:,;':">::'i : :::"".:'", < ..... ". '.' : :'.",:, " ". .., ":, '-" ': ' "':' ,'..,':, ': " " ',:.',' , " ,i," ':: : '. '. ". ;', ' .. ".; " ''':' : . ':"'i i';:'. :., ", .\' , "",'" " .... ..' ...., ,,: .",>:., i:\:;' .... ,,: i' :" :,'.":', ",!".: ~,: r---- iIIl'1....___,~_ ....""'llj :"0,' ..,~,,:(;:'-)':):~.:I_v .' . ""':'~ <.\,; ,,-'''. ,.J :1' :j '; .t: " "." ',..... ....; ", '" ". . ,:',.:; . . :.., '. ..." ',.....'" " " ',' " ':':', .' "," ':, , ".:' '...'. --.. , ,., ..,.. ,,, in -. 11._ _IF iJIIIII ~ _~..~_._,__ :'\R~, .~ . - 0"' 7' (g) ''1'' Mu" Compl'I' Thb R.pg,'j b'l fllllns In and Slonlng Emp hdlon B"I~w; Th-'It:M~I_i.i!poltot'6~...'''';:';"';'::\:,......~~'' .lfi2~f~tt~~~~~:~~~I~~f;]f~~ ~ :~I~~f.i~i~~~:~.~~:;:~__:;-~'~'~.:'::WI_",~H=::i~~'.._~~~L~a~~i~:~-NUM:__=___I-__:I~t~~;~~~~~;~-:_, a.. ~ [0"LOVHI~Q.YE!?INWHICIlO~!!~!NI? _ _ ADD~ESSORLOCAIION INCLUDING COUNIV, WI1ERE ACCIDfNT OCCURRED StATE WHERE l"":lO'J:RS JOBSLTe OTHER ~ 1 CONSIRUCTlON I OPER~~ION fR!i'R! ONlAUNCHWBOAT! Hoh River Jefreroon Count ~~~RER~& ~ :1 5 x ~ rw~s 'HiSAcc'D~Ni-- -YE~-- NO . ~-I; YE~ ~TT-"(~ -, DAtE OF ACCIDENT ~ - ~ iiMf -- - ~r DATE' IltPOIHfO ~YOu . ~ liME -. -- - -I- cHia HE~E- -. - - - - ~ t!~~1E~!~~2~~~1~~_:'~ _ ~_ ~XPL~ATJO~_ J~:-~-:Z~___ _ L~_I~_~~~~:-12 _ __ _ ! __ ~:~ ~_tT~~~~:ED ~ ~ L'ii:'~;I?-=_!'_~ r~~~~;........:O~R_~_..",.lJ~;!~~~.f~~~lt~~~~~~~._,_~.:J~~ir_li:;~~~?~"__H..l_,~L~~~~~~~.~.I.:. '~:u.;D. _. .~.._ J..~;;~~~~~~;). ,_. "1 WlllYOUPAVTHISEMPlOVEf YES NO IF VES.EXF'lAIN . fNIEIIEMPLOVEE'S CI<[C1("PP~OP.'''"C''IClf ~ ~i~~~~:~~~~~~~~~~~~~_~ ..." .'~['._,~S:i_!~"~!!_~-~~-~lavo n__ .~~~~~~~.~!,.__~_~J2!Q!?_"_"'~~~h"~~~~U_""__~~_~_'.'_..~HK MOXH a.. I AVE~AC;eWAGE - I-lOW MANV DAYS NAMfSCHEOIJLEODAYSOfF ."f ~~~~:~~--~--;;'-;;;;;;N-;;;: ;~~,;;:f:~!~l~~~'~!----s.-----.. ..~~~d~,~.._I3tlJ.1_df\r,,~.., ,.--. ----..--.--.----- . AS INVOLVto. NAME MACHINERY AND While i j k h hi r:I. h. 1 ~if'# d d t' i WASEMPlomW:11NC;.PlJUlNG.PtJ~. us ng ac amner s g ,t.o O1e~ _,':'.~..__..:-~~E~.~__..~~ .ji~._ ?MtLSSllOUtOBED!SCRIBEOASINOOOIISOR---;- ~- liS AND LASt OBJECT SIRUCK SIlOUlD BE NAMto. NAME ':.-.~~~.~:~~~ro. If AP~,._.,,_._._____.,_~~~~~,_________...___;~.,_~'_.:.._._____~_.._..M'._.___,'H,.___ _.. ___._~..~.._.._.__~:.".~. I-..-,--l---.~--'---'-,.--,._--_,-------.----------.:,,---...------,..-... .-,.. ----..--.---.-.c--.-.....-. --...... --'"POsljION--:.DATE'~. .-, -"" ....- ...--- Co. Engri12':ll';;72 " '.~ ,~.' ':j',:-,'.>; '., ' SHADED AREA FOR DEPARTMENTAL USE ONLY. -' ,,\";', COMP~~BLE '_...._'_.'~',_ ?!:.~~~~~I~.U BY.. '.,::"'::.",::..'t'.;" '.-'".,.'; '''','"!.COMl'UTEO-'','' ,0ATENt;lTICEStNT.' ""';";.":.,'Jl . '". AMOtJN r.:--- MIDDlE lASI j IElEPHaNE NUMBER j SOCIAL SECURIIV NUMBfR - V~ - --- Fraker----- - .. 374-n90 - . . , . 531-12-393g--u,----- .', ~ILlNG AODRfSS , OTY SAlE 'I ZI CODE " r ~A"o. ACoo.m-s("!f"e.~;.II~I5.f.t,3~iiiHoUiS--lOO':Jo. THr.'?,~~"'Ui/:!ashit,'1T;;.iEO,ii.-iH---.TH"c'.I?83rh;GHi-C )-__.--ll~1.4"'72-r.;--_11<OO-~M.-~l-8. <00:4<30. .-Forem.. an-....>r---. ,.-.M----l--7.-.~. .,n.' -.U. ...-...-...15..!..8!!uJp4c-'- , iG,JVE?A,IE~~~~O~KE~. 1:..~IVEDAtEllfIVRNfDtO O~K.IFSO: !~~L~~~~2TW~:' ;~ ~~!STATEWHERE I~?P, ~O~.~:f ',' ,OTtlf t: h~:GiiofiiM1>LOYER I -.H--,------.-~:-sTiEfTiDDQ~:F .....-==~~~r.~___H.__.~ ''2:~..-c~1-H~:~~~'-.<:<:~~~~.~'..l~i;c60'J'.~~I'.''~owl~d,~~E-~ . ' o I ' ',C t C t ' YOUWORlCfDFOR ill 1_...J~-f. ..t:<;~J!..C? !L~1!'l. t:y..1Ii8I1~eYnDep~tl,-,~~-~._~~.or~--T0!m8end. .wash1n.on. gelJli~~~~'~"..... .21....y..rs.., ._.. :;: I EM!'lOYU 5 8U!llNlSS 'STAlE TYPE 011 NATURe OFl ACilDliNWIecATlON, l~jaUOING COUNTY, WHm ACCIOENT OCCURRED ~i ~:..:_Count:y_R<>ade_ ___.___________._.___L.... Upper ,lIoh_.1 efferson_Coun ty,.. Washington __ .._..__"'_ g' I. ~E~~~Mf~~PEwN~:~~~cil~tJ~~l~Zl~N~R~n~b~T~~:E , ", ", fe"!~ :~,U~l'rii~~ ~~t~~~D~L'I~~~'~~~t~~_..-_OpeJ:D.t1ng-a-shoveJ...;and- drilling. roclt..w1th''',a .jack"-hammar-n .~ t~~e~h.~:~~JJ.,~f~lO 8f NAMID. NAMI OIEMICAL ,/.' ~ _____".___..__~.___.,...........,........___,____ and. ,hia..rJ.ght. ~ng..started.. to,.get. numb. and.. stiff ...., ~ h~1~~~~W~~~i.r- -:.:-~~:.:-;T~'~':~:~~:".'~o~~~~;,~:ii~:.:.,...:....:r:;";;.;,;;,:.::;~~~~~:.;:;,;:;....,:;,.,,:~.~;~..,.~ . .,' . -. .--.'.. u -. .-. '[----.--". ---- - - .- - r --, J .:''''''''J -:".,~,;, r .,,~'" ,- '"'"0:''''-:' riAl NAM! Of WI" ()It HUSBAND ^' TIMI or ItUURY IF DIVOl/ClD, GIVE fiNAL CifOE[ DATE If DIVOIlCIO "NO YOU tlAVE MINOlt CHllO~fN SUBMlt A 865. 00 COPY Of THI COURt OIlDft SHOWING UGAl CUSIODIAN Of _0%4__________ ..___.________ __~ ~~~~!:N_~:O~\I:.~.:~~~~~~~~~~CH_:~.S!OD~~. ~. _~_. GIVE NAME AND 1I11H CA11S0' YOUI (HIlDUN UNtlF.l. SUPPOI1ED B't YOU THt FOREGOING SIATlMUlISAIl[ lll\JE to fHE 'DAlE ._-~ ---.N,v;\f---~ -- t;ilA1i~5H-;P ~t-Gf I_H~_ ~I~~('.- - -'--r;iL~TIO,_;;;;~-;.cf~ :}l~W',~lt~~~~~ip~~UI:lrikUB~::f ' -.-..,- ---- ~_. ___h_ -- -. - N -. -. N - -~-- -'--~-I--~~ ---,-- -~-- MAYllf5ULTINCIVILOIlC~IMINALPftlAlTIES ' 11-15-72 'JAnt. Cll-.--..----,--.. ......d4. ugll17 _u...,.,...,.__....._ .---1-'....0--..-.- ._---~ ...;,"'....--.--.-......-..-;;.7-.. c. :.'.........'-.. ;::~:::~:r----~'=~~~-~~~--~..~~~:~:~-it~~~i:~-r-;;-ci~~~~r~ajf1;~~-k~k- g.::l~.:?~,.._,.. ,.. .. J._ ..............__, ._11J.,s,_r.ig1!t. _.!!,g .s.t!'r.ted... t.o ,. se.t.. numb.. .llnd. Dti~f...___ ,..... ..,.. .. ....... ...._.._. C~lflt'S.At40"UY~1 flNCl1NVs"'onAll ( :~MI.'.t~1~~'ll?"'1O. LargQ Dakory Cyst dorsum rt. knco, size of DmD.l1 lOUlon. I:ninful (iu'~ . .' .' . toflnxion._. :,".'to;v,~~'~~~~=~t~'=~~d"'t-;;...,..,.........---.-.-I-'7Ay;;;,.,i.ii".'...'-....-.-.O' 0_', .,.::-.-.. g" .',DJ:~.J~.,NOVllk..fOr..orth. eo.r.edie-coaaultat1.on-- --..-------...'....-...--.....--.--..-- tt,uI",,';OnrllAD ",;'" ~~~ ,NO 'I r~l~~~vlM~~I~~~ VIS PtO IfV(U)(I'1.,lIN rw: t."~~_~~,~~.~.~.A,~~" ,.'~:~.._ ,~__LP,~~~~4~O~:.I~,I~A.'.(,OflOlt~~~,.. ... ~~ ,. _ ....__ .."...,.....-.... ,.. , ~" '" Itt u.~ "lfttto 10 Ap.,QltlU OOC10lt. ('"tV( fjlM' AtIO .ADlJet!,5, ~ ...Dr,...1on..ph. Novnk,.,703 So. . Lincoln , .Port..Angololl,Wn. 98362 .'. _ t\f~It1M#Y",(.I\fltK: V" ~j() I WIUIHl\OIA'4VQTfl(' Yl~ '.0 I (OUIOtf1lcor'joilotl ~ \ _Ol~A~OIh"Arf~,lNI\I;fO~ _ _ " __ (x I ~::R~W:t~J.c;:;~:o.o::<cg~~;;..AU x.: Ig~A8:tT,~?Dn,P~~rl~('O' i ~ f' '~~:i)~~lO'>f'IiAlllf~I;~.~~~~1 1:' .u..... 01110"/'11"" . (11'1' ~ t. W'I;'I~~1'(~;':~O.TIUlOf'-"'" ~ vj','''-'Io' I"EsjiMATED TIME LOSS ~ i....UlllII.lftfANY wmr1l~MltlID ~1_""ro'~".":~v>........{X ..1. DUETOINJURY ~ """'''''''''''''''''"'''''' Xx ~. "^"I~I(lI'IG",n\l(l.AtI ,""f"\4 I'lI1tl'0I11fl YOI./.t/AoI,I1 "'10 Al'Cllt ~\' 11~{"(lfJr THIN""'I' tIUNlIIl' Edwin 1', Leibold, H.~..D,,"., P'O.~1lo.X.3..PO~,__F M,..""'Wn, ' 98331 374~62S1 y~ _'~ <rA'ff-"'((OI.1'~ltI\!MfI" _@if~,(1- .6Q · 1!/15/72 6024 .'YES"' rKifllAlltV '>M"lJOI1V",IiA((I'lIl) \1 I \ \)"-', ....H,""lo(,....O.''''1 ' " I 11('I'f~IO't(Po(\A~ '1/'>1 (111'1, PATU M(OUW t~lJMIII.~r""M"1 PACE ,.2 , E.MPLOYER'S COPY IM,Loyn, COMra.Tf Mkl I, lMl'lOYU. S Q-[rDQT. t.l,-"""fOIAllLY AND MAll HiE ORICINAl TO tHE OH'AJUMUH OF lAROV lINDUSr"'lfS, OL YMI"I^. WASH "6504 WE f'RVEP TO ~IAVE EM. PlOyfP ~ V(I'O"'l BffORE l^~ING ACTlor" or" (lAIM ~ l.__.... "__'___ ....JII ; '. ~';"' "'i' '--I'" !:: ,':" ", ~. Ii 'F -~, ...__ __I~~_~A'_"'.~ __10__' "l.... :...'t,,:'......~ I.~~:_ ~.~ - __" _"Jlll,_. ,_ , ,,,.....,---..~"'---1 u. ~" "=- - .. .', . ., .. .~. ~--,--~~~. -.,......-....1 ~ .......~... l"'~~ .-~' ,;~;'" ~.._'~...--'--...CI' r!'lli r----......-..~......~~ ,~",....,... .,~,.......,..- ,. - L.- ~ -:-~ --'~-l-'-"" ~ ie. ' \'" ~ , .,' ...,~'::. , . ,"'" ,~.:..~~.~ - ~ --"'-"--'-"--"- - ""m_ '/;:/-"\,',\;;:::"1:: ~~~~...... ..... ,..- ~~ "'~"') ~ h .~~ ".::,",".~ '_',~~, . IIjr- .. .'. -.....".,.,-..------- ~..".._,.~.... ~ - rlIl"'__'l11 "llJl 'IJl' :~~ti:d,::;~;ii:'~l;::~';.<:.:).:.:'L:,/, '~'~,"'::""";"", ',,";"<\. r.,;...'...: : -,.. :> ",! '\', '::,-.,.- -:" .',0': <"'__ ':'," ,'- ,:," .iL',.:\".'.;-'-,"':,;';';.,';'-;:.<" ',:';: '<-,,' .,\:. ;"\-',"_';"'_":_<<::-':'/;.;"::;':">:", ,-,;:, ':<:.: -":C;." ,:.",',.' ;'::, _, c"'''.:'_., "~ .~ .' [:.rcitQ~:~~p~,,, [;~~::;:~~~.~~~, Fl'~.~~a~~L;~I~;;~ ~~~~!i,~~ M!IIC:::: ~o~::~:;~. ,,' ~ :! ," O.partm.nr of Lllbor Ilnd Indlutrl.t, District Offiu, (5.. re....n. .Ide- for addr...,) ~.g '~.J ,ri(~'::~=~~~I~~lt~~I~~~~~i;;;~;lioTiab-o~-;;d-f~d~~I;i;;,TeloPhono ,No. _.___~~__h ._"~ . ----I Sod;!] S<Jcl.Irily No. of workmAn ~.2 firm namo of cmploYeL______~___~_________ _ + ._ .. ___._____ ___. __._~ ___ ,_____ __.. ._~_Addro811_ _~_______ _________. _._____________________..____. ___ , Havo Ihls workman'. hours beon Inclu.ded In payrolls roporled 10 Ihls dttpartmont'l.______._n_____h,..1I so, In what claaaL___________________._______~ -... . ... ~:ZI~::t:d~:::;.:::::~- .;~pi:~:j~~;~~;;: -:;::::.::: -:-~: -:: ;:'::~~;:~;;J::i;,~-: ':';~:~~; :::: :'~:: ::::::::::L:::I::::::~:::: :'::; ::: ~ ~ Business of ec'fl~~Jao;.;JI~-c-o~n-si;l;cifo_n-~;Jk..aia-i~p""arli;:~r:;.a~ij~~l 01 plant or placo 01 work whoro accidont occurred_w____n___n_u________.___u:..__u ~ ~ Check In which department workman was employed: Construction 0 OporaUon 0 Repair 0 On launched hoat. 0 ~ In Name of Bas he any flnlloncial Solo owner? ~ D=: Injured workman _'_h_W____. ..u~______h______.____n___ ulntorest In the buslnOslI?_.-_nn____w.Partnor? Corporale oUlcer1.______._. , .; ~ Will this workman bo kopt 'on oalary during his purlod of dlsabillty?_. .-_____11 so. attach an explan4110n..__.__..___nn______n.h_~n_n____ '"I: ~~ ~~~~~"~~.,,;..;::::::,:i~~~~~:-~"";~,.~~?::~~:- ~ Do you quostioi1',~lIowanceol c1aim1"'Why? (Attach lette'r II necessary),. n__.__~..~n_... __unw_____________h_.___.__~_____"_h______ ~~~ did accl,d.~~1 happen?.._" H__.':~..~----------'----------~.. ______.. _.__ _w _ .__..__ .~_.___.._.. _____ _.u_____,------------_:...;~.~.-----~--._.;..,,:~..;.;: __',.;": ., . . . . . ----- -.. ____..w_w~,____..___~__ .......----- .___'._..__..__. ___~..____.._ _.._ ....___ ____._._ _____.w__..__ .__'U --..---------..-----..----------_______;....._h.._W 'Describe the accident fully. I'It4linq' whether the Injured person fell or was slruck. IIlc.. and 411lhe faclors conlrlbullnq 10 Iho'Olc:cldl'nt. If necessuy Wl"lle a supple. menlarylllller.) I decla.re that tho forogolng. statoments are true 10 the b~sl 01 my knowledge and bollel. .81~i:;;;;~:;:;:?J;,::~;;~:;:-~:~-~-I~~..::-~:::. ::-~:~~~~::~~. ~~~~~;;;,-.-i:'-,'-..:~:~~-.:!f"-~,;,-::i-~:.:'.,~;it'~-I'~:;i;;;;~~J'~~:~{~~~':' ,-''<tlfed,cal,AJi/'B,IIJ'allowable ;'y,lafU, . ... B}'__...'...........h..... 'h' ... ~~."J~lalmNO,....__...'nn,."'-:m.."'-....,.. Fft~iMd~;~1!ft::..'i;e~i;.:~~ :~~>~ ri;:~n~;~;:;:::;::;nn; .' . '. S"Po'~~:;td~:.:~;~~~~..~::iiJ~:7s3f.;;:~:=2:C\.:~~..::l- :.~'~~.R' Eff7~~ffb~9~ :~. ,!Mt~ICAL AID AWARDS D4t;~~.I!ee C~~t:.~~~~.~..~~_~ lNol Claim Number) Non.co~t..~~.~..:..- Nam:e of inlur~~(,~orkman. _,: ~_~~~e..._ ____u_ _,"_ ---;.~D~~i--u.: .____~_F.:J;~w~~_'~___u_ _ SocI~l . Security No..:.53_5.::-_Q7_"':~_4~-:7..:':-':'.;~'~_ ~ . . '-'.. - . -, (I'~I:...n I'HU-;r On n"l, ','" TelephonG No, __37!t,::",s..6.~~_w';'n_'w_~_~_';___ ~~:':; :~,=~l:~~~;:~::~:_~~~~~:~~:::.~~~:::~:~:~:::~~:~:~~-_~~~:~=~f:~~~:~~_~~~_~:~'~~:;~~~-~~::::~-:;~~~~::!~~::::,:... D~I:a"i~.ora"~IT'd _:Oct._31-._~969-,m_____h___S'." h,u, aI "'ld~.,____!:1r!_~tl~_~-~~W'm--mShllt. hou,,:S__ta_4:30m___,~__ . ~ t::E::::E~F;~;I~:~~:~;~~:~~~~~=~~F:':~~~:~~~~~!~:i~:.:~;~o~:~~~=:~:~::::::::::::::::::: ~ ~ Describe' acdde'nl in full:. _:_:Uauling--load. of--grave1.. -t'O::"';1ower_~:..c,ve.r __rough_.road_.._____u__.:__~.:.;______~--.;.---. _.~.;. ~ .~,~~~:..-~~- ';__~-.~--~w ---. _-:-n u _h_-:_:_-;_ ~_h ---; n__.~--;_. -- -... n -:--'~.'-"';.;';::'.~.I~::-:1;;-~~~,~--~-::_::-~:-:~u-:~o~-:-: -~.:.-:-.:7-~:::--_:-;~- ..~:-,:--7:,-:---;-"-~----:;"~- .~__. : ~ Wastli":o a~CldGDi In your opinion caused 'in any way by someone not omployoa by your employer?___l19.~_~;.~;j._'__ . . :.~ How long .havo, you workod f~r thla employer?___" .--_~_~-::_:~-..~-- e- ---.,.~--.2-yrS.-----_.--~~------..-----Wllg-O per day~-3.61..-per.J1r. j ~ Dale. you reported accidont to omployer:-.Nov..._3.___~97O':~~-:~---..-TO. whom reporled_uCDne.Fr.aker..t...JM>-4~lJt'gp-~m@~~__'":"~--- ..,~.~ ::~:.::::!::q O:~~:::~~:~._:~~~~:~~;::,:::.::-::;:~:;~li~;:;;:;d.ql~~-;,~~:::::-~~:IT:=~:?E:~~::::::::.:::::::::::: ~ = ." . .'. If dIvorced and you have mInor ch'Udren_ ~'u~mu a copy oj tho court ardor ,showing leqal cuslodlan of lSuchchlldren. '.' -'::: t; :,"'. Also qlv,e presonl address 01 such cuslodlan. .c; ~ OIVE NAMES AND atRn! DATES OF YOUR CHILDREN UNDER 18 SUPPORTED IV YOU .=~::~;=.==~__~;.~,~~;;~= =;rb:~~;yJ.;lC= iK~ ..---__..___,___________u____ ________._____ 'i -, ---- u_________ I' ______.'__._n____..__ _._______ i~ ,.:'~.<~ ~ _ . ~ ~.::~ar(l 1~/;:Jor(eqOII\~.~I/Jte.~~~.t. :~,~Q ~J:.r.. bOBt of ~~ knOwl~~;k~d bOIlOt., I . _", _, ..: ~' " ~;~~~t~~~;~~~'5.~~~;i:;~:~~:~~::;E!:j1~;. .... -)N,)I(:l:l~~~.:~~I~.-J ,1':," / \It~ me ' :'Soe.S.c. No.,'..s3S.qr~0l67. Nama :'o~'~.nlllfed .workman\" ""Ir.Y.~, i,~.J:'r .. or. _....._..~.__w" _ .'--ci".im-.,:tu.inbo':.~;',\~:_:_7. AddlO..Swm.Hl,nax.:364/..:.. .hmClly,PorkiJ._.ltlsh.. __ ." "mplaya,. Jotttn'SOl\ County IIw;r.D.<lP't. Add,a.. p.Cl1"!; TOloIllSond.. .'nab. no'll.! InluUl'\J .10-31-65'. 'l.: DAle IlrlllJol.lmonl ~3l.-69.,...Worktnan'lI A~o 1Q-6...J5' IIl""y ., '''I'''y HlUl1ng',lOilld . of'. gl'Bvol. to lOWOl." HoIl . ovor rOUgh" rPGd :01" .". al D "hi. NAME: ---- .~~~~~~-, __~~~~.~~!2~~~ ~ Phy.hnl fi..dl"g"I.I.. Il.".il Right.direct. ,1ngU1nnl hornia. ~g ~'" z.it .,. . : lZ Ol,?"". 1ti8ht. Direct. Ingll:lJlAl.JIorroa. :)~ Ol.. "..Im.., u.aJStmngulata<l ha1'lrlaredllcod a wok lAtOl'. than rctarrod. to Port.~L;B__i~__ ~~ X.'raytlndtn71 ~ .--~~~,~~ir. _, _. '.. .. .:",..~. U ~::: u.. workmotn had Jl,evIO'JI Inlury '0 lro&1. no__... ,~ii n:'. "O'km.~ .." ''''~ ll..'od by "yo"101 p'O""'o, ..,mulE ro'dl':~": no. I. thet. uy p,e....IIUrlll dlUtilU 01 th. 't.. In'UtOfI1 no. .':YIII lhi. 0' _ny olh., pt....h.tlnr; rondlllon t'omplicut!t Ir"lm~nl or r~lltd ,-.cou,y? . no. . i II C"Ondlllo.n dl.qnv..rllho IO'lilt of iIIc(ld.n.~;;:;~Z.d? /~.# "'fI~:7 .<w~';fiJ Probably 09 ~"I~~ 5=1- No 0............'1" II hc.spU.liUUon IlltjlJlr""l. name he.pUaL.. (/../-liY'l-"Jjn ....,i'1~.."t'>'-~..",r..4.,.6' ,..Addr... ,.. ""_ t.:':'~'." .~..,.:/'":" z-J__._."._.._~~.'_~~~_. l. , I , 1""~-tJ.r c,,"":) "'/"*'., ,0__ .~:' ~~.'JtIl_(i:l,1m~..I~IJ.l),!':,lil.lI\l\1nL__'"_'. ;6~~'-.-.'._.~'_.- -~-,.. - . . _ _.' ,.\..,' .'i ~:~:i~~~.~lli~j~l;*~~..:;;:i!.. ^d:~:,~-~;:';~.Ji~~~~g-;i~;;~~~:~K33il.: 61q""tu,. .~ (U/I~.{" ,_ "l-(. .... . ,.,n..'1'~O. _,"y..A("COuntNo...I..roJ,. .__..__~u,.. .,."....~',_\._-.,.. (M',OYU - .IMOVI i1mT TWO - riNK cory _ nus IS YOUR COn' ..If yel. ..pIAln__ " IU.. D."t, ,.,.. A,nll"t HII",b" Ite,"pl ..r.'f)"'l~l r""-'~- - ._ I _~'f'- . '17' .. :;0;--" '-.-.-..", ~ -_..... -."'. ... ~_..~---,,~ . - --- -.m! RXf~n~, ,,~ - ---_.!' - M; -- .. ----- ,~ EMPLOYER'S COpy --...--- .------.--------- -- ~----- P-_._----_._~ _______________ ~__. _.__ ________. - _,~____. __________ ~_____________ ____ ___________._____~___.__ Empl~y.r Mutt Campl.f. Thli'Repart by FlJIlng In and Signing EmploYlr'. Sluion ~,lrOW. Thin .Mall Rlpor' atOncI to ',. 5 Departmlnt 0' Lgbor gnd Indu.trll~, Dlatllu OfficI. . (5.. rOVlrle .Ide 'or address.) 5g firm number'ol cmP1QytJ:........,.-7~_q:.;_._____.___nTetePhone No.__.~~.?.::J)~9~__~.u_r~al Security No. of wOtkman_ _ :>.; {Numbor Auiqnlld by OOt':'Ulmenl 01 whor and IndUllrlllll1 ~ l~ fiT", ?,;;;d;lOmPIOyo<t~!'tf.!__~~L~~!_ !?~-!!:!--~~_hn___nnh_,.Add'O'L~~~~~~!'Ll'~____~~~!!_ - 8%8-. ..,.. Havo'lbis'Y;ctkman'. houri beon Included In payrolls reported to thll doparlmonI1.....___l'~_~_______. If so. In Wh111 cia..? _u~_:_?.____.____~_______ .~--. -,-.'~. If nol Includod. qlvo reason~_'~_ ..~_." __.. _. _ .__~ n__ ____ _ >. _.._____ ____.. ___~ ______ .___ _. .____ _ _________.._ _________H_________.. _~__...______ _ .___.__ ... How lonq has workman been employed by yOU?--..?q.,,~_~,__~__u___Occupallon when In/uredL____~l:__~~~~~______u_~__..__~_~_. ~.~ Buslriessof'employer~~_. ~~~'-~ .~9'~~:r__Locatlon 01 plant or place of .wbrk 'where acc;idenl occurred___u______~____~_~________~___~_,_;" 3: A. (U li'nqolqed In conslrul;llol1 wOlk slale piuUcul4r kind)' '. , _'.. ". z ~ Chock in which department workman: was employed: Construction 0 Operation 0 Repair ~ On launched boat 0 i.~ ~j~::Worltman ~~~;.y!_.~~?:~S~~-,-_ _. ~____ ___ _,. _ _ ,,~_.,._~__~_ .~'::r~~ ~~~~~bn;;~ess? __.__!!~_____.~~~n~;;n~~~orate olflcer?_______'__. ,:.,,;........ w ..,' . .._-....._. . . ::-('f.:/, \, . .',::;..~'S~I!,t:~~~'.;..~"~,r.kman be~e}il.pn.~slary' ~rlng hls.perlod of dlS. ablliti--...-Y:~~-----~Jf so, allach an explanllllon___ng~ -~.~~~:!.9..f!~__________~~__ .' .,l1~': ..-... ~ ~91969r4r.30A':tr. .' 'w .X"'~::::E Dal.~__~q.l!?!r of accl nl..,_, nu~"r_.~~_____uuP.M. Last day wo.ked_____~_____n.:.__nn_Jlalc roturned 10" orlr--------8--.:.-liu3(f-~~- .--~ E IoU Wan"workman_ engaged I'lheroqular cou1so of his omploymont when in/urodL____-YDG.nh___u_h_Ph_______ ShlJt hours.,u____u_~________.. 5 -: Old accident occur on your preml.ses?_____..__~__~~__._..IJ nol, where? ___."_____~____~ ._,_~_ _____n_____~_h____ _n___~____~.__:.___h.____~_ ~ t;: Date and hour accldenl reported to yOu_~_.~.__~~~__._________P__:.l:i.. To whom repOr1ed__~~_~~~:r___~_~,____PoslllonJ!~!._~g;". ~ Do you quostion allowance oi c:1i'1lm? Why? {AUadl loller II flCCeS3Jfr} .___._________E?_n__ h~----------_______n____.__~______h___.._n~H_._____ How did occldo.nt hOPPo.?-------~~-~~~:~)L~9.!!)!lhl?nt.!l.l}h!ll!;'.!1;Llf.!!!L~J,~!;Lm:!c'LWI!!1,___hn__h_mh__ (De.crlbe tho accldonl, fully. Ilallnq whether Ihe InJurod peraon Jell or wa. Ilrul;k. etc., /lnd all tho lolClot. conltlbulInq 10 tho accident. If neconary. write a lupple. menlary Jeltet.1 r declare th.SI lhe for~g~lnq statemenls are Irue to the best of my knowledge and belief. /1 si."d'. 'hl._!?'.~~___dOY oL_~1;1.._~m__m_. 19-~~__n~Il,t'!'_~_'!!!_!J_~!!ll~;Y:m_m BY/~.. dkga1~~~~_____ . '. (Employer) . .,,::," L~{OUlclaIPoll~n.!...__ . -AJj;Jg;d-;'o-;,-;m"Pe;;abie-;x;;# ~r- (TOB;-US;D-BY;;A~;;';- O-;.;r - - - ~~- -~~-:-, - -. ~ -,~ - ----~ -:--.- ---- tIledical Aid BiIII allolPabl. by lalP, By__n...hh..'.n....nh'q.nh.h.~ 'j((/YP>. ....... .Claim NOh..hn........h".h:C....'hn AI/owed -for'allthorized -Ireatme.,jj:. .. ~I~~ml E:.'~mlnor ,;.,-..~f' ' '" ..:<_ :_:-,":~', . :". _:'".~ "'" .':. alut action as:;'JdicdleJ. ..' , '~.' By___..~m.......-_.._..hh........~ ',OUANE S. STOOKEY' ,_ Fum NO.._.;\.u._..n.....hmm~.:..., Clalml EJeamlner Supotvillor ot Indu.lttalln.u~ilnco RlO 41-75 :,' ,,'INol ClailIl-Numbolj MEDICAL' AID AWARDS ~, ... -".~: ", ',c_::":,- . . " :NoIi,Coni.,_...., Nomo ollnju,.d wo<l"non.-------J~vg~_._m___~..___________m_h~~hm____ Sociol S.""Uy No.,,$J..J2".;900:___,___. ',.'": . .... .,,:,;.-~'. ,.::'. :._:.. .,-,': "".r .... : fl'l-I:....~':~tN~., o~ TY"I:. . .' L^..T,..,_, Tolophono No. --~~:.::-;..;,;:~._~:.._:,::.:;;:..:;;:~_u__.._~_ ~dd,...'li~~~'h .JI'm'll'.lo.,,"~dd,....d):__ ~~--~l+...-S.~::ati_:#L-:-'-~.if----Cl'Y ond.s'.t..'----;--!'~i-1:~~J.l...-_-::_,-,. . You, Job nn~ wh.n Inl~'.dRriad.Flremn.f~_JeUeriu>n COlllrl;y::Sox _:X:;:';.7,.;J.6,.lJ, H"';hLS~a."'W.I~hh;i,95.,_' D," "dd'or ,,,u,,,d ~,~9..,"_1J1~_m_m___._____S'''0 hoo<. oj ocddontn.~_t;/!.i.:~~._~~:::~~g~l'l'hoW.___~!_~:!~,-,-l2-C!--- ~~~:=~~~l~~~~.;~-i~ w ~ '!'lea the accidenlln your opinion caulod in any. way by somoone not omployed by yotlr eniployQi?_________n();_~__ ., Z ' .'. "';"'~"~,' ""(." '. : . r! ' . -6 . ko (Yel or no) :S ~D.~t~:~~~oported ac_~~~~~ ,10 omploy~t.~19,u. 9 To ~h~~ reported f4...B.e:~"-.-~,,..~.~.iN~';;...;.:.iiii~i'..--....--.:m...waqe per day..~~.~......~.h ~ ~ If omployertwal nol nolllled lho same dole as the accldonl. 9Ivo,r,oalon .:.~. .' ..,.____....._.,__ . _d___'__ .' ~ . '0 ~ ~ .----...-......-.,.. .~._-.__.._._........--...--. 0= ~~ ... Nom. of AElondlnq Ph,..ldon ....m..E....F."":r.r:dhoJd...~....... .. Add,... :..FllI.'IQJ....J~~iIlg!;.9I\ ........__ ;:~Full nam:O:'~fw'Ue or hiJabCln'd ,":':~:. Ora.~._.__.....~::..~~.:.;<:: . 'm...,-:': . II divorced qlv; final decree) 'dato ., .........'...h:~~..-....._...--..-..... .__..... . U dl.,orc~ and fOU hay. minor chlldr.", .ubmll a copy. oJ _Ih. court ord.r .howlnq Ilqal cuiladlan oj .ul;h children. AI.o qlv. pro'..nt add".s 01 .ueh cUIlodlon; =."C":===="=~~_,::::.~. ,-:,~~;.~ME5 A~IUR'H DAnS ~~:~;~OUR CHi~DREN ,~.~~~~~~A~..:~._B~"""7.__ NAME Relatlonlhlp Oat. or Blrlh ~ar NAME R.14110f!lhlp -D-;j~ Mo... OilY .Year h~~~~ ig~~ ," e.!! ~!l -'---'J:f. ---'L- . ~J3-- ------- IJ ., I d.~I.r..lh.;1 Iho loregolng stalo:me~t.:_.t~ .Ir~o, l~ lho heat oJ my knowl'dq8 "nd belief. '., :', Slqnea.. 23; . dAY '0'" " .:, ~-'.." ':--' ::~.'-~.':---.._, lo.6St,"a'_..~_':".,,_.u.._. Fa:clcs,., Wlllhln?:lon. --.-.-~:~Ih..- ---.,.--.--~~MP?RTA~T~~=~?,~~;sTci~~,~~WEEp6~~~;7~~;;;~,,%~,..-d'1l"~1#-::~:~:,:=-."'c; Rl Q,i,~L~,? N.tmo of JIIJur.d workman. ._~.j~~'-.E.u8ene..,V,.._Frakor..~ _n __ __~....'. u~___u.__ ~"___'___~''''__R_~__ ..___ Add,.... .;-. - __ S t. _.ltt._~.._Boll;.,231-- m__ ._______ ___ _ _ ___ __ _ _ __h__ CIty J'()~~J__ R~_I1f~&~ EmPloy..~,,_J:eff.~_o"'.C_Q,__ !.'vY.. ~P.t..__.,w____.____. .. Add",..:-,,~t_~__~~~!I., ..l!!!!M~8. on 0010 Injurod._." _,..:.5,.23,,69. ___ 'm... ...___.._.0010 110" "00tmonL._.__S.-.23::1i9..__.:___. ___Wmkmon', Ago... m__}::l~~..___.w W.tory oflnJury.(U~C"llremIU'llnvolv.d. 91.. right or 18ftl ~_~~~~~8 .,~~~~S~~~~~~.~~~_t;~8_.~.~~_!~_,=~c:!~~_~~I!.~~~~~~~_ -buming .and.watering and ;It.!e1tl1IuLI. had. got. nomcth:lnS-J.n_them.._____w__....m_..,__________.u._u. Phytltalll.,dl",. I" delall III u',emUlo. Involnd. "Jlvo rlghl or 10111 P.. B...l.eft.comea..u. ..~__..h__..__.~__.u~,..___ .~__.__.~._.~___ :,-::~f~~i .' .(;' - -f':.' '~~"~:""'l'.,Xi~ loft.comnn;' - --.---... '- 01.. ""..Imont u,ed.. pontocamej' removod P. B.with Q tip. nl!odecradone.. X.ray f(ndLn~ .-none,..~ _'J~"~"':'-~.2~:L;~::1~2,?,, ; Claim Numbo, < .I'~- ~ ~ - ~~_. ~ - - _. ._. _. .. P... _".._ - ,. lbt\ wOI'i:mAn had p,r1vlo\lll inlury I,) IU"'~? no lIa1l._wotll,n\an "VI'I ~"'.ll--Ir"~I(Io<1 hy ,wynll!? br pl....Otll or *jmll~r <;ondillf)1l7 no If yo.. tn:plaln ; ~ " h 'h~i. .ny p,,,.,,.ir.4nl/ dlH'ufo III t~". UIU lnillr...d' no Will lhi. (lr Il"Y f,'I,,~t\Il.I.-OlhHIIIJ rnn<lIHon ('(,lnplk~lCl' ll"~tm..nl <1, ,..I",d H'>:"Vll<IY? no h rntldlllon dLHJtll">llllftlhlt 1I,.llll of .'<Tldonl ,j'fti"llb"o\7 v... xl Ploh...hly (J II h{\ll'lt~liu'ion ''''lull.,,1. nlllnn hQ"p\I~1 POhl!Jly n Uo LJ Addr".. r.t,r"Altt.,1 l:m", La, d,,/!' I., 11'.~\n)"" :'::;::::~,::~~kj;i~:~;'d2_. ^"d".. lMI'lOYU.llfMOVt' \IHf1 IWO f'1~j"', COl'Y._.lttU 1\ YOU, COl',( T"'~ ;..j;".l' fa" i..'''f.I''~'' ,,"11 ;.."." "ff"..t i.v- Ii'.':'.." 'p",;j;io,; si. Hr. 1, Rox 6 ForkB, WOBhington.98331. P.Yl'''' At.'corJunl Uo lU.. O.p.. ,"".,.. A"."n,l4"mb., 'I11l"'",.rv..,,,, ~. n- ----... ~~__1t__ ~"' ._-~ T '1::-:-:: _ w,... iili1iII _Im"'_____ ,_Il ~~-..-~~.._- If ~ " ,'" ~ . .,,'. - ,.. 'Wfr ! -- 11___ ~lIlIIl F:<< TI --....,."'...... .,~"'..~.,'".........I\I __ ~ JIll---_ -. -=- "lOIIl i- -- _rtiIIIB Hili 1"" __,_,..",,,,_,,,,,,g"~"m,,",,,,"'n<""-'I""'~ - ."" ~Ifl.,..-T 1I ,. 1 ..___.f,[ I L _ - flii/Rll . ' '. EMPLO't'ER'S COPY "u 'j '~STATi"C1f WA51l1NGTON I IN.' C"~~N"",b.',-___ . '.b~:P:':~~~~!-_ R E P 0 R T,..Qf_~_C_~I~ T Clai,,: No..._...:..~. III E;;I~)'u, M-;;;Compl.;-Thl~ R~;;;;-b)' Filrins In-;';d--si;~i~;E;;I~;.~~~-s..;;;;;' B.lo....~ The" Moll R.port'~t 0';(1 to - ~j D.partment of Lobor ond Industrlel, DI.trlct Offlco, (5.. rIven. .id,. for addre..,) , ~~ Finn !lumbar 01 cmp(oyor___..h36Q~1~~~__ __~~___Telephono No.. 3B5~3S'_OS.__. _ ___I Social SeclIrlty No 01 wotkman 5.31-12-3900 I::i j (Numbor "'.Iqned by Dilp'llmenl 01 Labol ,nd Indu~tllolll ' . '. ' .." ....... jJi Firm name 01 ompIOYOLJe;f~.._CQ._,H:lghway..nep:t;.____~~~._':w~_ '_-ow .__ ...-__Addrestl"C_ourthQU8e,..rt.&._.TO'WI1S8nd~_HBsh.__ - Have Ihis workman's hounll>oen included In payrolls rQPorleG.lo thls'dDpartmenl1.___.Y88___~______. U aO,ln what class? ~~__6~,.:t__n..w~__':_____n__ If not Included, give reaSOA_ __ _.. _ _ _" _ h. _ _.. _ __ __~ _ ~ ___.. _ __~ ~.. _ _ ~ __" ~ n __ ~_,_ _ ,,___ _ '.~ ~_ _ ~__ ~ ._____~ h__ __ _ _ __ _._ _ _" _ __ ~__., ..~ ~ ijOW;joAq ha3:.~p,rkm..a,~ ,i?oo.n.$tmp,l,oyo,d by you? ~..-.,.~17, )~e.arB, -...... ~ ~..,:O~cupatl?p, ~h~n In~ure?? R~adJ~ia1nt.e~,7~~~an-_l_' :'i~--~--~ :~ B~alness of employerBd..Jiaint..._&..C.Onst.oLOClltion 01 plll~t or placo of work whore accident occurrod_Hoh..River_Rd.H216..:___.-.- ~ 0.. '. . (If engaged In C'onstrucllon work slalu parllcular kind) z: Chock in which dopar1ment workman was employed: Conslructlon 0 Operation 13 Repair 0 On launched boat 0 ~~ ~j::dof workmlln ______.~Im~_~Me~_~__..___~___~ _ ~_. _~_" ..._. _.~~:r~~ ~~~~~bnuc~~osa? _~ JlQw~_~_~ ~_~~~n~;;nC~~Oralft olllce'?_________. ~~ Will this workman be kept on ealarydurlnq his perl~d 01 dlsabllltYLule8,_~~..~..1l 80. al'~~ ~n explanalion__Sick..Den.e.titsuu__________ ~~ Date and houtof accldenI1/l6L6_8__~llt20~~~ Laal day workad_n7/-1.6/.6ah___n~_ Dale roturned 10 work___1-/23/.68__nw______ E Was workman engaged In the regular courso of his employment whon inJured?~____ ~Ye3 ~___.__~_..___________._ ShUt hour.lL_DBys_~____~____ .'~"": Did accident occur on your premlso8? __wyas___~.__~____ _.It nol, where? iJiDC-~-' ____~_ _.~__.. .,__ .____._ _________~___~_____:_-~~----------~~--- ;(~ Dale and hour accident reporlodlo you~7/16/-68_..~_~.6.tOO____~_____P,M. To whom repor1ed.Edwin~AluBecker__Po8i11onCo...En8'.- ~ ::J,.;I:"::::::,II:::;::?:.:'::~~;:-'-::;~~:~;::~~~g~~:;h9);i4~~~:::::::::::::::::::::::::::::::::::::::::::::::::::: iD-'-II~iblt-~h;-a:';id'-;I-iuii;~-;I:;J~~-;h'-;h:; -Ih~- i~j~;;d-;il-l~~~-f~il- ~-,;:; -.~;~~k~ "'-t~=-~;d -a~llih;-I:;~;f~ .~;I;ib~II;~-I~~;h-:~~id:~~.-il~~~;;;;;r~-~i~e-:";~~;le~ menlary Jellor.) I dsclare that'the loregolnq. statemenls are lrue to tho boslof my knowledge and bollef. "s,.d IhIL~kth__.d.y oL__.llUJ':____._,m. J..~...:..-c,::. ce_.L. _ -hn--___By_,CtLu...7Z-_&..:J1./2-LP:.m_____C_ "".."';.,,.....,..,...;,,; .,'..,, .... (E"P\~~ "<"",,'.' (OlJlclallPoelllonl ,r';~op.f.iiiabig,except f r ifti' BE U'X BY DEPARTMENT ON'Yd. ~;,..", :i'/'. -. ':'i.,:~~~~i5~t~,~'~' t~:' ,"::~~i~;;~~~L:~;~~;.:(::,... . S"P.,~~:,~~2;'~"" ;~:;;:,~.............:..;.........-.....::..~'.~-:.......,;(. CI.as.........,...,.......__..___........... Eh.'JlLO.YER'SCO~Y Date Notice Senl Cant.u....n.... Non.cont......_~ ~~m_._______.._.:::'.._..____._ ..,DOLII: LAST Telephone No. ______~'~ ""_~__~:,,~_~ ...,;_._~_..____' \..........I:,."''''1C''.1y...:1 ^ddre~ (to which all.mall to be addro.ssed)~dZL_L~_,._!I...3w/ _'..:_~,:.d......~~:~~__'.;~~~_~,C1ty and Stata_d,&:J;A;;L:U/~____": ~:: .~,:~~~~::~~-=IL~~~~~~~~-.~~~~~~~~~:t:-:~~:::::}tIiMfl1>>~~~~:;;:~~:z_________~e~~~I:~~:2=~:~' Give dale Illstworked___u7_~_I"--_=_~_.u~____.;..____________1f you, have relurnlld to work give doto_________~~-~-__~__-~..,-u--~-._-.,..__-_----- . . 'Name Of.~~PIOY.r----H~~-..d.a..--~'~-.;.~_-~h.--_~-w--~-~-AddrDn---~~__~~~...-.---,_-, ... Were,yoll dolnq your reqular work at lime of aCC'ldent?~_______~._.__:.._on'emPIOYOr'3 prOmISOS?_~__';'_____~ . "~ ..~i~:~.~:::::~.~_~:~l~:~~:~::=.~~_____.__~::~::~:~;n_m:_m:::::_n:::::~::':' . ~~ Was ,the accident in your opinion caused In any way by someone not employod by your employel?__~__':l.t..d__....'_w",:.; .' . ~" . aZ.' . .'. " "~.. or,no).- . .',. (7Y:) ...~ Ifow 10nq have you worked for thb employer?________________./~7.~,~uu--__________________...-----_____Wage,per dayw_Gz. ,S:.-----.:>Jt..o .... i~ ~E:e~:::~: ~::::::~:~~~;fr~~::~:!~~~~~:~:~~~:~:::::::;:;::::::::~::~:.:!::::::::f:\:~~~s~~:::. ..,. S= . IfdJvon:edand you have minor chlldron submit a copy of Ihe courl ordor showIng-legal custodiari of ' such children. t\.\'" \ :~~t:; . ..'''''i~llO.9iYe presenl ,,:ddresa of such custodian.' - ! d:' ',\,.\ ~ GIVE NAMES AND BltII,TH,DATES Of.YOUR CHILDREN UNDER II SUPPORTED BY YOU ! '\'\,' ri"u NAMI: Relallenshlp Dale of Blrth Mo, Day Yeer NAME .- "" . / . ~I 'r> ~ . :..L2,., II ~~ ' "', .. , , }i ~ Il~' , I declare lb.! lb. fOreg~lnq IItem.ollar. tNOJIO the be.l of my knowtedqo and beUef. 'II \ !ill 1, ....~. ... /.~;.;",!l" / ~.J - ,., L, 'I , $1..ed::...j~__,dey.L W,---.c...../..-.-- J---. 1.....""_. ".m--..:r.a.'t?'~..... jV..hln~tol"" ..________m.m.________., ~ " ~..,-:~:-~- ~~ ~; ,,~fgRi~~~~it!.:.:;i~n.~~A~S,GN~~~~K-w-~~:J.R!~:!!~~n.~~:~4~--:--~M~-~_-----:~--~:::; :'. Rf~;.~;;_,~: ~. ~ ,....' . t \.:. t: t'--:" .. 7f~c--:.,.HYSICIAN.S REPORT .. '1 ,Nol CI.i.lm t?lmbol) "'::"";':':,?:.-:::':,:,~", Du Rrako _._~~..:..~~::::w-.:~.:=.=:.::.:..= ~l~~E~1~~!~~~~,~t.~..=...'....." = P~r,hot nndh,..in delall'H__J.\UnbP.~..4te..C:L~c;l~ woO ~. _ n_~.' UU ___u, H_ ~ .u~_.~,' _. .4~n__n_":___~____.__u___~~ .~~~~~._ nn_____ eO ~= ,....~'~w.__. ..__..__~~_. .~_. _~. _~. ~__w. . ...__ _~w._, .ow.._ ~. _.~_~, il ~:;~::i.:~~;t:_~~=~~~~,~~~~~~~:._.-._:.--.:'.-...~:.-.: .--.-.....:.:.:::::::::::::::::::::::::::-.:::;.::-':.:-:..~:: !liE --,..._...:,__.... __.__.m......'...___,__.., ~:\'''~= J:fu ~orkm.n ~d plov1ouslnJury 10 .roa7.., DD~___~'W~'h.~~~'~ ~$ ~~."~k~..n...~..r~."",:",,'ed ~y..n~~.'.r,pr~:en'~r "~"". condll~.:: . no. p ,____ _lIY":'.~.'PI~~,-.,~::::~:::::~::::::::::::~::::::: Dr,; ts Ih.,. Iny pr...daUnq dIsCI." 01 tho ar.. Inlured?, ~O__ _~. .. ,~,_"~_~_,,._'."_'. ^.__u.u_____. un~nw____~ WilI ,hi. oc 'ny ..h., pre..",".. co,dlll., compile.'. "..'m.n' ., "'ud ,o<ovo,y' no ..... ......_.n.. _n_..... ....__...' ....______ I- condUlon duqnoMd the r..ull oj aC'ddenl d..cnbed? V.s III ...-obably 0 Po..lbly 0 no 0 If ho.pUaUullon requlr4KI. nlm. hospUII.. _.'~' . ^ddre....___.._~,.~.w~____~w~~~___......_._~~____.._~~. r.lllm...l.rt hrn~ Iou due 10 Inlury? 10 ~nyD , ! f :-:~=~r;~,~t~ir:~l:'~~""~~~~~:'.'~:~d:~~'--'~~;~~;:;"~~.~I~~~~~~~~~:~:~."-'~_~:':~::~:::~'-'-'_..._.._. Dale 7-1(j-~.~.." ,PaY".AC'count No" .,,__~.C?~~~_.. ._.'.__... 1""lOYlR - UMOVI sinn TWO - PINK CO,"Y - THIS IS 'WOUI CO"' (UI. 0.", Per.. Au.,,", Nil","" Slfllllp) ,~('i).,oo r---- ___.,.r... ~,...., ",..~ ~. '~ +,. . '"'~ ,~~.. '1""?'~ "I '71 UWI"- JTiJ:ii __.__111 -_...~ .- S. F. No. 16-i&-OS-(Rc.... 7-011-7-61-20M. ... WASHINGTON STATE EMPLOYlllllii' .. RETIREMENT SYSTEM ., EMPLOYEE'S PERMANENT RECORD To Be Completed During the First 30 Days of Employment by (TO BE COMPLETED BY EMPLOYER All Employees In AU Eligible Positions ~~' ~I Sub. I Refer to your Transmittal Report of Deductlons. Part B. Write in depart- ment numbers. (LEAVE BLANK) Member No......................................... Date of entry........................................ Orig. member...... New member..._ TO THE RETIREMENT BOARD: As a condition of my empioyment under the requirements of the State Employees' Retirement Act I submit the following information: (TYPE on PRINT NAME PLAINLY) SECTION A. IDSTORY 1. Name-Pztile.:t:::.7-- _L.Lb._e]:::L.-.--..-lLem.--..-- ..-----.----..----'- (Last) . Ii (FJrst) (Middle I . L (r~l~.u~rrJed) ,'-' 2, Mailing address ..S~r: ..~/:'0j3.0.JG:x6-':'-;.--E/!-rl{s._w..'J5 i22.,Q/i... Street) celt)'} (County) (Stat6{ . 3, (a) I began my present employment withiI..~lli.:L<f..!>..lLC!2,--Q~Il7..;.()r.l:l:if.hJ([dil'.s.. . (Name ot dcpartrncnt'lo;&n'ls.slon. agency) , II aLlIj1-;-e::r::-./itl/L- on the_l-4X-f....__.day oLf2e./o..l2eL--,-. 19U (b) Title of POSitiOn-Tru..-e.Jt-_4:r-/.1LU?jI.-).&.%o'2te...r.:aI.J1L OIJ.{.....__.__ (c) (If applicable) I am also employed by__________.___.__'-__....:_______.__..__'---__ (Name of department, commission. agency) 4. Present rate of monthly compensation: Cash Maintenance Allowance Agency From Whose Fundi Compensation Is Paid Total (a) (c) . 5. Record of service to present employer and other public agencies since October I. 1947, to date: Where Service Wu Rendered PERIOD OF SERVICE BCIZ!nnln, Eodln. I Len,th of SaIery PaId Period Mo. Day Yr. Mo. Day Yr. (Month..) 19 19 $ 19 19 $ 19 19 =J: 19 19 TiUll of padUan HeJd Name of Department Commllllon or Agency 6. I am a member of or receiving benefits from the following retirement plan or plans: 7. 8. 9. 10. ~;;:..., .....~~_..."'~ ....... ~, ~ .'... 1 T --. ~ - _~lIIII ,:",>:; ~'~""'._'~,. - .. ... ..~, "OM, ~ ..HI - 'V 'Ill ~...,c_~, ""'. ,~ -.._,,~..... -.......... .' .... :!IFf\\! _.~ ___... ...'l\I, "H , 'rIIII1iI.!IB --'1JlIB!l .b.. -~--;~l_,"".':';. ~-~~-:;.:, '\"':':,_ . ........~.~ _,' _~.:..:........ . . .> r-~>"'-""""-- "I"W . \, .._....~.- ... --.. _11111 "" ... - ......, "'-', ~~"'."'"'~~'J""'_" ': _ .','_,-: '-:,,,,r, :." '~'?):'--r,,', 1 , . 1i. F. No. 7G.J6-!).:Il)_lOM. 260911. . (LEAVE BLANK) WASHINGTON STATE EMPLOYEES' RETIREMENT SYSTEM Member No....u............u.......~.............. Date of entry....................................~;. Orlg..member...... New member...... EMPLOYEE'S PERMANENT ,RECORD PRIOR SERVICE Date approved by Board To Be Completed During the FIrst 30 days ot Employment by All Employees In All ElIgIble Positions ................................................................. TO THE RETIREMENT BOARD: As a condition of my employment under the requirements of Act I submit the following information: Certification No................................... Date Jssued........................................... . SECTION A. IIISTORY 1. Name..,_,~I!r.._,_..__..........__. 'Eu&ll11B_...____...'_..._..._ ...V,,=,_.....,____... ILast) (First) (Middle) (Malden,if marrIed) 2. Permanent address...._,..._.......___,___......__c..-,-..........-......... _,.!9..~,L______,_ !Uallelll____ IN.a.ah..-,..__,: (Street) (Ctty) (County) (State) 3. (a) I began my present employment with,-....!M;l'eb3QI1,Qqm!,!;,~_~,!t1;,.,_Ot_1!.il!hMlD_.___...,_....,~. (Name ot department, commission, agency) at,_.Hoh_!}.!..~::..__..._.._,_,..__..__..__ on the...__...m.._,~.'.l,~,_..day of...__!'1!.~1!...'_m...__...___, 19~... . (b) Title of POsition.__,_~~;-.E!=!E.!!'!!!!'~..___,.._,_...___.."...._..,.._._._.__.._.-,--,-,-..-__"___m__~._~_._,:..,,"___...____. '(c) (If applicable) I am also employed by,..,_ ......,-.......-,;;;,-.;;;;;,"d;;p;~t~;;;;~mmj;,"j;~;;;;;;;~;;;;-----'-..-"..---- Present rate of monthly compensatton: I CMh Maintenance I: Allowance (a) e200.00 (c) Tota,l Agency From Whose Funds Compensation Is Paid $300.00 J'ettereon County ROOd lImdll 5. Record of servIce to present employer nnd other public agencIes since October I, 1947, to ,date: Where Service Wa. Rendered PERIOD OF SERVICE Name of Dcpnrtment, Comml5.llon or Allcncy Title of Position Held 'Ending Mo, Day Yr, Lf'ngth of Period (Month.) DeglnnlnA' Mo. Day Yr. Salary Paid 19 19 19 10 19 19 19 19 6. I nm a member of or receiving benefits from the following retirement plan or plnns: ....-.~._~~.------_...~.,_~_........H..__..._..__,...__.._..".. nm.............__.__...., ............_._......................._..........._._._............__._._......._.__......_............ .--......-.-...".., .._.....-.__........__......-..-_.__..........._._.._.-....~. --.....................-....., _..._.......~-...-..-.._....._._........,-........._._...--_..__._-..,.......-....--........- . 7. Social Security No.,Il~~,~;~~_~~ll.,O____...._ 8. Check by (X)-Marltnl status: Slngle.._,__ Mnrried,,,...~. Wldowed..,_...... Dlvorced,____ 9. Check by (X)-8ex: Male....x_ Female,_._,.,_ 10. Date or blrth,....._!~1..~!9.~~_...__"__ Place of birth ..-.~C!,!'I.te.'.....'m__~.!'g!.l!!L__.._...___,.._I'!Il.'!)!1,,!!<<,!O IMonthl (O.y) ,~'ear) (City) (County) (Stato) !I'" "l~~ ;,,;'.'/~t,;:".i, l:.Q .S .. ,g .E " :S " o '" t: .;: i:l :l: "f:! " t,)'" f;;l ~ t.> ~ s: .... fa ~ en :B ~ " o 0 ;; .s ll< .. ~ ,~ It, '" z il 01;- ;E::i'a ":',8 tJ-.' CIJ ::3 $ ll< os ~: =i' ::J ,Z ] ~~. ] !Z e "!ll! 1 1./ <- .e. ~ s ~ :j ] tJ 'a !: go ~ e~ i ,J j~ li' 0 ~ i .c >: ... -~--,-" ~._- ;; :3 " " ] " .:; II " ,." i~~ .".. ~~~ "j;~ ~~- ~'Cg i1~. 000 ~l1<e ~ S>> ~a ~ I ~ ~ ~ ~ ~ ~, ~I~ ~ ~ l;; ~ - 11- ... .. .j [ J c. '.' ..", 'l' , .\' , ., '~ ;."~-'" I /.'. /1 ~~ Ul" ~~0~~~~**~0~0~0*0 ~ J~ ~ ~ ~ ~ ~ tl ~ r;J .. o " o C! re ~ ~~~~~~~~~~~~~~~~~~~~~~~~~ . . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ". ~ g " l~ 11= i:l .5.3 ]~ ~Jf :;~ ia >:0 I .lILOf-UMS, - N .., ... It) <0 too co '" ~ :: ~ ~ :: ~ ~ ~ ~ ~ f: c::: ~I t:1 ~ ~ " ':.~,! ~~ {I~; ~_.,._...._- . '" '" ~ ~ ~ ~ ~ ~ ~ >.' -"=m al 0 1i 0 8:.8 ~ .~ o 0 ~;a tJ n ~ .~ ~ ~ t41 '" .. ~ ~.~ Il: ~~ ~ S'~ _ 1:'. ~ ~~ ei H '" . ~ [:l ~. ~ H ~ ~ ~ o o~ Z . a o '~-5 f ~:a ~ ~ ~ ~ 'a.~ ~ ~ 8 ~ a .~~ . 3 e 0 ~~ ~ ~ -a~ ~ ~ --:E " a .~ ~ '" e ~ Ob U' M~ "tl 11< o :; " " c ~ I-f-- 11 ;J f 6 " '" "5 ~ 11 ~ a '0 c B _~ ,1'- -- .~ ."..:1. ',,-, . (";;,,"~':'l II rl ,. ~ g . . .--....- ," .~. '..., - UI " 111 ...__, _r - -I 'T lUll n I -,..... _..111<"__,-.._... '" ..... r--- I I' . 'I ' " ,'..' '" ,I:' .' " .', '. ", " ,', . '.. ,', '.. . ' " . I ., -"__...."~_.,.. '.' . ~~, 0" ~~~. - ~: ,.jj'~ IIllJJllJ .... . ___ ij _Iliiiii 1'''l1li ,-~ - ,..-.-,---...-,. --- . '..'.' T_ '111181 1 -iliIi , (. '. ~l_/ ... :"..~ ~':.' , l'IIIIIIIl r- "~'" -' ,~-..- ...;,_._:-:....,...':.~-., I~,~, r. ..,.~:.~\~"_'_.:'"... ^ ., I ~ " 1-' . ,'~'" .. _d ..' __ _ ". ",~ . . L, ", I . . . ,; M" r.-' ~ _.... ',. RE NG EMPLOYEE'S FINAL COMPBNSATI REPORT fu:.:.ction A: Monthl Hours Includable Monthl Hours Includable ~ ~ Compensation ~ ~ Compensation ~ 1,730.27 06/81 s 2,192.88 ~ 1,720.59 07/81 1.952.93 08/80 1,921.56 08/81 1,952.16 09/80 1,730.27 09/81 2,127.44 lQ@.. 1,730.27 ~ 1,952.00 11/80 1,758.21 11/81 1,952.14 l.illQ... 2,107.46 12/81 2,269.96 01/81 1,952.14 ~ 2,533.90 02/81 1,983.37 02/82 2,294.00 ..D.lLB.L 1 ~968.03 03/82 1,980.76 04/81 1,952.14 04/82 2,153.88 05/81 1,952.88 ~ 2,154.04 --Dfi1B2 2.247.56 ':cction A: Sub Total (Total of Compensation Listed Above) $ 50.270.84 ------------------------------------------------------------------------------- Section D: Other includable compensation earned in the .designated period and not included above.. Annual Leave S 1,734.52 ,.1 ~~ ill?!: include. payment fo:; services (lit), f prior to the deslgnated penod. 2 .194.10) ^~:~'J. Same as above. - r I Same as above.. Same as above.. NOTE: We can Use only that annual leave, sick leave, etc. earned in. the designated period for Average Final Compensation purposes. You must, nevertheless, trans- mit contributions on the total amount paid at rotirement. Sick leave cashouts are not 'to be reported for state or school district employees. Rxplan~tion of other under Section B above: Sick Leave Compo Time Other (Ex- plain Delow) Section B: Sub- Total Crand Total A & B $ 3 928.62 LS4: 199. 4f[ NOTE: If your cashout of items listed in Section D above is J~DS than 100%, 15~2d~catc the payoff percontage here by item: Annual leave ~ Sick leave ~ Comp time - othQr~ and the hourly salary used to calculate tho payments here $ ~6 . Even if tho items listed in S~ction D are incorporated in Deetion A, the in~ formation must be provided. Raturn TOI ..............................................................*...**..........* IMI'OIlTANTI PLEASE RSTURII AS SOON AS POSSIDLE TO EXPEDITE IlEMDER'S RETIREMENT ' ........................*..........**....*.........*.*****..*.*..*.-.*-..*,...- Dcp&trtrnunt of Retirement Syatcms 1025 East Union Olympia, WA 90504 ~!!JI~~,_... _ W'ifr ,.,.~ -MIll.. ........ - -- lli.lJ.l [in...~_","__ I dOl rfJ ::E r:: 1n G;;; E-t2 %C'l W~ -:.- .-o- w' ~..:? ~~. =C::C .s~5~ ~t~~~ ~~~j "'n ~:J .~~ ~~ VI :E w I- VI ~ .. o Zt-w~ ::><>- ~ffi8 ~ ~ l; ~ Q~ c: 5::.! ... uJ ~ 0...< t-~O: zs::!: w ~ :E 0 ~ <l: a. w o . ~, P .? <-> -~.;:,--" ~,--., ~- ~ "' J'o ;: L;L ~ .') " - u..... 'I ,J r, O'./'J .'" _, ,I) Z. ,').\ C /) -< .:) .Z:::: >- "::l""'" ~.... - ; u.. ~ '_"'l U. :-_' Q !: (\j...... C ,:) .'1 '"? u... (\ .' , I I : ' , ' I I I' "', ' 'I , ~ I. , ....."... .,~" _1!lH ~ -". " - "i' ,'. ...."'" -~ B~ ..-,-- .---. _'lIII r-- __,,__ " _.. 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", . .. ....',:' ",:" ,...>,', ..:,',.." , '",.,' ,.. , ',' ;, ':> :'....' ,:..... .' ',: '... ,:,,' :" :, : '.:::: ..,',' .' ,..:"...::::;":..'. ,:, "',... ,:'..' ...",..", , : " " :',",,:. ~. ';;... : )'" ',".',..,., . .' ,:, ",' ,::;' ",; .. .:.'., ',," ,':, " " ',' AUTHORIZATION .. PAYROLL DEDUCTION FOR AGENT USE ONLY FOR EMPLOYER'S RECORDS Group N"mll EMPLOYEE NC!N? />1 ,J -V /.? I;' (i A/ H:.:r c; /./ ADDRESS d;r/)/? /i'r- ' ;:<(iv' /.7L, DEPARTMENT MYROlL NUMBER Applicant Name ).j, C ,.",y ,J' Home Addteu (Street) APPLICANT DEPENDENT TOTAL Cltv I hereby .uthorizlI my Employer to dedud from my w.gu tho .mounl ,ho....." .t the right ud m..e monthly p.ymenh of thil .mount to COLONIAL LIFE AND ACCIDENT INSURANCE COM. PANY to co".r COlt of inlur.nct ur,i.d by me. I furthe' '9'.. nol to hold my Employ., r.lponlibl. in the .....nl . premium p.ym.nt il not m.d. wh.n due to the Inluruce Comp.ny. ~NCS~I~}~tE A! <t.. ~~S~RANCE I {,: SO 1 St<lte Zip OTHER ..cY,/VI L-yl : I 1 1 $ I 'I ..; I """ I I 1 I/O 15" Borth 04tll CANCER INSURANCE Emplovee No. TOTAL Pol,cV Applied Fo, \E D.I. ,c.r;',;j, /, /9 7k Sign.tur.x ' /' AP~fc..nt ~/r-"-;1 )~/ ~_~ </ <~7 I/Z/j'L.-~ . '.1r""~( O<lle 01 Appl,e.tion r""" ~711).1 ,. :' :~ ,',: : " ,':;..:::: ,.: ,:.. .." . : . :.' ,.:, ,... ,;' . ' ,.,' ,"':.. :, '.,', ,",:, ,: :;:. .. >(' ..., , .;" ',.;..' , ,,' " '. ':','......,' .; ..... , :" ..' < ,'.," ...,". ',' .,' .'- ,:: (,.~,.::' .." ..... "', ".' :,", ", ,9 .... ",''',';,';, i. .'....: .>' '.'.." . ,': .,.::':',,' ,,' ", ,', .,..., . ; .'..' , ,'.' .' ::, ,,':.' :,,:., ,C...,..:.., ...:r.,:,"'",' :,..., ." :.,:':'.:" , : ',:', '.:'., i, ,,'" '. :,..;, '. " . '. .." " ,,], "..' . , " '..""",,:, . '''.. :.""" ," :;,' ",J . 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" '-' , . . . ~~~ '01) 5~ ~ ....."- it) '" 0 z '" u . 0 a h . ~ :i! It.a c l- i 1"3 ~ :::> .... . 0 '. "- '5 . . u ! ,," ~ ~" 0 ~jj . ,; . ; jl H f . . ~~"'~ " i ,~ . 2 ~ '5 ]~ '6 il <3 ~ ~a:~...:= , . . . STATE OF . WASHINGTON . EMPLOYMENT SECURITY DEPA~ENT NOTICE TO BASE YEAR EMPLOYER THIS NOTICE IS INFORMATIONAL r JEFFERSON COUNTY COURTHOU SE PORT TOWNSEND WA 98368 --, PLEASE SEE THE REVERSE SIDE FOR A DETAILED DESCRIPTION OF THE INFORMATION SHOWN BELOW Employe, Account # 945077 10 ..J Date Mailed 07/22/85 2 3 4 5 6 7 8 HOURS AND WAGES APPl..lCANTS NAME JSC # WaA BASE YEAR REPORTED BY TOTAL REPORTED YOUR % OF BASE SEE APPLICANTS SSA NUMBER APPLICATION DATE Map OUARTERS YOUR FIRM BY ALL EMPLOYERS YEAR WAGES REVERSE SHEEHAN JOHN M 131 085 1/84 386 5,461.11 59.99% 099-32-4156 06/23/85 1820 4/84 3,276.14 ,', , " , ,', '. , . , ,. ~ ' : " " ,,' , , . ~, " . ~ I ; --...... -""'" '...- - _II~ ~ ..._.-- 1 - _. ___. --....-_'IIlII "-"11' ' :::; ," " " ' , .' ".: . -..I , ,,',"" ", II .,' " i':": ',,', ::, " . ,: . "',.,, .' ",:'- , ~:", '. ,r .,. ...,<',:'., ." >. :,'.'.,' ,,', , ' '" , " " .," '.:i ' .:," " .' "".1, ,:::' '," ...:<', ::'>,' "". '.",.; .,,'. .,'.,',,' " '.: .:>:~""""'" '::'-:" ',,:,...: .' ", ,'" ' " ,',: " ,', ::' : " "', ,'_ DEPARTMENT OF L~_ & INDUSTRIES .;:'-'..', l Ol YMPtA. wAsDoN 98~04 ,".,' ; " " .. ,', " ", , " , " ,"", \ , :', ,.,', , , ' , , ',.: ',," , " . ...-. .,: ..'. . ...." I' "u >> .. " " , ,"', ::"",.' " ,,' '. ,.., " .. "', '",.,'" " ,",' .."" ' ,"', .:^., ': " :, ... '" ',' " " ,',,". .,,'" ',' ",' ..>q, :.,.,',,' . ': '. ' ........" .... , ;,', ':' ", , "':"',,",',:",,:. I', .. " , .' " .'. ,..' "':, , ".,,','. : ."., . ',/{ ::. ~1 "" : ! .; ~ .,. -~ f'.' ' ,', ; " ' '. ! " I:"'" :i.:', ."'",''''' ~. ~ 1..,-."./ ~'O'M'{ ~"""""'M"l 'r u ~ pO~I"'Gr PJ,lDlat \ 0" p(~Mlr NO 96'> JI1 i' :. . ',::' , .,' --..~ ~ :a'I:l'J ::!'Io.~ :a.,lo] =I~.l..;t 4:.lt' ,:, 'Il.l~'" a......."'''........, .. 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"/" ;: ii ~,/; ',: , ';'1',\",' ... " '" "I~" ..~A~f~[;;: r I""" "),'! 'J.;-,,~," .' - " ',,' >.t." '..,. 'S}; ".<>:-:""\ '''J'. ',',\"" , " '~ - -' '\';: ". '. '. ; .,..," -.-.......- - - ,~~ . ,. - .. ... . _.". __~'iUniJj._r, OIlUi''i!IIf; --, : ...' ..' /.... ,,' 'I ',. ,'..:::' ;';',' "'. '" , "":.':,:'. ,..,.,.,. .. .'. ",.'. .": .,.. :" ,;.. ,",',.,. ':" , [ .,'...., p..oi. ,. ' . , ,'.., '. ..' '" '. ':' . .. .':, .. " "....,',.'..',... .. ..".' : ,," '...: ..,., .,".:. ", . " .' , . ,. '.: " .,.'." '. '. .,..,', .:', . :. ' , ...,'... ' ..., ", ". . '.," ... '...,.. '. "..':,' " .......'...:.....',' ..., ':, .' ",.. ,'" ".' ",' ""'. :..., :..':, '., ';.,.. ' . ,:,,' . ", ' - ".', " ,.'; . " '.' ':', '.. ,. """'I" .' ,"'/ .' .'. .,', ..' " .' ,', ,',',' ',.,' " ,..'." '. .. " ,." ',. . '. "...' .'..:.... . " :'. '.,. ::,. "'. ",. ',,:.....,". ' . " ' . ":, ...,:.,: <. .': . r. ,...' I. ,', , .... , .'.,:,": ,;' ',.. ~,":) ." ': . ; .:.... '. :, ..'.' ...': .,' ..'... .':'. .' ,... . .: :.........: .'...'. . ":': ,..' .....;'...:..,': ' ..... ,.,,:..,' , . :,,:'.' ' '. .' ...,...,'.:....:'.,....,'. ::, ... " . ",':...;' .....:.' ," :.:...:. .':" .' .. '" '.',' , '" ." '. i ,.,.' : : ."<.:,, ".... ,,'. .: '.. " ',:.:,:,-:":>',:'" .",'/ ,\ '" ., \.. '.,.',., . , ' "', .' '.,:':, .::)~{.\. :.', " '.',.. . :~. ,:,:,;.:: .r//:::::, .', ,'.' ". ,. '\ ","Y-:'1','\."~"'" \:< ~ " " ,,: ;', ',\1 , .' ','~, " ~ -, i" " r' 'I " , , ...,; .:.' ( ." '''' ~ , . " ..' ..",." . .,' .... ,... .UlO urOU 1111 ~PERVISOR OF INOUSTRIAlINSURAf'lCE DEPARlMENT OF lABOP AND INDUSTRIES STl~TE OF WASHINGTON OlYMJ'i" WASHltlGTON 9B~04 . ORDER .~~L~\'i~NG M:~DCL()~INC;ClAIM F{)R..t.I".D~~L.T~!'I..IO~...?!lLY .-.- WHEREAS, tn~ SUp'!tv,\or of lndu\wol lnw,on(e ho\ nr.lr.rrn,n,..d thol tnl\ cluim ,\ allowable and that ,here ha~ been no (ompen\oble "me k,\~ 0' p..,mo:.lnl"nt dl~(Jhoill'f' thO! Department do':!\ therlltote accepT ",po""bOl,'y fo. m,d"o' ",a'm.O' ",od""d 10' ,f" ,QO"".00' <O'""d by ,h" da.m ood ,h. da.m ;, hereby clo\ed .'.',.. . " .. ':/' '", "" ,>' :' '," .,' .', "':.. ' .: . , ,...''. ,:,".. .:..' .... ,,' ",', , ' '. ' ',' ". ' :'.. .," .., . ''', " '..... . "..< '. ,..:...' ':: ',' ,.' . '" ,,", :..' , ':," :',. " ,:.,'; '.',' " .'''." '::', ",:,'..':' ,.", .' ': '... :.. ., ',. " ".,' .." , ,.",. :; ...... ,.:: '," '.. , ,,' . ..; .,'<' ,': " '. .:.. ..,',., ",' .." '... ' ,'., .',' '" ',' .,.... ."" ,." , L--.....--.. ...........__.. _.. .__' ,-" _........,.:'::.".~.'".~"'_IN-"~,.':".,,,~.':."~- ANY PROTEST OR RWUEST FO, RECONSIDERATION 0' THIS ORDER MUST BE MADE IN WRITING TO THE OEPARTMENT OF LABOR ANO INOUSTRIES IN OL YMP'A WITHIN 60 DAYS, A FURTHER A"'EAL. ABLE ORDER WilL FOllOW SUCH A REOUEST, ANY APPEAL FROM THIS ORDER MUST BE MADE TO THE BOARD OF INDUSTRIAL "'SUR"NCE APPEALS OLYMPI... WITHIN bO DAYS FROM THE DATE THIS OilOEiI IS COMMUNICATED TO THE PAR.TlES, OR THE SAME SIi,l\lL i\ECOME FINAL. '.... :',', ,,:: ,: " . ' "':,: i:.: '.,: .,.. ..',' , . :,::.' " , ">, .,' ...' ,..'. .1: :., " .!, , ,,;',,', { " ::" .,. " I ,,' .III ,'" :.. ,'r,' :..':: ,; ".'. ,. .. ' ". ',:.. ::,.. '. ,':.. ......', , '.:..: . " .'. ,",>:,; '.' ',' ". .... '.',1 , . . .': ., :" ' " . '~""'.' ..... ," ......:.~.D..r.ll...!UU,l': ','><:olcn...:.l .: 1~:, " ,,', "':":;:',/:'::'>,",;':'\':':'~';.,~>:'~<~:it,.:,,,:;\~:::;,' :..~,...I" " .. _' '. 41 " ~ '"..' "" .'... .::,;~"~~,,. ,.._~, '':'i.J,.'.'', ?:..;l" ~8~04, Derach the Phy~m.'s Copy (31... ~:----'"i--- e::' POO" Iybln'"'''' bv p, .. <oyer (Ihls Includes Ihe bollor~rtlon of the Onglnal ;..........................m~ ftc'" ! EMPLOYER'S COPY I WORKER: Before completin,9 ,section below shaded preo, ~EAD lE':1~l WARNING ~n reverse side of ~his page. ] Sub...ir g,illinollo l & I ell folio.." P.HYSICIAN: Complete PhysIcian's Report. De!ilil&lop portion of Onglnol where designated an!bmlt 10 Department, I rop po,~o... 01 POll_ ...bmin.d , of labor & Industries, Attention: Accident R~, Claims Section, Olympia, WA 98504. Delo . c Physician's Copy I ~1O:h:"I~<~~~~Job~.:"':~~~~. 01 prd Copy). for your files and pro~plly moil the balonce of the form 10 the employer (this includes I e bottom portion of ~___________________ the Original ond 011 of the 2nd copy). , EMPLOYER'S COpy Of PT. OF LABOR & INDUSTRIES TYPE OR PRINT IN INK _ REPORT cg 6~~';I~~~l?~NGTON 98504 WILL BE MICROFILMED. .,~) . . ~("<<~d-- / ~:2 a~Y"-e ~;/ /~~Y' PRE-EMPLOYMENT APPLICATION \ , :Y c~ ~ I ~ ';~ \~ ,~ J') '\\ 6 , . , Jefferson County is an Equal Opportunity Employer and encourages applications from '., all persons regardless of race, creed, color, sex, national origin, marital status, age or physical, sensory or mental disability unless based upon a bona fide oc~upational qualification. (State Law: Chapter 49.60 RCW and WAC 162) C:::l1mmAr ~'T"AtJ ~l1pAl"Vi ROt" (Position Applied for) IMPORTANT: Complete all section. Please use ink. Print name only. 1. Name: C:::hARhan (las t) John (firs t) Maher ( middle) Wa.. (state) 98)68 (zip) 2. Address: 707 Lincoln (street) Pt. Townsend (city) 3. Social Security No: 099-32..4156 4. Date, of Birth: 5/3/43 (age will not be used to discriminate) 5. Home/Message phone: 180;..1708 6. Business phone, same 7. Education - Total years of pre-university schooling: Circle year completed: 2 3 4 5 6 8 9 10 11 @ 8. Hav~ your passed the General Education Development (GED) Test in lieu of High School Gradua!: lon? Yes_No T Year 9. ~~ attended Years From _~!.,,_l)a81'. College "1 1961 ..Jtashington U. 3 ~1g~ City University 2 9/78 J O. ImFERENCES: (please do not list relatives) To 1962 gJ~ 6/80 Degree B.A. Mc-B.A. NAME ADDRESS OFFICE/HOME PHONE (h) 385-3019/ 2121 (ort) (0) 385- 2)05/ )226 (h) 385-0799 (h) (0) 385-2992/ 5088 (h) (0) 385-&501/ 732-4290 o I. Bruce Reid 2. 1. R.a7"'f\M U,I' bA!"t. Gael stuart 1807 Redwood P.T. 934 HoloOllb 1626 GI Garfield 21)0 Maple 1001 C enter Rd. 4.~~~ra~as 5. Harry McCool Form 100~o '~', ,_\:' ___:;::h__'''~'''''''''''''''''_'''' " _ .~".'-:, ',',"~ ., I,,'", !".'''~' ._'11. EMPLOYMENT HIS1'ORY (.inning with latest employment. A. Company Name: n~pt nf +hA N~~ mThrnS Address: Indian Is. IIadlock City Job Title: Explosive Worker Dates Employed: 1/82 From Phone :385-0100 Wa. 98339 State Zip Immediated Supervisor: Ernie Johnson t/f!# To Salary: 8.0t /hr Beginning 9.21/hr Final (Monthly) Specific Duties: I oarformed a v~rietv of renair and renovation nrocedures on naval munitions (painting, scraping ,sanding, stencilling), worked in inventory, operated a variety of power equipment, ~nd industrial trucks, sand blasters ******************************************************************.******************* B. Company Name: Wash. st. Dept. of Enmlovment Security Phone:/l.~7_9407 Address: P.O. Sox992 Port Angeles Wa. 98362 City State Zip Job Title: Disabled Vet OUtreach Rep. Immediate Supervisor: Ron Sayton Dates Employed: 9/79 9/80 Salary: 800/mo 1096/ mO From To Beginning Final (Monthly) Specific Duties:---I-Provided employment.educational, housing, and social service counselling to Vietnam and Disabled vets. In addition I worked as an employment interviewer. and unemployment claimstaker, and I managed the CETA program for Jeff. Co. ************************************************************************************** C. Company Name, Peninsula Surveying Address: Phone, Pt. Townsend to City Job Title: Rodman/chainman Datu Employed: 1/79 From Wa. 98368 S ta te Zip Immediate Supervisor: Alan Duback Specific Duties: Pulled Chain saws). Assisted Chief surveyor and maintained equipment. ************************************************************************************** 8/79 Salary: 5.00/hr To Beginning Final (Monthly) and sat trioods for survey crew (using machetes& chain with computations, set hubs and stakes, cleaned D. Company Name: Port Tm.msend H.S. Phone: 385-2121 Address: VanNess & Blaine Pt. Townsend. wa. 98368 City State Zip Job Title: Custodian Immedia te Supervisor: Neil Potthof Date Employed 2/75 6/76 Salary: 4.76/hr. From To Beginning Final (Monthly) Specific Duties: I performed a variety of janitorial duties in the main h.s. annex, and ~ymnasium. .upervised the evening reo. program, drove the Gardiner bue rt. pulled maintenance and repair work around the building, supervised student aides. Form 100-. '~"\"... -;,,--._ '_:.~._.,~.,_~..'fl..., :' .;:~.~~,.,.,J _'r~r\~"'" "~'_"~:. D.RTMENT OF 'RETIREMENT SYST_ Public Employees' Retirement System Final Compensation Report "Compensation Earnable" in Final Two Years of Employment I~AME: SLATER, RICHARD /oJ SSAN: 195-14-1743 DEPT: 22U901 RUr~ DATE: 04/04/80 TERMINATION DATE: 03/ 31 /'86 *STATEMENT OF WRITTEN LABOR AGREEMENT COVERING THIS EMPLOYEE: DATE SIGNED 1J~C' ;/J /9'?;:1... EXPIRATION DATE 1>€< CERTIFIED BY 1. Amount of accrued vacation time paid at retirement. C!l./~4J-r"j c...JO;t...IGlAJc:. Hours Dollars ".u /'7 aC>.4,Jr~e.r-. 109.80 1,236.35 2. Amount of accrued sick leave paid at retirement. 49.12 553.15 3. Amount of other earnable compensation paid at retirement, i.e., retroactive pay, severance pay, overtime pay, clothing allowance, housing allowance, etc. ~ ~ NOTE: We can use only that annual leave, sick leave, etc., earned in the f1nal two years of employment for the Average Final Compensation purposes. You must, nevertheless, transmit contributions on the total amount paid at retirement. Sick leave cash outs are not to be reported for state, school district, or higher education employees. ~ ~ % Payoff 4. Amount of vacation time accrued in final two years and paid at 109.80 1,236.35 100% retirement. a. Accrual rate per month 10 hours b. Hourly rate of pay 11. 26 5. Amount of sick leave accrued in final two years and paid at 48.0 540.48 25% retirement. a. Accrual rate per month 8 hours b. Hourly rate of pay 11.26 6. Amount of other earnable compensation accrued in final two years and paid NA NA NA at retirement (see number 3 above). * ..'IF THERE IS A WRITTEN LABOR AGREEMENT, EMPLOYER MUST SUPPLY DRS WITn A COPY. .....'~ ;'11- . . HIGHEST CONSECUTIVE TWENTY-FOUR MONTHS' COMPENSATION Please indicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Monthl Hours Includable Monthl Hours Includable ~ Worked Compensation Year Worked Compensation ~ 168 $ 3,651.10 ~ 168 $ 1,951.68 2/86 ~ 1,861. 60 ~ ..12!L- 1,861.60 ~ ~ 2,131.84 ~ ...JJlL- 2.078.48 .J..2LaL ....lZL...... 2.041.76 -12L8L -1l6....- 1.842.96 11/85 168 1,951.68 11/84 ....lZ.2- 1,930.72 10/85 184 2,131.84 10/84 ..1M..- 2,018.48 ......2LllL ~ 1.951.68 ~ ...l.6!L- 1.755.20 -BLB5..... Jz.6-.- ? Ofi? 76 .......8J.8.L .....l.M- ? 0111 411 7/85 184 2,120.84 7/84 176 2,016.32 6/85 160 1,861. 70 6/84 168 1,712.00 ~ 184 2,131.84 ~ 184 1,968.80 ~ 176 2,041. 76 ~ 168 1,797.60 Total of Compensation Listed Above $ 48,882.72 ----------------------------------------------------------------------------- Yes ~ 1. Does your agency report on a calendar month? X 2. Does your agency use lag pay? 3. Does your agency use pay periods? X 4. If other than above, please explain. *..**..*.........*..***.****.*******................***.*..._.....-...*.*..... PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT ......**--*...****.**.*......................._**.....-**.*.** **.*..**.*** Return to: ~ Department of Retirement Systems ~~ 1025 East Union Olympia, WA 98504 Phone No. (206) 753-5283 SCAN 234-5283 ~";:i,.",.;""", I, " ' " -.........,"1 HI~HEST' COJlltUTIVE TWENTY-FOUR MONTHS'~MPENSATION ~lease indicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Monthl Hours Includable Monthl Hours Includable Year ~ compensation Year ~ Compensation 0/ &' C; 10? $ i ~ !;; ). )0 Yts Id' $ I 'ls' /. c,f Pj'tc, /60 I P 61. ,:}o ~7 I/O!) /J'6I.CO ~ 1ft! e#1 3/. p~ JfL'~ A:L .?J 7 p. <;If /P;'fs ~ ciitJ <I I, 76 ~ ..2..f- /'11/'<.96 ~,('. /(p? jq,( I. (pf 1;11/ /7G jtl5J. 7.;v //f.r" ~ .;2./3/. f't/ 1ft) If ,; ,?-od, y'f Y'f !,./ ...l!d- 1'70. t,? %/ /6C1 /7.r.t'. ;;2.0 .s;ft' ..l2L ,;ios;{,7t, jt d~ ,?,p/ ?4? ~ 1%-1 .,j.1 P-O. pI '?'f'd .2L ,;I../)/{,.3.;2J ,7f/ ~ 11&1.70 ~I /c,l? 1'11,:(. d-O ~f ~ ~/3/. ft/ 71/ IN If.?!. Po -t(J:' ~ ,;20 ~/. '1G %1 /6,f 17<17.6e) Total of compensation Listed Above $ '7'?;r~ou/J, --------------------------------------------------------------------~-------- Yes ~ l. Does your agency report on a calendar month? 7 7 2. Does your agency use lag pay? 3. Does your agency use pay periods? / 4. If other than above, please explain. ****************..************************...********************************. PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT **************************...****************************************w******** Return to: 1\ Department of Retirement Systems 1025 East Union Olympia, WA 98504 Phone No. (206) 753-5283 SCAN 234-5283 Certified by Agency (Telephone Number) (Date) , ~-,--,,,,.. .~'" 11:;__ 1""[, -. , . _-'.__..1i; ""III ;"~\ '.. "~'~ ~I' I' ,.,,) , e '.~~' 3,651-1+ 1,861 -6" 2.131'84+ 2,041 '76+ 1,951 '63" 2,131 '84- 1,951,60' 2.052'76' 2,1.20'84+ 1, &61 - '1.' ?13,'llH'+ 2,041-76" i ,951-63' 1,8'61-6'" 2,6'/0 . ~ a. 1,842'96- 1,930'72' 2,018-48" I, '/55' 2' 2,010' 413+ 2,016'32- 1,'/12' + 1,960' [I" 1,79'(' 6" 213,101,.- \2 ,1 3 1 . 0 4 + 46,082' '12* ~-- 0-. 0- c ..~ .~. ,~~ ~ ~.~, ~---. 1;W'1f '- ,("",' ,- - ":' "~,: ' II1II ..~ "'l'i'lrl -. .-.....,...~ ...,,- ,..,Jiill ,~ - "'C'. '..,'," I W I Depl. ofL& I copy - ORKER: Before completing section bolo~aded area, READ LEGAL WARNING on rev~ side of this page, I Top pOf!iOfl submiued PHYSICIAN: Complete Physician's Repo(l.~ch top porrion of Original where designor<<:~nd submit loOepart-1 b h $'C' n:en~ of Labor & Industries, Attention: Acci'dent Repo~t, Claims Seclion, Olympia, Wo. 98504, Oerac~ ~ho PhYSi-! 8:,~or~ ~~:t~n submillod CIOn s Copy (3rd copy) for your files and promptly mad the balance of the form to rhe employer (thIs Includos I by employer the bollam portion at the Original and all of the 2nd copy.) I ~-------------- : EMPLOYER'S COPY -- ..-..-.....-. ,...... ~. "~ ~=,'.'~,~, , lM':iIIl1l1iiJli iliLll 11[ ....L.. mIIIIl ~ J.,.....,...,,_"'~. ~ , . ,_K~~"" IJ ~~ -y ,.t;I i ilL _ j TI T Ill!lRL _~... -- _WI ._~ "., ~- -~ _ J *,i_~___,,_,___.__ " :,1', ','. '.', ,.' '\ ' . ,.' '.. '.' :.' ":,,' I " . \',', ."," " . .....-.~ ./j',....:.....~'_ti~\\.,:, ~ '~, '~r, .........-..,L_-;--....,., ~ lr ..', --~.~- ~_:,,~I"':'~"""'h~" ,. !""'j" \('".,' :-. fit . ...i,...... CONSECUTIVE TWENTY-FOUR MONTHS COMPENSATION HIGHEST Please iI:1dicate compensation by the 'calendar month (first of the month through the end of the month) in which it was earned. Month/ Hours Includable Month/ Hours Includable ~ ~ Compensation ~ ~ Compensation .06/83 ~ $ 2,97.0..01 .06/82 _lZL_ $ 2 Q7D.D1 .05/83 ~ 2,97.0. .0 1 .05/82 ~, 2.97.0..01 ~ 168 2,97.0..01 .04/82 ~ 2.97.0..01 .03/83 184 2,97.0..01 .03/82 ---1ll!L... 2.97.0..01 .02/83 160 2,97.0.01 .02/82 ~ 2.97.0..01 .01/83 168 2,97.0. .01 .01/82 ~ 2,97.0..01' ~ 18Lf 2,97D.D~ 12/81 ---1ll!L... 2.8.01.87 ~ ~ 2,97.0.01 11/81 ~ 2.8.01.87 ~ 168 2,97.0..01 1.0/81 ~ 2.8.01.87 .09/82 176 2,97.0..01 .09/81 ~ 2,8.01. 87 .08/82 176 2,97.0..01 .08/81 .-1iL 2,8.01:87 .07/82 176 2,97.0..01 .07/81 ~ 2,8.01.87 '::' Total of Compensation Listed Above $ 7.0,271.4.0 ------------------------------------------------------------------ Yes No 1. Does your agency report on a calendar mon th ? lL 2. Does your agency use lag pay? ~ 3. Does your agency use pay periods? lL 4. If other than above, please explain. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PLEASE RETURN AS SOON AS POSS IBI.E TO EXPEDITE MEMBER I S RETIREMENT * * * * * * * * * * * . * * * * * * * * * * * * * * * * * * * * * Return to: Department of Retirement Systems 1.025' East Union Olympia, WA 985.04 Phone No. (2.06) 753-5283 Certified by . -. DEPARTMBNT OF RBTI.REMENT SYSTEMS Public Employees' Retirement System Final Compensation Report "Compensation Earnable" in Final Two Years of Employment NAME: SA~STRDM, MILTON L SSAN: ;31-16-258u ~UN CATE: 01/~d/83 lEKHINATioN DATE: DePT: 2209 / / 1. Amount of accrued vacation time paid at retirement. 2. Amount of accrued sick leave paid at retirement. 3. Amount of other earnable compensa- tion paid at retirement, i.e., retroactive pay, severance pay, overtime pay, clothing allowance, housing allowance, etc. Hours Dollars //d. ('lOAf! ,) Od / 1:.L / 1/9 NOTE: We can use only that annual leave, sick leave, etc., earned in the final two years of employment for the Average Final Compensa- tion purposes. You must, nevertheless, transmit contributions on the total amount paid at retirement. Sick leave cash-outs are not to be reported for state, school district, or higher education ~ ployees. 'I. Amount of vacation time accrued in final two years and paid at retirement Accrual rate per month -L~~ Hourly rate of pay _lL!!::..... a. b. 5. Amount of. sick leave accrued in final two years and paid at retirement. a. Accrual rate per month1f~~ , I/., 1'5- b. Hourly rate of pay ~ 6. Amount of other earnable compensa- tion accrued in final two years and p~id at retirement (See number 3 above). Hours Dollars % Payoff 2Y{) ,/0'77.1, 0 I-I-!l- -fCj~. ?~ /()O';Z ~I? /'/ r~j-2 H'r -:;'f-'~: 1'.-tT I ;)5% V 'If ;'/ :iJ ,9~ (!/~ illl(l yf/trf slL ... . HIGHEST CON1l'ECUTIVE TlvENTY-FOUR MONTHS COMPENSATION Please i~dicate compensation by the calendar month (first of the month through the end of the month) in which it was earned. Monthl Hours Includable Monthl Hours Includable Year Worked Compensation Year Worked Compensation ~ ' -12!e- $ cJ,'170.() I OtkA ~ $ ~ ~ () ~/f.}, IC)! a:Ib !~g o'l/t), ~ ~ Li..- /, ~ 13'-1 ~ 'I o;Jt:) ~ ~ ii:L '/ ~ /a r~9'7D,OI " IJ/8'/ ..LEL.. q 701. 1f7 ~ J2L If / ;/t/ ~ -, ' ./0#2- ..PL " /0 If I .....f.1L. I, tlWJ- ....i1L 'i/f / /7" 1/ tik-' /7t 'I, . /($ 1/ ~ -1lL ~ erR' 0 I 37 Total of Compensation Listed Above $ ------------------------------------------------------------------ ~ No l. Does your agency report on a calendar month? ...L' i 2. Does your agency use lag pay? 3. Does your agency use pay periods? / 4. If other than above, please explain. * * * * * . . * . * . * * * * * * * * * * * * * * * * * * * * * * PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT * * * * * . . * * * * * * * * * * * * * * * * * * * * * * * * * * Return to: Department of Retirement Systems 1025' East Union Olympia, WA 98504 Phone No. (206) 753-5283 Certified by Agency . . DEPARTMENT OF RETIREMENT SYSTEMS Public Employees' Retirement System Final Compensation Report "Compensation Earnable" in Final Two Years of Employment EX)l.MP!!~ Hours Dollars 1. Amount of accrued vacation time paid at retirement. 2. Amount of accrued sick leave paid at retirement. 500 5945.00 240 2373.60 3. Amount of other earnable compensa- tion paid at retirement, i.e., retroactive pay, severance pay, overtime pay, clothing allowance, housing allowance, etc. 20 237.80 ~: We 'can use only that annual leave, sick leave, etc., earned in the final two years of employment for the Average FinalCompensa- tion purposes. You must, nevertheless, transmit contributions on the total amount paid at retirement. Sick leave cash-outs are not to be reported for state, school district, or higher education eiii=' ployees. ~- Dollars % Payoff 4. Amount of vaca tion time accrued in final two years and paid at retirement 240 2853.60 100% a. Accrual rate per month 10 hrs. b. Hourly rate of pay 11. 89 5. Amount of sick leave accrued in final two years and paid at retirement. 40 474.72 25% a. Accrual rate per month 8 hrs. b. Hourly rate of pay 9.89 6. Amount of other earnable compensa- tion accrued in final two years and paid at re ti remen t (See number 3 above) . 20 237.80 100% ..' --... .",,-- ,~~ - _8Il - i '0 ~' ~ " IN ~ 'i z ~ ~~ ~ . ~ u '0 "iQ " >< ~ ji:i u u !Q IJ ~ z ~ '" '" ~ ~ <.l c 'Ci ;; 1 tl 0( ~ . 3 0 en ';g ~ <n :a '" i:' ; foo '" " ... 0, .. " '" I :0 'll :; 0 6i, " ~ c ,s ._ ,!l ... "~ s ... 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'~"~ ~:...~ .\ ':;!:k-~i:~;;iL';.i,';~~:;;!;!:.{i~ii.~:~::ij;1:,jL;;;~->";ii:L;~t~i.~i;~~J,,,'.;,, ~,~.~~::;~,<;._i ~.;:,~-.::;:~:~:,S;:,~t::.~:;j1:};1.1Di'lS:~(:~j:.t:;_, "," "0' I Submit original to l.\ I 05 ! follows, top porlion of I pt:I90 $ubmilled by : phy~icjan. lower por/ion 01 I pagll sybmilted by lemployur. t- -------------------- iEMPLOYER'S COpy WORKER: Before completing section below shaded area, READ LEGAL WARNING on re....erse side of this page. P~YSICIAN:Complele Physician's Report. Detach top portion of Original where designated and submit to Deportment of labor & Industries, Attention: Accident Report, Claims Section, Olympia, WA 98504. Detach the Physician's Copy (3rd Copy) for your files and promptly maillhe balance oflhe form to the employer (this includes the bottom portion of the Orlglnol and all of the 2nd copy). 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