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Home My WebLink AboutReel_0024E MIDO." . "'Sf jlHEPHONE NUM6E~ - "SOCIAL SK. URIT" NUMBEIl ""-/. s.,q~.~~____'Y~,S-~~b\ ---'-9.~-\"" ::r:L~.L...... OTY&5T"IE TZ'PCOOE .'8"\'<\ €-.,_~~.~~ ;:;~~~_.__.._____~_.___,,__2~~~_~~;:-"-l.\> _~ ~_l'l..'S>'5I__~L_ O""E Of ACCIOfNT "'_~ HOV~AC:_tOH'lTOC(U'-REO A t_SHIFTHOURS".... I YOUlfJOBJI!lfWHENINJUREO ._1 Sl:X OATE~~RTH 'I lHE1CHT, ._WE~~I:l'.._.. ~~;~;~:t~:~~"::~~~~:~:.~i~~~~~=;i~~~~~~~~u.~_~;~.-~}~~~~o=~~~~~~~ NAMfOFEMI'1.0Yfll STR[U"'ODRISS CITV liP CODE HOWlONGHAVf . YOU WOII~ED FOR ~"""'. ~~~~_~~~.:t~~~~\)'?~!!;_._.._.CQY!~.:r~_~.~_.._.",_~._.~yQ~~~~~~~~__~:~_~~ _~~~~~~~_~._~1::-_~__.'j,~~_,,_ (MPlOYU s 8USINES!> IS1Alf TYPE 011 NATURE OFl AOORt\S OR LOCATION. INClUDING COON!Y, WftERE ACClDENT OC(URII[O ~j~/""L~~-'.\,)~~~_'=',~______........~~?'Y~S,_..~~~:I..1 __.~""-'i'n:.\::s. Q ~_<;'.Q,L~3.:l______._ DE$CRIIlE ACClotNT FUllY. SfATlHG If YOU Hll ORWOE $T~(I(. ! D~~T~~::ct~u~~~~~~~ _\N.~~ \"'~,-._Ytb~.L~~__.'J:.r.\.S;_WJ,.ui-S_~.~_t:l,_l\o..,_.Y.L~~g._9..~_._.__,_~ AND IA$T 08 K 910.,110 M NAMED. NAMf CHEMICAL 'NVO\:':'~:..c._"::~:",,?_y.,::.!.~::-<_"'s,~~.._~P~'.~_.W3'-..~-;_.,\lg. .._y'..,~__:t..~:E:k_~j,LL '-9.J?J'~~_~~\,b__ roW..,MRfiiOiiro;-.-"lNAMfi.Ti~.---'--- -!I" <:.~.~ ,. "'....: ~ ..,n:.~!.~~5-~~~~:: unu """'UII Of ,., ,_ .'.'uenuIO' "lOW OO.O""ClIIDI 0'0"1"". '''':NAM;OI'W>fl~ ""':NO" ,""OfTNruii--..---..C..c-..---r..O'YO,;(":OiYi;;;;,iiiiiil,OAi,--- ';D'YORC,.:;:J:~~:O;~su:::';:Jf~~= ~oi:..~\...'UL '~. . : ~~II~:[t~~~~~~~sf~~~~~W~~t'u~OOIAN., ~-~Vi"'NAMiAND'iiiiHDAiiiOf'YOiiiCHllDIEN UND~oIifDIY.;ou-h__- -'HE f~COjNG STAUMENTS Alf TRUE TO THE ; DATE --- ---:--~--..--_.._- --~.--.-_.I.-'-'--M~.._-,._...-I._...'.--- -- BUT Of MY KNOYIt[OG( ANOtlfUtf, I UNOU, : ,,':,' .', NAME, , . r[lAI~ll" I Act: NAMf mAfION!.HIP ACif STANO THAT ANY MISl!rPrf.51NTAtION8YM[ : 5 \, 12- =L~-~~~~===-==== ~"i~~~ ._t;,.ll-?2.__...____ _...-.:.Wbile..wa.1ld.ng...through. . ..swh,-a..p1oce .Of.SZ=:t.\lppant....,..... ('OOAjll'SA~P'lff')l(.A1 'INOllfGSIN DtTAIL f,"r~l~I'MI'f1?Vftl ) -~,-+-.~~_":""_-.J.et"l1lld.lOdged. woll, in ,oal.t.-r1ght.,-,.------..-... ~ - li'-- rigllt ., P _______...........__._"._......_ ~._.'.n. __.' D ,,~-, 0........ I""~.'.'.".'.~'_.__'_"_______ Clvt 1 ~C )l-'AY PlNOI'IGS Examirwtion. tr..atment; sliver -...-remowd .1Uld8\,,,1oll\'-'l, ',lR\'t!l~II1l~,ill~,' sterilo.P,1'9'1;j~,Rf$,'i!,;ting"applie.1.m.__---......-'''''--''--''''-'-''-- It.UtW\O'HttAO , I TtfAUO"ANVONl'O' "'[\'IOllSINN..,roAItA't t~'(J ;1.~~ "'I!.I"'~\I~llAI(OP-ID".crn (~/t ,,j',~ -w"CA.St'":;(""io,,'o'A~lO',Htt"i<<I~:~"~;'A-Mi AtjO'Ao[\"'~ ".. ~' X'-, . -. . -, ----.- ..m.... _'-' .... ..,_ ,_. _......._ . .~..-.... '.'M~"'_"_'"'' ~ _.~.~'. ",~:,;, p..' -;;;'~t'~;~;';'~;;~~'l~ '1\" ~.",lo f' ~~lf-~lri~:~~~gr~~(cwt\ICAU tlrl.,fA~OI'Ht.'fAINJtiltO' t;i. ,,':;'\:.J ~Jf."lMINl()1'&n"'lOtl(O'w"'" _.'~~~,;~~tAi:il'I~;~;:~~~' 'f'-,iJ.l,if Of 'I~I _....!!?_~...__... ~',;~ ._1. WIUllllSlW\O,.nI(OH .,.;0 I ESTiMATED TIME LOS'S :WtlIMJf.IlfANY us WQW.Ol.... 'O'"I'~1 \?,f . j _ _DlJ.E_,TO ~NJU.RY ~ I....'~ i H'AAAM'HOI!.A'"I1IY' ,,", L':\ .i~NO.NO;'';'''''''' ,~,,~ "'''oo,,~ ,"""......., """''', ""'" I/~("" [ "",..~" "u.'" 6".~"~t tP'J Port T"","eond, ..ll',\loslUngton 9ij.3Aa."",,,r',;J~JJOO ' -I::'...~tM9 ~ ! .JlJ.Q:Jli. - '~~(\11'1 rA~lfA((()lI!ll'llJMllflit.IA"'''' PAGE _....2 i.>- "0 I cOlJlomicOHOHlON . OIActUO!.lOIlf IIll "!1lI11 .x' Of till j~:~.~!Of!'(t1~fD1 'iiO~lil'Y 1(:':1 '-I"III"Coci{'~ I . --Tis: 'PtO~A8IY. (,,11 -X UljDI"'MII~fO ) ,,\1 1 IMKovrl: COMNHf PAIU I" "EMPlOYER $ ~froR'." 1rW.~EOIA'ElY AND MAIl TIlE OQ1GI~I"l TO THE OEf'AIUM(NT o~ lABOR &. INDUSTRICS, Ol YMJlIA. W4SH 9A5004. WE flPfHli' TO HAVE "EM, PtOYIIl'S R(PORT" BEfOllt TAKING ACTtONON ClAIM. H 111,,,,.,11'" ,~:' ,"" ".' ": c' ~{:':I\t:'. ~:"::'hr: ; .~ ~: :,1,::.':;' i{:':>' ,;,.:.>,: ';'.',' i ,':'~ _,' ;:' "; \:::;!:';.:;.':,~.:::~\.;/.{ v.\;.!, ':,,\-';' , " , "~I'"~ ,'., Vi :...,..t, , ' I":"":~,' 't',:-:, """ ]!~:~\,::: '," " I:',:, "0 t~ ~".:':"'l f....~... ',f:":" ",; ;""/;:;' ,.-.....': '.",:', , , .','y,':< ,',,' "', ii' , ':'\::'j-,f':' ',;,i.:X;~_, . ......?";;}';'I :Y:i ,:r:,t',::b:, . '"_ "",Ii.... '~,',' (", '." '''', ",,.J-r .' . .'. "r?if:: .,l".ll : ":" " ''':,' , ,": ' " ' "," , ',. '," ",',,',", :' ' ._-~. ..,.~ ....'.1.."<.1" '. , " "\.,', " ~'''~''.:' ...... I l)W'"' ,__ ' ,," , --". -- ~ r 11111 _ A..__n ____~ ,.-------- p---- -- '- " ,-,-- , -, ,ll'1111!'!J ..'.. . S. F. No, 'i6<16-.l]-Sl)-lOM. 26096. . (LEAVE BLANK) WASIIINGTON STATE EMPLOYEES' RETIREMENT SYSTEM 1\1ember No............................... Date of entry...................................... Orig. member...... New member...... 'EMPLOYEE'S PERMANENT RECORD PRIOR SERVICE Date approved by Board To Be Completed During the First 30 days of Employment by All Employees in All Eligible Positions Certification No.............................;..... Date issued. ....................................;.... TO THE RETIREMENT BOARD: As a condition of my employment under the requirements of the State Employees' Retirement Act I submit the following information: SECTION A, HISTORY 1, Name__..stOVBr...,_..___.._,....,_, ___,.rmm,__m__'_____,_.., WDBlei.____,__.........:.....__ _~.:.::,~.......:::,:_~______,_"..-'.._,.:., (Last) (First)"'. (Middle) , (Mnlden,-tt married) 2, Perlnanent addressl4thmolL..Sher1c\an.~,__,mml'Ort.m~OWllSBnd____ .J.effe~aon.._,"':washinut.=, , (Street). (City) '(County)' " ,---:-~taTel 3. (a)" I. began my present e~pl~YIO~nt \vithm,.1GtfGra~n-~ouDt.y...,Dep.-t.r.~.oi..li1.ghw~a-...:..-----. .' ,',' ': ,: : , , ,(Name of lfepartmen . commfsslon. agency) ,.atP.~rI;,-,TQ'IlIlaOIllLm-....~..m,-,-,~ on the........1thm..,_day oLMq__..~___"lQ.._,_ '(b),. Title of position..,..Chaiman..._,__,__.....__..m.._,_......__.._,_~_,____..._____.._,_.,_______,__,_____,_..___.._,_,___.:.__,___ (c) (If applicable) I am also employed by---..,.....---'-'---'iN;;;;;.-.;,deP;;rt,;;;;;;~~;;;;;;;;i;~:;;g;;;;q'i--m::...........'C"-- 4. Present rate of monthly compensation: C..h Maintenance Allowance Total (a) (c) 260 00 260 00 5. Record of service to present employer and other public agencies since October 1, 1947, to date: Where Service Was Rendered PERIOD OF SERVICE DeglnnIng Ending Length ot Period Mo. Day Yr. Mo. Day Yr. (Months) 19 10 $ 19 19 $ 19 10 $ 10 19 $ Nanio ot Department. Commlaalon or Agency Title ot POlltlon Held 6, I am a member of or receiving benefits from the following retirement plan or plans: -.-__,_.._____,~,-..,--,_--..,_-....,--,-...,-...."..--'m'..-.....,. ..-..'..-....---,..--..-,_..,_.._,__,_,_.._,__,.,____,.....__...'_..m_,......_..._.... -------'.-____~__.,._......__._.,__._.........~..._...~,.._.............., ....._~'._.'H'................".._"."..."._..._..._.__,,__...,.._."._._.._,,,,,~".,,..~_~_,,.._ 7, Social Securlt)' No..019..,;J,4...7181-_,_, 8, Check by (X)-Marital status: Single...._,_ Marrlcd_z_ Widowcd__ Divorced___ 9, Chcck by (X)-Scx: Malc,z,._ Femnle___.... 10. Date of bfrth..,__,l,.,~_,18~___1923_...__,.. Place of blrth__llenm_..,_____e..~t.91!!:..,_..._,__._..!:f_~!!.,_...___ (Month) (O_y) (Yt'.rl (City) (County) (8tlltO) mil "W' ~ , '..._~- - iD'1II_ - w.17'.~...._",. ....." - JIll lif ~ .r.:::;Y;'''.''''~ .. " :.,.', q, " " I , I "'" I I ~ I ;,; ig~ 10 I :l .~. I '" ~~~ " I e ~ ~~3 ,. <a ti~- " <J .:l I .s e" " ~iii ~ 01'" 0 .. .. .. .. .. .. ,-" ... ... ... .. ... ... .. ... ... ... ... on ... .. .. .. .. ... ~ " bO ~'g~ >>, .S ,0'" g " ~t:.l:l II coe 0 Jl1.~ :=l oS "'~ ",-" " " ~ " ,s tl : ~ ~ ~ ~ ~ ~ ~ ~ m ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ;l ~ ~ ,. ~ -"_ sO ~ ~ ii:g 0 .E~ .. '" . ~A S 0 E:l " '" () '" .. ~ ~ .H &l 0 " g e ~ gj .. e .c ~ '" tl ~ / ..: ~ ~ ,n: ril ..,. .; ~ ~ ~ m ~ ~ ~ ~ ~ ~ ;l ;l ~ ~ ~ ;l ~ ~ ~ ~ ~ .~-~ ;l ;l ~-" .. ' {.J' ::1 " ~ = ~ 5=' ... ]~ I 0:: ~ '~ f:l 0 ... w:> "" i:'. " ~o J3~ tIl :S [j ~ 0 "', ~ ~~ " ~ ~o .s c .. o u ... 0 '" ~ 2 " l:1 !!l " I ==.8 l~ -' . 0 l2' '" is M ~ '<I" -"~ z al 0 '" -'" " "" 'ill!. 0' '" l< E:;'-a, 0 o f\ oOl, e I z .~~ : {.J " .-8 ~M , :1 '-~;~ ~f i .'" ~'= ,'. ~'El I .~ . If .. A.~ III ~ " ~ ~~ ~ . ::~ zal ~il ~ ~,Jj $ 0' t: ~ E:; 1l .' ~Il! "" d~'2 ID "0 ~ ~. 8 ~~ ;3 tIl fl' p: '8.'ii1 " 'E I ~ I.,.-r- ~ :l! " . !s ~ = ... 0 oS ~ ~ ,,0 0" ~. <- ~c 'E ~~ ~ " ~ -, Ail 1': ... oS . '<1< ~ ~ g 0 >> sO Ii il . ':3 c 0 '" tl c .~ - - i i ~ '" e i ~ l~ il a ~ 'ir .11 '" ~ '<I 'S t S '<I c " ~ e .c il .... . I ..O~ .-S . ~ .. .. ... '" .. .. .. '" ~ :: ~ ~ ;!: ,. :e ~ :!l ~ .. .. N ::l ~ ~ .. .. .. f- " ...'~' "~~"''''~''''''-'--'''''''"'--- , ........-....,..,... .-. ,.-.----.,.",-.. .. .' ,",c, ,- -, ,~ --_.._.~,' ,. - , ~ ~- _"":l" ,=== 1M _JJltJii~iJ:.,IJ,-4MK.e:a~~ r-- _. 'IliW~ ~ . -"- - ~::.::..::.: - "" .,,--..~-_. ]~ J.R<f' ---.......... ,. .... ...-, ,!'im!li.... Inr___ ....' ... "m;&I Iii! _ ..__..___............__ .--.. "-,-~ .- _,._ l!'l!!!!!'11..,, -, ~- "~"".~':..-::"'_~.' '1 ':~ . . ," ~ .-: '" ....._~. T~ ;';"/'," ;';,''.:<',' IIlIIP-- .. ,. ---. ____ ____ .1I1'l1" __,,"." ~~ "'.....!lB jiii~ :-:-::: 11 fl """---' -~ .';',;;:;'+,":::;"." ;~j , ".":~>>(' ;,", '.'i ,~'r ,.,'-<'...., ,; , c) " :, ' , '" ':: ;:,:; J,;:;::}:,.IC' I; ;"', ~. r --_..... .., ,~, ~ ___ ::r ".i -;::- "'.;.'.:'<' :< .- ,''- ".', ' ":"", ""',' ',' ,.', ',: " ,'; ", .", : ,",," :',. '",' ..,", ,..' , , " ',' "'." , , ".., '"" ',' , ,",.," ',.. '., '..': .- , ,:'; ",i., ,", . ..' " , "..' , ,:. ""':,''- ' " :,:.,:, , ',',' , , :- ': :. ',.-'''" ,.' ".', ' ',' .- , , , .. ;"".".' .- <:", ;..' '..,',,' ... , ' ' " ',,' c. ", " " , "..,'.' ." ) .,:'; ,,"" ,',' ',..:, , '.,." , ,', , ,'; . ',:,:.-" :''- '. ,", :, . , ' """.,.',,:'.<. \,' .. , ' , ;, ,,' , ':"-' ',' : ':..,'.., ., ,;:, ,,' " : ::' ""',, : , ,", ,'," ". ,,',' ."'.,'.,'"" ,,' " " .::', ,," ,'..'." c ,,-, ,.. ,', ,,'" " ", ' " No. 16<49-IRev. 8.131 Fon Icovt. Unit Dept. EM- PLJ>S~ER ;..~: I ,)'j to your Transmittal Reoport or Dcduc- Part B. Write In department numbers. l':av.:.;.,b....,J. jO, l.I(L ..... ..................D~.i~............. D_EW.TMENT OF RETIREMENT SYSTEMS PUB~MPLOYEE'S nETJRE:~IENT SYSTEM NOTICE OF SEPARATION ... ~I SOCIAL SECURITY NUMBER ~j:)l, I 10 I -:A3G stN<lme THE FOLLOWING EMPLOYEE HAS SEPARATED FROM THE PAYROLL OF THIS AGENCY ~ -- FlrstN:lme .lld:l~ N.m. I r: 0 '1'c 'f.:~pmllo:D';:q:! o Resigned EF Retired o Deceascd o Ineligible Position o Granted Lcave oC Absence \.:t::..lt~l'.s L,hl".::;tr 11 ENTER GROSS AMOUNTS PAID BELOW ROSS PAID FOR: Month to be Reported Amount :.:~~:it~~~~t without pay until.. .....Daic.... Salnry ;'i()\!C:::ll)~'r J7(.', Tcnninal Leave ?, ~~()!. . =~.. Sick Leave "j'.:ffcr::on COllnty . .P"~?I!:.. ~.'.k:f~n.k.gJnJ:.I;!!!J-.tS:..J:~~~t.~ ., Emplo)'cr Agenc)' 7;".:;') Other 'l'()t'l L , , fl.'..-. / :C",.7 .:-:\:~ ;';.<'::':~ '/ , . ~ .., ....,.. "sjiin~i~re'.o"P~rs~.nncTo.j..p~y'roii 'o'iii~ei:"."..'.'''' STRUCTIONS: Forward white and )'t'llow COIIII'!! 10 Retirement noard. Pink copy R'0t'1I to ^R('nc)' Payroll Officl'r. The last month's salar)' amI lilt' :.ddltlonal deductIOn ror Terminal J.cave must be shuwn sl'parall'ly. ~J :'" " ,'" " " '-::':-':'" ,,', ,', ,., ',: ':", , '. .- ','-," .. '.', ":" .-" :,:, : ",:' " ",:", , ," ,",,',' .,",,:. " ,'..':', '..'"" , "', '..',' " ',,' ',".' ,",',' ,," :' ,'" ':",,: ',:,;, ,':, : ":.. " '" ':':':",,';.' ,,' , ;, ',,' ", ': ",' ,', .- '.. ..,", " .--: ",' " :: !' , ':' , '; " ',,' ,,: " " :, " '::, ";" :..."'" '... " " '.-',:" :.'.. :, " , , , '" :';:'" '-', , .,..., ", : ',': " '"...' --: '," , , ",' "'.',' '. , ',;,',:.-:' ,',:',' " ',..' ":'.'" ,..", .,,"',.',., " " . ':' , ;":: ,.'.".,',.,."'...".," " ",."',.:: ".' ',,:" " ;.- '". ' . ,',' , -::":",' .,' , '.",-''-''-'. , " .".1. ,,' ':;,' ..:;: , .. ", i' ,:' ','.,', ,,'...( , :,:,,, ' "," ... ' --..-...-......--- I 'u ',Iii"_,,,,,_,,,o.,''''M '1IIIl ~ ..' :1 ",'. " ' ',,', ,", '" ", '.. ,'.: ': " .,' ' , : ',,' ,,:', ': "". I ,:,;: I .: ..',' .': : ','.. .' ~., " il'~ . " "" :i" "'" " '. ' .i':: ':,:' ;<''", ::', , /: . ,,' ',.': ,:,' :':, "\ '''" j~~ .~~\;: ___...,.. "....~.".._,-...1~_ " jjj , ,. ~il'i~jllllliilif ..-........-._,_.. 1 U~. " '",', " ~, 'I ' "', ' ' " ,',.-',,, " ", '", ., ' ' , " " ........_....'-"....',....;.+",- ..~.._.. .._~~. ."~ .. -.,---__ ll'.~ ~---...~-., ,." - ~ , '. ~,--.. ~..........--. T-lil ---........ R _~_,_____~ .......'IIlII @ ACCIDENT PORT I ClAIM NUMIlUI [ "Mull Complete Thb Reporl by flllln91n and SIgnln9 Emplo~.~ :; edlon Below. Then MglI Report 01 Onc.lo Depgrlmwnl of Lobor and Indul!rl~l, Ol~mplg, Woshlngton 98504. AtlACH tfIlUIFMO~E SPACE NE(CJ(D ~'MPloiii,:~:;i~~E~~f?fIB:~~~~~~~~~~~:-;~~:i~:~~~~;;~:~~-..:~~~;~;;::-;~~~:.~~~;':~~= _~~~~~,:~..~:~if~J.:,sA~~,,~,.,~~~~~5::;:t~r;:r~;;1~i:~::~~~;~~M~j~;~:--~:~~-1~,;d~1~5~~;~~,~5-.:, ANOWNfII,PAllfNfR :',-~ ." fHISEMPlOYEE'S I ~'-;~~fi~f~i~!1~~~:~i~~~~~r;_~~:;~~:~;;~~;~~;:~;;i1~~;~;.~~.'I~i~~~1S~E_:~'~~~J~S;~~i~=' m -~A~\~~I~:~~~~~E ,~~S NO IfYES.AHA(U tDATEOFACClDENT ; TIME AM! DATUEPORlfOTOYOU : TIME. AM, ~Hl2~f~~~e, 9 l~'~~'T~~~~!~~!__::~l..ciA~ifRE,u~:~:~~I~~~"'-'lt~wAS~U~~~[tfr:(;ro-'NJ, ...:I,',~';:~N.761.stllfr-~~~;t:l'!}..- '-I.'~ ~;l~~~~~-,;,,~,;.r ~:~,N".:~'~"- -iFVEs.-WHV?'.--'-' ~ .;__~~~me losi..__. .__ _, _. ~-.._._~_._----_:~~f~~~~~~~~~~~~~~J.~:".'-~:~I:-~~U..-~~'~'~.~~_'_, ~._ J~~f~I~.~~_~~,.'~~~._ _~:~2_m,::~._j _,,~~t!!!~.~,,)'__ Will YOU PAY THIS [MPLOYff YfS NO If HS, eXPlAIN HlIfR EMPlOYH'S ,.,ICI( "'fP~~f...n CfPClf, ~~~~l:E~~OO~~~~:;BllIfY? .(~ ,~:.~ No time loss ~~6EoOJE:~11EJ S 4,84 PER (}C '. ~.~Y ~~;K M(,%Hl ~~tOE"",$ --=nY~~~~~::~~:~::i=r~~~~~~~1:!;~i~;~,-:=_,::::====~=_-~=.=:=:= OE!.CRIBE ACCIDENT fUllY. STATING Jf EMPlOYEE'fElL 011 WAS 6'E~ifBJ~T~~~~~~~~~.~~sl~~l~m Ut;fJG~.J~~\~~YpC~ Lid on tool box fell on head when pitting grease gun ,away. INGOR CA~~YING? fAllS SHOULD OE OfSC~fBEOAS tNOOOiSOR- ---.----'-~--.-~----.-------.-----.-..-.---.-.---------~---- OUTOOO~S. -AND LASrOBJECl STRUCK SHOUlO BE NAMED. NAME CHEMICAllNVOlVED,lF ArProflR.ATE. :: . ;i",;'; '" .,' ! ',::~,~. ' ',. -'... . - .,',' '; , .'. :W;sfHE"'ACtiOO;r.;;v~;o;;NloN~'---'~~'(5.-'-GiO-1"'-iMliVOuliiPOrnDAcciO(Nj .TOvciiRiM-PlOYfR--...._...--[T6~wHOMrIfPOriITO:--~--~iNAMi&jinEi'-..,.~:-~.7'~ -"r.Alr.>fDINANYWAY!lYSOMEONf.' >",- ,.,.... "...... ''-". . _, " . ". _ . r ' ,~~~YI~"Y~'W~.o"~ -'~~_.~_ _,,~.,.~.:L_..________._.__ L!-r4::~~~~:!~;;'i,~'f;:E,:.~;,~!::~: "',,' N',",'), "'" w',',' 0","', It. , ',"'0. ,", ',.l'^l Of ru,"', ' " ,: If Ol"VO~C,ID. C, ",",fN"'l OIC. "', o...n , ," , " ~ If OfVOUUO ...N,O yOU HAvr Mf~.O~ CWLO~Ul S1JBMfI A "':;~':""l.~':"': "/.,, --~....:; (I . ' , I COl'YO~If;fCOU~IO~D[~!,ttOWINGlrGAL("U~'OOI"'NOf ~~ I ~~:.......... '~"'~.=-:t~~:'~:::'..~::=:'~':~~~':::':;:~'4~~~~'~~~~~~~_~~~.~:~!!.~~~!.~~~~..P.!~~~~.:~t.~~,.:~~~~~__, ',:..w." ~Y"".. ','.S;: ,._01 fHAME, ~~D IIITH DAnSOFYOlJRCH.ILD'E~U~DlIl,' SU", OITED;IY YOU ',.' " ~. .. 'THE fClIfGOtNG ST,f.UMHHSARf Tl1Uf TO ml . CAIE ',":' 3'7C:;AA"-7~'"A~~" j"'" '"~~_T~'"", """"''''","'',,,"''' , ',,;: ," -~'--""-'.,.,- --,-'--'--' ,---,--------.---- '-.-'----r- MAY "lUll IN "'" O. '''M'N^, "NAlnES, , ~L:'i .'.'.'.. ".,,'--,:';,- ::--.~.""-- ::~ ==~==--.-===--- '-=:===:E__~::~: ,,-.~,-:;~~~td~."l OAYfOfffll$,,_'A1MlNT HJSTOfIY . ~-- -'-.- -ii;;;,~;!;IC~iiiCAi'iiii~,.l~~tool-box-ldt,pat1f/J1tl~-head-----_._"----",-,"'--'--~---'----.--" ( gtt.~I:.wtl~nl1?V(D ) ~ . r~~;;~~:::=-~~-=~:~,~~-~~~~.;::i:~:~,~:-::-- . -:-.::~,:.-~-'---~:'~~=-.:~ ,: ~.:::, ~::~= ~ 1,~;~~~~~s~1~~~~~;~~,~on~kn~n,ii;Eiii',Aiii ".,..--,.-. ."".'....._m_ !'" 'I "CAY fffU'lO '0 ""iClt... I)O(tOl, (..~1-4AA'.( "'lO "'OOff>>, a t..~;';t~;~'~';;;-";;;~"~;~;'--'.~' ..~...~......yis.. '.'OO-hrW~,.i~;'S-oii;;W:8it;ft-' ._..~., -- -. .,,_...... "'......yii'. ;:;; I (\'\lA!>lOl'h"Atr"j'uv~tot _ '.::) i",. I ~::AII~W:t*1-;~;..I:O~f~~~~"'!r, ~ i . ...t..}'.JlI.....'I/rn ,....""('~llO".Plrrt . D.' I....'..'"' (l".,.'....., ~ l".~~::;Ltwlmtl.1 (~~ q~. ~,~ON\I .~~~~.E LOSS 9th and ShoridAn i w~~ e~end.l "VA- :: ~_W()f"1;'l,..,~.nft~~I\I.n>._ , ,:':" DUE TO INJURY ~ 1\.,\;"If'JI"'''MOf!.A/I'tff'. r ....,ll~#().tll""."'n\l(t^~ ''''fAV "f"l' Of lyM yout '....Ml "h(J Af)("'f:r..~, ....,>O.I.~' I liP (Ol"lt 'NO,",,-..ltooD'tHiCO;loiiM;t~-,.. . ';'i'f ; L>1"'C;,I()'..tOltlmrtf~11 .':,', ~ IO'THrlt.j(fO(tIIIlI!:,(.~fr.IO' 'x X (I'Y r lfP(Qor I """,'.lttl~,\l tMnOYrl1 COMPLHE rARr I., . EMPlOYU!'S RfPOIH, IMMfDIAHlV AND MAtl THE OI'lIGH'Ml TO THE O(PARIMfNr or LABOlt' & INDUSIRII:S, l..?LYMf'lo\. Wo\SU Q8500l, WE PP[f(R rOIlAV(' CM. J"lOV(l! S ~(ror!r' f1rrOil'f TAKING ~CTIONOr"Cl^IM ! U1U11O</ftlUMr.I' <' 'I ?J.3?,WI\V'r, p1'. 1'.{) ~rt. 'l'ownlIend, WI\.,." , ~!l3~""H)",.31l5-\l300 ~klJ-/r('\l:XI..-Ut.1)JM I) I i - ------f ----L--.4-1~-73-~;J,93h7~;;/,lftl.50,AM,.1 \ PAGE 2 "~i. . I,:,"~:: 1 ;\:~ ",' ! ) ~~:~C;;.1\~",~~::rl'OI' ~ " \ t'('N~ll'"nJ('''N .) EMPLOYER'S COPY (' -I.,. . ': ~~~fl{~~ ,1j,"",. " '11' "... I)" r- , , . " ' I" ' :\,' , , ~'" _, " " . , '\', , 'I "'"'". "-~.,,.. "'..~ .--,.,.,.. .'~ ~ _..~~. -= ltllL~ ____ .....---............ _1 .... ....~ .." "" '.""'.'.,." :;:. "'.', ,;'. ' :;,: "',' ': H .',' " ,", ,..,'"., ' ,:' .-,','.- ,:j: ,:''-,;::, ..' .', : '. .:.", .',' , ',:,',.- : " " , , " ",..-, ',,,! , ',: '....', '" .. : " ,'..'".',.>.". c ':, , ' .' " . :>' . <; ':, :'," ':. ' " , "'". , :'" "",' ".' ..: ",', ,"'., ,',,",', ,,',., ,,' . ,/,<,; " " , ',,' . '",. ' ' ",: ' .' ' , '.,',,: ',,' ' . , ,',':.,',' ,'.':,,: :. ,: ,- , ,: ,," .,', . ,.."': " ',,', .,..'" " ,'.' , ", ': ,', ...' "', ,-- ','.-'.,,' :' '; , :', "',',, . ','., .' .'" ,,: ':,''-, ": ,.' ,"., .' "',..' " ,'" ".',.' ,'" , . ,",","''-' "'>:'." ,'."."..",., ',::::' ",'" ',' <<':,',' ,,"', ' ,,':, ,",:," ,', ,'. ' '," ,.:', '.' "..,< ':.-' ,.', " .,,' ''-: '; ":' '" ...: ,'" .,,' " ,,-::;':':, "', ,.,':' ",,;,' "'~"'.. ,.~:')..:'.:....'! :,> ~ " :" :.,.. ,,;\"1,,"; '.' '" .... '.', ':' ::' ,., ;:. , ORDER ALLOWING AND CLOSING CLAIM FOR MEDICAL TREATMENT ONLY ~~ ~ w ~ ::> o ZZ -0 00- Z" <~ "'~ 0< ~3 ~~ ~O Ow ...0- Z< Wo- ~'" '" ~ o r"rwonl to Sl~Cl,on ~1.3,).0'90 141 Pc. W., which pro,,,des 111(11 no rOfl'pcn~,,!,on shell! be pod lor The d11le of Irll'Jry or Ih\! ,hr(!1! d(1Y~ foliowll1<J Ihe \01111}, vnle~~ hlS dt~ob.lily shClII conlmue for (l p'~rlod of r\1II1y con~t'(ull"'e d(1Y\ from ,h~ 001(' of '"1ury nnd bosed on 'nfornHlT'Otl ,ncllldet.l or, The foil's of The above c10im ,nd'(ill,nq lhu! an '"I"'Y W,r)l,n Ihl~ fHov,~,ons ond Ivrl~d,crlon of TI'e Wor~llIc" ~ Comfle"~or,o" 1,0 ho~ occur/cd buT Tho I Cl~ 0 'e~\JtT elf \(1,d ,nlvry no (Olllp,"Hablc ,une lo~~ or permonenT panlol r1,\Clb,I.,y rc\ul'cd. now IT IS HEREBY ORDERED THAT: 1 THE ABOVE eLf,1M BE ALLOWI.'D AND CLOSED FOR MEDICAL TREtdMENt .. lHAT NO liME LOSS COMPENSAtiON BE PAID. 3 lHAl NO PERMANEN~'B1:&,:;ADE' DUANE S. STOOKEY -;' ..-"") ---- SUPERVISOR OF UJDUSTRIAL INSUR/'NCE~ ;,; ,.i- CL.o.IMANT'S NAMI: EMPLOYER JEFFERSON COUNTY HIGHWAY DEPT COURTHOUSE PORT TOWNSEND WASH 98368 MARSHALL E WALTERS OAn: INJURCD F 548086 I 4,360- 1 I 5-05-67 CLASS OAll: NOllC!:S!:Nl ll"ANCH OFf'"lCE B-3 I 8-24-67 IBREMERTDN ~ NO PROTEST RELATIVE TO THIS ORDER OR APPEAL THEREFROM CAN BE RECOGNIZED UNLESS MADE WITHIN 60 DA YS FROM THE DATE OF CLAIMANT'S RECEIPT OF THIS ORDER. All APPEALS MUST BE FILED WITH THE BOARD . OF INDUSTRIAL INSURANCE APPEALS, OLYMPIA, WASHINGTON WITH COPY TO THE DIRECTOR OF THIS DEPARTMENT, ,I il ,', :':~'" , , " ';'.1,'\ ,:':, ',',',};",v.r"" " ,"',,1',"'" ~_...._-- . .,:', ','-" ":', ' :' , ',: ,', ',,', , ',,' ".', ,:",:' ,: " .- ,'" ',.': ' ',- ':\,,".: ;' .' ',.,: " ,:':,., ,,'. "'::,,, ' , ,:' ':",:, ,,'" ,'",; '. ':';' , , ,:', ,::" '. .- "::,' ',,' '.',' ,,' ? :",~', .' , ,'," ' ,,:,:: ,,--,,:'- '-,' ':'", " , ..'-' " , ' :, , " ..:, , "" " :', ,', ' ':' ,," ,,:,:' ;,', ': ,:,,' ',:, ',' '," ,"', "',.." '", ,,', ,,' ",'< ,;:, " '.: ' , " ' " . .' ..... '<. ,..' ", ';' ,"::' " ,:..: ",', ,"" -' ,,' '. " " ',', ,'2;:: , . ., . " , .'\ ;., '," ::,:: " \,' ,', ,:' :,' , !, :,"'i ,il :' ,-"'....'~.~,..,'.~-.~.....-,~.....' " '.~ ..-, ~, ij-- 1>!iliQl- -..-.. n~liL r. ~ ,'C;::-";'-".~;~~::';:':'~.f MEDICAL AID AWARDS Amollllt ~:', Compuled Dale NotIce 58nl Con!............. ,rr':j;:~};"L;:;i ,'.>\,::>"". -.:;,j,,',; ;I:,'''; ;-:'~:'~;;:J ;~L:i~i.~,~,;~", '2/.Zgrh;';I:~it;:1{;::}t:: (, ' "~ ~ . . \\i;:j,~':{:.;:';;':;~',:;L,:';;".,,::.L.,~;' /.;"'V::~" ,'\>-'" "',''-''.f,'> :' .,..,:/~ ':'ii';;':;i".':''-'" ,c' .M9":1!i r~ 7 STATE OF WASHINGTON R E P T F A C 10 t.M T I 4,' CN~lolmNumb"~ '.b~:p::~m,:., .OR _~_ f-J.~~lai~No,..:, .....__='..__'... ' Empl02y.r Must Complll' Thl. Roport by fillIng In' and Signing Employer's Soctlon Bilow. Th.n Moll Rlport at On,., to, D.portmtnt~f labor and Indultritt. Dlllri,t Offl,o. (51lt revouo .ldo.foroddrlu.l 1, Firm n~mber of employor..-u-~~~Q.~~__h'_______TolePhono No.~.~?":~~9~__.._.__,__ S cl~l Sa 'Iy N I k ',;, {NumbClraulqnedbYDoPUlInontatL"barlllndlndustrioal I - 0, CUrl 0,0 WOf man,_,._:,_._ _._~.._. li Finn n.m. 01 omPI.~.~n!.l!f-!'-~.~'?-.._~:P.!'_~_~_'!~~!'.~n.__.__._____..Add""n.q~~Q!gl~__J~o.~:tL~!l~~"I!~h._ - Havelhla workman', hours b~on Includod In payrolll roporled Ie lhls doporlmenI1:___nS__________. 1110, In what c1alll?___!!_~_3..____;__,;,_____:.:___ If not Included. qivo reasonn__ .--'-----. -.---.------..._ _'_______________ _____ ___ ___.___. .__..__________ .---------------__._.;..':.______2~-,,_ .__~___ .... How long. hall workman 'beon omployod hr YOU?._n hh1Q. y:r~ I\Ih__h.OccupaUon whon In1urodL__maintenanc:.e_________________h__h__ ~~ B,..no.. 01 .mployol~,~Jf!l,l,~_~__~~~~_Loc.tl.n 01 pl.nl 0' pl.eo 01 wo,k wh.,o ..eldon' ."""Od.h.._h______h_..h_.h..____h__ ... Q" ",',' ',(If enqilqod in (:on~tructlon work 111418 parllcul,!\r kind) ~~ Ch~~~}nw~lch:dePllrtme~t,~~r~~an,waa.e~Plo.~ed: Construcllon 0 ''', Operation 0, RepaJ'2f] On launchod boal'D '~1:: ~j::::dOlwo'km.~ -----~h.~.-);;....!'!~;J,1!~ri!H_n.. _ ._.~. ._....~::,~:. ;:~~~nt~e~~~...i H. .nQ..___..~,'1.~~n~~"'OI;;'O .ff1co,,---______. ~S W.J11lhla workman bo kepi on salary during his period 01 disability? _~_yerJ.~__n_+If SQ, allach an explanallon.___~__nn_____~__________"':_____~__ ~~ D.,. and h.u,.1 ..cld.n,5~~7L.3ffl.._..___~:~: L", d.y w.rkod.___n___.,___.____u._D... ,ulurood,o w.rk__~_~_!!~_~~_____ Ow 'Y&'3. : "I"n E Was workman engaged in tho reqular COUl'se 01 his employment when ,lnJurod1--nn--n~_____________h_h_____ ShIfI hourtH'_____v:_.~hn_~_.. 5"': Did accident occur on your premlao.l?_..__.._n~n___. .__, _If not. where? Uh..___+_____ __ .h--~--------n______n________:...:__n________n__~__ ~t: Dale and hour accident reported 10 yr$:~5'~1..~_~~!_h___~__~n~n_:.l:: To whom reporled-~!n?_C?9_~~~~_~__~___Po.lUlon__~_~~~_~~_ q; .. :Jf;,t::::::.II::;;::;!_~~~:.:~~~~~~~~;~i~ij~:;~~~~~~~~~~~:~~~ii#~:~5f~:~~:.~::~ -.:-,:.---,--~~--~~..'?~h,..----'m'-,.__.h_._____________n_n_m~:.__---m-----------,----______._._____.__..m_____,_~u..__._ ~88::::;~81~~:rjCe:ldeat fully, stallno whelher Ihe Injured peucn lell or, Wlllll slruck, elc.~ olnd illllhe f,}ctars t"Onlrlbullnq 10 Ih. olccldenl, If nlcenary Wdl~ ~ luppll_ I d~,,~ lbo' lbo 10,,,,,0Ing.I.'.m.n" "0 lru. 10 'h. bog'f' my knowl.dg. .nd b.II.I, " ' . ,. ,'" 5i'",d.thls-~~__,.d'Y.OL_m~____n____', 19-n-----.n----li:~PI~;~;,--'-.----.--. --"~~"?~~~!FfO~~-~ilooj--;;cc;;-:;-;-"',.' ': .~,,:'AdjlJdgeJ7i;;;f.eornpe'JJable-excep;jOr (TO BEUSEDBYDePARTMENrONLY)" - _. - ~~' ,,',~ --:-._"--;-!~7l~ ;-";", M.edjeal Aid BiI/! allowable by law, By__...................;___,........., ;;?l~~,e:;r-P;, '. ,.,', Claim No........,...............,:....:'. ,c-. Allotue~ fo, a~lhorjzed lrealment By____~,.,~.:.~:~.~"..:.........,,pr;.. DUANE s. STOO'K.; . Firm No......__................../... .' a,1d dclJon as IndICated. Clillms E~"mlner" Suporvlaat al Indu4trlal Jnsu.lIlnce' Class....h_...h___.....n_n..~...+..~.n. EMPLOYER'S COPY 935127 (Nat CJaim Number) N I I I d k r., , I ", Sodal Secudly NO,,~, .... '_:___"my' _ ", ,a,~eo,'" nure wor man:n.._~, - -- .._ _ .. _.___n________ , ':::? r- ,..,':;:;.~' ' " " U" 1,.'-I:A.:t~:....,.I:T Oil n-I' L4~t,:' Telophono No. _~I ...---::~~W-~'~_. ..,. Add"..U. whlch.1I ~\II )f b. .dd,....dl-----h-,;Uf_____m__0.c.ait::.:c'_0"oo__c_Cl'Y .nd 5'.'..___ -:"---hh:--U--uL-;;:;,rZ--. PI... of blrlb-...u-UI.410.C./,/-/kV_____h_____Sox.._IY}___,.Ag.._/".)__-:_2-:::_Lk:.------H.IghL-~.!..2::W.lghL"-I.%,J____ , Dn.. .,dd'n' .<<U."d---.ms:_~..5-_"-__~.;?---....S..,. bou, 01 "dd.n':_h_(~~-~~:a'.;Y-}'-~.h---,Shllt hOu,,__uhu__moo________, Gl.' .,d,O'.I'" wo,k ed~. ,~-l--"-r.I , .2..-=--oo(;,.7-___,'-h---II",I'. ...,. h..., 'I'..u.n~d,.,.,.t..,. w..k .'" d0. iT __c_..:;::. , --:-r5::.-c",l-m -;r--,,- N.m. .f .mpl.y,,___ u uu,La.m-J,J1-Lb-h'l' ----~rK.lI:J.,h--,-.Add",,--------"!LU/:':_____?/czLL.>N...-----u_,:z::.. I I .', .~ C":' ,,', . ....Wer~youdoin9'yourr ua wo a tlmoofllccldent?n ,---c...r-f; ---1--: _~h___~__Onelt1ploy~. premIBeB?___~n~_, __ __n________ s~ 00 ',e dbe .cdd.ot In fUI.I,,-u:'@fU1&.----U..kL0, : "t"'-h,-";,-",,.-,,'.~.G: ..,,',-'L --,:,.-(",--~--:TcfJ-<9.~l'"!.'------!:*fff!u-a..Ut1a.<:l ~.. ), I ' "(, I', ,n ~j , ~~ ~-_m,W'. ...--:t:CCLf"'%- ....::<:fi<: ...gc~c-r-Ct.t;l).tL<,,\-,s ~LOH....__,"~ <-IbY:..h_h_'__________ ,u_ -<!,A Was the Lecident in your opinIon caused ln any way\1y .Iomeona not employod by YOUt'8kpI0 er?___h~n~hs:::L_. "'Z , " (Ylsorno) ~~ Howlonq b.ve you wo,ked fo, 'hi. .mPIOy.,L.-------:..lG)--~.---.--<n.----7.)./f----.~'Y:'.g. po' d.y___________'___n_ i~ Date, you roported accidont 10 emp!?r.-S----lJR4,<"",.: _ =---.t;:,'i:;'''~~h,,~~fJ,u ____ftlo ~;'.WWhhom ro rledw--u.:-e~-u.::l't:QQ;g~.r::;'__.::___d~u_;.~l;.~1,:;.J ...IX " ',' ,,' " '.',,-;".:,; I . {Name,lIl1e}/-" ' zO Name of AttendIng Phyaldlln_uu . ,'<i[;.(2~ --e;;. ,u".J:-.,/ ~].l...-:._": ~ ~,,'=,,', ---____Addresa._______________________.____________w__,'--'--,. 2~ .. '... V" . . ... ~ Full name of wlfo or huabandnwW_h_. '-<------.,.-____________IljdivorCed qlvo flnlll decroe daIOn___~__~n____~______.~__-:-____.______ ~=" " , If divorced and you have minor chiid.~en ~~hmlt 11 copy 01 tho courl ordor showing legal custodian of auch ~hndren, = t,.::: Alao q~~il proaont addr~la oj such custodian, c: GIVE NAMES ANDliRTH;DATE.S OF YOUR CHilDREN UNDER 11 SUPPORTED BY YOU NAME . Rllatlcnshlp 'M~"t~~~ !IlV~.r NAME Rllallonshlp M~al~~~ BIV:u fI.'~~' --- J _ H 1 dec'". Ihol'h. lo.""o'ng 'I".m.n""~,huu '~Ih. b... 01 my knowlo~g. on .b.llof., ] .--,..=. Slq~!d,,,,,:./....~.y 0' ----YJ1 ~bAJ 19./,,::)...,0'_ .' , ':W~:n:- __.__.,,_..,. IMPORTANT 'afIr: WOltKMJiN mGN "r:nE.~2~w .w..-.-.~~v.:)--_-___u____u__..__ ":R~. .9 3,5T21J~~"j-:..)--.=~'=:==PHY~IC,A,;s-'REPoRT..:.=:. -;-;--:-"- , " :::::~~:'i;;;ti[~:~::~~.~~~~_::::::::::::::::::-~;;:pt~:~;;;a,~:-;. "s.:'.~:~'!tf:.::#ltt5lJ!!::.. Cmploy" "'tln,'raon .Co~-/ltgllUla/J 'Dtlpa,.tlIMnt _",. ,_ Add,o.. ,00u.rl.,HOUl1I1,.. pt,'_ O".'nlulod ,5/.5'/67., .......... .....,..",.._m,Oo'. II", "."m.n', -..5'/13/61....... '-.n.....'~fm;:,~'~,A.1~hj12/1/16 .",._.._.__._., "'''ory 01 Inlury...I'<<l.l" ,atl"'1I;'ng.,.'ght '1'Ib"01"tlQ,. on'ONtlptl1' 'OIl8.1lItIt1Tr- agOj"'nDurlu!l/,pa1rrldum---'--'-"- ...-...... ,.._.....brdcthlng 01", Of1U{Jldng,.", ...",,__...... .........-.....-m.-...-.....____.........__....._.._m._'..... ~ 'kydu'Il fl"dj,tgt 1" d.tail ;2 '-..~.",.. i~ Z"" W ...,~., , . '.. '" . '., "W. _.. ~_ ~.. :z D"qn..,..-..~tto rll1ht.ohtIri.plftlrlIJ1,........ "_""""_'_"" .........h...... .. ...-.....-----._____.....h.. : ~ 01., '.."m." u...,.J:taatnat~...z..t'a.rlb ,-splInt. tlppl'tlrf. .." ".'____, ,.....__",__",.. .",..._...., _'.._h"m.._. ~;;; X,,,,lIndln.,. ,'. "....rrtlgu.:ttv<<.t07'. QlJpa,.,nt,fr.a,otww. ......_ __ " ,.._._'....",..nh... .........n.n....._._......__m ~f ~::: n... wolll'l'nan had p,..,IO\la Injury 10 ....7 No 0- If... workman .....r ~n lre.lod by anyono lor pre,ol,1 or IlmUu condition" ;j~ ...., 4. ~\ th.,. any p,...ziltlnq dilflue 01 the .,.. InJur0d7 No. WlII thL. Qr ny other pr..ellll1nfJ (ondltJon C"Ompllc". 'rUlmonl or relArd I.covary? No II condltloft dl.qno..d the ,uull of amelen! d..e,tbed1 V.. Ii II hotpllaUu.lIon r.qultltd, name he.pUi' . _. _. ~.. .. - ~ ~ .'M_ _~ ~_ _ _ _ _._ ~~.,. _. _., _.... ~. __ _. _ __ ~ _. ._~_~___ . -."" -..-- '. --. ,. .'-~. -~... w.,,~.~_ ____. .~_ ..M._.._.. ~_~ ..__._._. No . U yel, upl.ln._ PrDbably 0 fOlllbly 0 I/o 0'" ~"!J~~~.~!:.~:!.~!A:i.I.!,J.~;.~~~.t.'(h:~:-:'_~-,,-..~~;c"".,.':';:~~~,.._.=:::-.=::--::~~~"::':.=..;;-=:.::::::-.::..~==-~-=-:::.-::-:==,.~"':~~,~.~~=~=':':= AIl"ll.tIAQ "h~'I'_I""l 1'10"0 pI'nl illr typ. 'Ilur nu"o .nd Id,Jl'", 1'h'1 ""."'.'" II. 0.....'..11 e"l, ...h.... ,i'J"'toI II, Ilullu", ""'11.1."1 N.m...,.~1 ,~~W101l. ,11 .~~,'^H-.l. ,U..W.. "" .Add...., J/.Jlld{J.rllJ6.1faUr'st;...n...ZtnmtJ~I'-1f1r.-. ~t /12~O." 5/lS/G7 "P,y..AccounINo.., ...,,'.. .......~J'OD~ ..Addr... u_. IMPtOYU'_UMO"" 'SHllf fWO-PI"'K COl'Y-UII' II YOUR CO,V lUll D.", h,.1 AU.II,,' Nllmtttl S'D"'p) ,f"i"".IWI , "'I'';' ;'. "'. .~, .-', ':', I" ", ",', -. "'-":,1, r- 1" . ,-'-. -....,,'.-...."'".... ~..., < ,. .~ '" II... jil"iT -, - _1 __..___ _!!Ill ,,,... "~""""""" ,....'''',.,''''',:,'-'''''' ", . '.. " i ,---.. --.- -. .', '" __r 1'" .",\, ~-- ~ - IP<lilllillll" ,: : : ~.- <: '" ':'," 'i, '-"', , , '. ", , ,'.',',',", ':." "'--'" .. " ,".... "" ': ":' :" :':" :', ,', ,\, "';, ',( ::'..',....:' " " ','.. ,,' ',," .,', ~ ~11111\11.1111111111111.1111 ! illll/11111 11111111111 I1III .;1: ..... }lll-!-I-I-I-I-I-I-IJI-I-I"l-\-' -I-I ~I- - -I- - - -II c :e I 41 ~ 3 CD~cnCl)cnC)cnCDcncnOcncnOlcnOlcncnCDcnCDC'l(1)C)C) (:"~ 'u ~.-. .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ,'8 ~. "'~~ -, ti.',.~ ~', ,,', r5Q tall g /f 15.2 ~ ~'r:: Po .,._'.t.).'~ ....~ " '~"'~~ ,- .:~.~ lllS> " 8,0 ~".B .- g ,J-o ;:I fS.,.~ !~ ~.::~ ',~~ z',:',,~ I',:, ',~ :0,0 [:4 ~i r..> " ~..'..',~ " J~ ;':'~;,=ii ~'..,'~ ~~ z .'2 1l~ ',.0 ,~ i~ ,.",.E1 zo tlt 'E .. .- " .. ~5 :1 ~ ~Q ".. ~ 6 .:l ~ 8 iI: I ~ tl 1i a ~i .. ~ j~. 'i ~ g >. 1 ... ... ~ CD CD CD CD cn CD CD cn CD en CD ~ cn CD cn CD cn CD CD CD CD CD en en CD ~ .... ... .... .... .... ,..,.-l .... .... .... .... ..... .... .... ... ... ... .... .... .... .... ... .... ... .... ~, ,aici :a -- - - --.J__ 1l i z I '".r.u....I~I..I..,I..I"'I"'I'. DO '" ~ := ~ !:l ;!; :21~1~1~lo:llf1I..I~I::1I.-; ~ ~I ';'I\:_:>!1 ,,'.-'" ",", ,,',', /: I ~ I ~ , ~ kb -g5 ~.8 8:a ~ " .8~ a b ~ g ~ e,\ ~ ~' ".c > . ~~ ~ 8~ > E'"O .f;l ::l-e ' III 88 ~ "0 e, ~ !if:) ~ ~ ~ ~ .c g. tl ~ ~ 5= .""'tr4 ~ e~ III .~~ ~ ~~ < ,",0 ti 'g! ~' '"' go o oS u ~ ~~. l(i ~ us!] .'l ~-!!j ~ a as .. to ,~ o Ub d CI 2::s 0 o.l!~ 8 ~ ~~ ~ ~ i ... -T-" - g ~ I ! " . 8 a , " ,"", ":""<" '"..', .. ~ ~ .. . 8 ~ - -!1!1'~~ :!' :1,' ~. '~"""-- -"'~ ~-,... ..,. L. il!1!R! 1- I'nl .. i;l, p:----~ _ ,_,_,___,. ~1 , . ," '"'' ".~" """"Q1 --."- -- ., "', ~,.. If lIIiIil r--'--"~.~-- furnish below lull particulars of your pasr occupations or employments during me Ian ten years, as called for under the column headings. If you were at ,chool within this period, give accurate identilication and attendance at each school. Begin in the lOp 'pace with your most recent activity. If the spaces here arc insulficient, please com- plere the recold on a separate sheet and join IOBcther. PLEASE TY,PE OR PRINT INF9RMA!ION BELOW From To 19S:IP..,.. 19,:;,..1-... Month ltlon,b 19........., 19.......... MONth Morr,b 19........, 19.......... Month .lIon'" 19.......... 19.......... Month .\Ion'b 19........,. 19.......... MON,h ,\IQII,I> Town and .ueer addre.. of place "here you worked. Ndd:e::~frye::rnl Superintendent. NlIcure of your position or occupacion. Why dId you leave :9.......... 19....,...., REFERENCES Give u ,derences the names and pust.olfice addresses in full of three or lour penons well acquaiRled _ilh you during the' put few yean and noc relaeed 10 you. They .hould be persons o( ~aod sunding in their respeceive communi.. ties. Please do nor ,efer 10 any officer IJr (elluw'employee in the service in which you are engaged, nor co any (ormer en111Io)'er. N,\ME PROFESSION 011 UUSINESS "ra;...~,(?,A-'I.l....d.(:.a,f.l1..~,:M.j-i(U'I.... e.,r:..,iJ.,~.I.I..:Q........."..,.....,,,,.. tR.T..,I.""..."......,ez::.iAt.<';;~.!J..,~.I'"'-,d.ML..7.;f. ua~~~~c::i~~:::~~:::~::::::~::::::::: ";;:;;;,,:;,~~:~:':::::::::::::~::::~~:::::: :::::~~:~~:::.~:~:::~;~~;;,~~:~:~~:.::;;;:T.::: I,. ..........................................................................."............................................................................................................................................ I he'rrby declarr Ch.1 Ihe fore,uins SIAlemenll .re uur. and I hereby a('lvly '0 che C~mp.ny lor a bond In my beohaU of such kind &nIl in nd'l UlOunl as che rmployu (0 be named IS bendici.r)' in the uid bond may now or herra(re't require. I ..ho helchy .,rer for nlYlIlclf, my he'in, raeC:UIOII. and admlnllu.rou, to indemnity che ConllHln)' "!Cllinsc sny lours, Ilanlllge>>, CaUl, char,e. and e11lenMU ie may susc.in, incur, or become lisble lor in consc:quc.'nct' of my lell ..hUe wadl"r che ulJ bOllJ ur any renewd. thereLl', or any uew oond luueJ in con,inuulon thereof Of a. . sub.dlulr Ihereolotj and any prUl'er evidence of Ihe payment by the CUmrlll)' of III1Y such loun, \lamaXClf COle., char,el, or eapen.e. sh.II, in d'le ablence:' of "Autllln ,he 1'II1ff 0; che Company iQ makin, .uch l'aynlC'nt, be concluli"e evidence IlI1&inll nlC~'. my hed,., neeUIOU, IInd adminiaualuIS, of the hu Dllit Clcenl of my liahilit)' eu Ihe Com,'any ""der thi. '~,etmt'nt. I here'by lonher a"ree chae che Company shall line the riB." to .leelIne 10 Jeranl che bond a!'I,lir.1 f'Hi ''',lI, in CUt cht bond is .,anled, the CUR'f)any .hall hne IIIe litiht cu whluhaw or (IInce'1 1111: bund al any lime; lha. chI! ('onll,an)' .hall not ~ require.,t co diulou Ihe leason. or IIruun,l, Ilpon -.hie" any IIccion un ih par1 in connection with el,e .aid lAlnd mil)' lor huC'Ji and th,,, ,ht Conlpsny .haJl noc tw rrSJ'onsiMC' (or IIny luu 0' IIUI_lIt dUI. I may lIuHer hy ruaon of .ny such actiun, any I,alucory provi.iun. cu the concrary twinll heRby rxrreuly ",aivtd hy nK'. This a.rC'C'nH'nl R'"Y noc he chuled or modiliC'd orally. No chanAe or rnuJificadon ,hall be cf(ecci\<C" unlt'u maliC' by wrinea rndOlSrlMnl htre'on ai. (~Ib a~ s rho I ~I r e';r' ivt of che Con'pany. . r1a]OJ .J .i..oJ '1, ,_ :- - " ' ,hla ...../..7.............. Jay or ,1J.7/.1..,~t.,........,.......,........,., . 19f!r:i{ ( .....1111.) / V .... . 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',: " , :: ',': ,', .:..., ,,,,,;,, ,";.',' ","" '" ' '" ~II ' .,' '",,: " , " ":"".':11 ", ',,' i< ,:;11 , ,',' , " ':'':;\';~;:,:;;~;;!II .. , , ," ,.., ",,' , " ' " , , '" :..'~~:;11 ',',:~'.-',,"!:'" :", ; ',"', ,', ,', " I: ':i'., ',', :':' -. '" " ",-, " '<', "'.-, .-', ,,'-',; :" " , ',.", "i'" " '," ,: ' ':'..',., ..' '.. , ,";,,;', , " , : ,.,' ,", ;',' "",' ; ',' :" "",' ,',:,' ..."', ',:'- : ,..': ,',,', "!" "."," ", " " :', ",,' , , : , .. ,..', ", ',', :',: ,',' ," ,i :; ',', ..:' : " . ": i: '", ;, ",' "'.:', i " : .- ", "j :,' ~' ': ',,', ',I r',!,! ,I" ,10,,'1 ""II';woblc (>I'd tho! ll,,~rtr H t D"/.',t'I",\.,,t ,10'" Ib"le.lore C1CCt.'f-J1 re'pOrl..j. ),,- (1']"11 ,p',l rlo., ,1""'1 " tw"..by t.Io\,'d ::>UflERIJ1~OR OF IN()u:)r'RI~I.URANCE DF.f'ARfMHH OF lMiUR AND INDUSTRIES ~r/-\IE Of WA5Htt~GrON ".-- I " "". , ,. :,:: " -:" '" ':, .... ::' :: ',i ~:;, ORDER J\llOW1NG AND ClOSING ClAIM FOR MEDICAL TREATMENT ONLY I'.,:,,;';;',,'" ", '.' I ,. . I "II, I < "", -'.,,' c.. "-J' .,.,j i 1_" l '''<1' I I I I L__u. - ___ __~._._~~~~::.~_ INDUSTRIAL INSURANCE ANY Pfl()HSJ Ol~ REQtI~ST fOR PFCOl'-lSJrJl"fUl,I!ON CF THIS OROER MUST BE MADE IN WRITING TO THE Ot1',....RTMHJT OF IAOOR MID INOIJSUI1E~ IU OLYMPIA WITHIN 60 DAYS. A FURTHER M)Pb\L~d,;IE ,..HUH'" Vlttl FOltOW ~U(t! " !{lOUEST ANY APPEAL FROM THIS ORDER MUST BE MADE 10 fHi. iJl).um Of. rrmUSIP.IAl !N'-,W~AN(E APPEALS. OLYMPIA, WITHIN 60 DAYS FROM THE Dfl.:f Hti'J O"-'DFl? IS COM,."UtljC....lf.n Je.> nif:. Pf,iHlFS, OR THE SAME SHALL BECOME FINAl. " , ',"'-.-.' ", i',':" ',..,::;..' ",'-, ", ":' " ,',,",' :"" , .. ", "" , ' ."':'",:, ;' '. ..,,",',. .. , "',:,. '..', ,.;,"', ,,,,' : , ,:' ,',' ': '..', ',' ,',.' " '/'i'," ',', "': "','" ""'.'(,' "1 \"':',:;:'.'!,'- ,;,.:) ;::., :,' , :'" ",' :,', ":,'. ..' .- ',',' "', " ,-,,', " ':' ',\,,', ,"';' , ",,".'.,:,',.'.. ,',:: .' ,," ' "" , " : '" .' ",'" ~~;~~'~') J' ,.,.i '; ,'.,: ;..)~::~'{;"i.fi,:,' " :,' ;11 'II I,t ~--"^-"' '-- ....'. ., --~ TlL _~"'F1i illlllll ';"',," ';'::~:})~'11',:i,:ii~:::;;.;""': ..:::~~~</ ' I r Oupt. of l & I copy WORKER: Before compleling section below shaded area, READ LEGAL WARNING on reverse side of Ihis page. I Top pOr/lon submjlled PHYSICIAN: Complete Physician's RefJOrl~ch lop portion of Original where de5jgnat~nd submilloDeparl*: by physician ment of Labor & Industries, Altention: Acci~nl Reporl, Claims Section, Olympia, Wo. 9gS~. Detach the Physj., B II I' b '" d i 0 omporronsu ml C cion's Copy (3rd copy) for your files and promptly moil the balance of the form 10 the employer (Ihis includes I by employor lhe bollom porllon at thE: Original and 011 of the 2nd copy.) : ~-------------- 1 EMPLOYER'S COPY :',: :: ;~,~,:;.:'~;>~:~'~::_\:~':;~,:;~', " !'~, F- """'''' ,< '-"',rrH"....~_ . JI._ " ......A '1 - .....,~-.'--~".;.,... ,....."^,~',..'\ _....--...) ,_",.,~'. ~ ~l '.', :/,",'" _..",~.1' "-'~-'" --- "_ 171!l "" ,., ~7'::l " ... "\"'''"~ ._":.~~'",.h , . " . --; - ,:..~_,:.. -'''-,-7,,) _w ----..,' "--~--_. ....'.._iliil-_,.....I1'liiii ..~ .....-~'- .. __.~"m~~~ . ,-,.~" IYrr "" ~"'~,-\.' ,_ ,'_".,~.~~.. ...., ".'.1\'-','-' ------~. - .-. "" -. =- IU 'III .. S. F.No. 764G-D-5o-I0M. 260011. . (LEAVE DLANK) WASHINGTON STATE EMPLOYEES' RETIREMENT SYSTEl\i Member No.......................:................;. Date of entry...................................... Orig. member...... New mcmbcl".n..~ PRIOR SERVICE Date approved by Board EMPLOYEE'S PERMANENT RECORD To Be Complebd During the FIrst 30 days of Employment by All' Employees in All EIJgible Positions Certification No.................................;. Date issued..........;................;;.............. TO THE RETIREMENT BOARD: As a condition of my employment under the requirements of the State Employees' Retirement Act I submit the following information: SECTION A. HISTORY 1. .NaI11e~__-:We.e~~tr~--~........~..- ~..._..Gec>~~j..._........;._... ~.:.~_..na?M'iZI;)-_.- (Malden, 11 married) '2. Pern,lanent address..,_.,.___,-.:.._.,_.,.____,.,.,.,...'"..._....,.., Br.1nnol:1-.:;...__......, ...Je-t~'''&Gn' '....\'i'M~."'. " , (Strec~~' . "(City) - (Counfy)' (sate1 (a) I b,e,g, an my present employment ',v. ith..,JeUO:L'non-,.Qount"'...D....t..,-<>!'-H-!,....w, a-..5---.. I ,,' ,.:" ' " , (Name Citaeplll'tmcnt-;tommlssfOn. ngcn(:y1".:J ',' ~~0':t~;::;~~:=:.==i~i:~li;:~=~=::.:===~~~~~=!~1=~==::~~~-===~~:=.,......,.._. '(c) (If applicable) Iamalso employed by.__,_..,_.............,.,_...._.....,__,..,_..__...._,_.,.....,....,.,. ; ..,' ., '. ' ',- , , ' _ {Name of dePllrtmen~. commission. agency} Present rate, of 'monthly compensation: ' Cash MaIntenance Total AIIowance (a) 265.00 $ 26 (c) $ Where Servico \Va. Rendered Name of Department, Commlulon or Allcnc~' e.trClraOn Ooun ruokDrl el' " n n n " n n n " " " " I am a member of or receiving beneRts from the following retirement plnn or plans: '.___,00114,__....,......,_,._,_...._,...,.._...,_.,...,.,_...,.,-.'. --,...-..-..-.."...--..........,.,.......-,-......--......,.."'..._..,........., ))1 \ f f\ d~ 7. Social Security No".,_5:5~..J.Q...ll6."l.. 8. Check by (X)-Marltal status: Slngle__. Ma'.rleL,%. Wldowed,....___., Divorced.,.,. 9. Check by (X)-Sex: Male.~.. Female_,.__ 10. Date of blrth.....J.l.~;:!~-.l6___,___,_ Place of blrth_..,_..S4lll,t.tl&..-..,-,...lC.',""'..-.'.'.-Wllllh.....,--, (Month) (DAY) (VeAr) (clty) .-lC'mtnty)" ~fJm.tCl) !!r' : ':'~':.''-<',''~i'-'' ~ I',: ~ .y'.' --- ~ '1:l " ti '" .a il " b/J .S " o :::l oS " ~ " o c, f:: ~ "-,Q ~ I"l .. ~ .0 ~.tf t.) ~. !> ~ el ~ :':2 00 ; .s ~ I< ~ .~ ~ $' ~" ~ ~l t.J " :3,~ ~',~ !;!'.. Ill: ~ zl o " E:: ] rz e '" fl 'e ~ 1<' it I ,:; ~ i ~ 3 tJ ;g, ~ Ii' ~ i i $' ~ .0 H nil .... ....~ ]-gg b:'Cg coo :ll1.e . J. ~ ~ ]i:1 iiA &10 II f- .!> <lll <- I 8 ei i~ o ~ '" "' " .... ; ;," ~""". h' ~~ ~'" ~00*0~00~00~~~~00~W00000~ ,', ,'" ~~ I Tn i~ I ~;; ;~~ O'd,C ::Jo. ..Ef; '\l~~ /I&!- tl s: " ~ ~ .. o " o ~ . . ~ ~~~~~~~~~~~~~~~~~~~~~~e M c" ~Ci" ~ . o = !~ c:= o = !< n &~ ~ ~. ~~::; ~a .' >:0 '" '" " " ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ "'OI.gNfJ. ... ~ I'll .. In ll:I too co crt ~ = ~ ~ := ~ '.0 ~ ~ ~ ~ N ~ ~ C!; cq ~ Gl ~ o C) C) Gl l:l ... .p " a> :: " o . 1! o a> a> b~ 'g~ :::8 ~M 8~ ~ ~ ~a llIFj ~ ~f:! :~ ;~ i~ II I I ---'\_~'-''''~_'':"1'~'';' :.. I ~:2 'll ~ 1::8 ~.8 a ~ . 0 .o~ l:g ~ eb > .~ ~ ffi ~~ ~ ~.s ~ ~,g ? l=l~ ~ ::; 'E ~ >ad.! rzl s.: u ]~ ~ .. rzl ~g tI] iV~ ~ ~~ ES 'j! ~ : ~! o 5 %L z ~la ~ 'E] fj 5l;a ~ ~ 1) ~ 'g,.~ ~ .8 8 ~ o .s S ~'" o o~~ ~ 0"0<:1 .E ~ -a~ ~ ",--,3 .. " o 'r ~ .:: ~" ~~ oil c:< o il -e 3 '" ~ c o --g -s ~ o 6 ii ~ c: ~ 5. o " e. -'. '!Ill ',-',.,..',':,..",<.... /:~:i\j;',: :i'~ .; ~ I! ~ ~ g .' . -'-~,~, - " ..1M., "',_ ". 0111 III ~ ...... -"- -" ~'""- ""'i;j lltllll r ; ullfdlll IP::-- ri ''';;.f' ,: ", .' , :i r------ _._-, , , ., " -~... ,.W" - ....,... IIS.ll.ll11~l .. 1 rn-lWJiieI!"_______~ ~ ".U.':II!I DEPART~IENT OF LABOR AND INDUSTRIES, Olympia, Washinoton ;', .. To the Employer Addressed: Please be <Hlviscd that on this dati 'he Deportment mode on award, as shown below, [rom the Aecielen. Fund in reimbursement [or troveling eXpense incurred ot the request of this office, :':,:',:,,:,,:,:, -e.... ' ,,:;' ,', -,~,,,,,~,,. "'~ . ~~ ....'.. ^, ~ -C!:. ____lIlI._..._ J:lifil____I>...A>.1 ~- .......... ,.~" ,.,. ,,~- ~. --,.., U___ JIlII r;;,:, "'----- ~ - ..'..', '.'.. ': " /,', ... ' "', .','" " '.", "':',' ,,:,:"':', ' ;.."" " ','" , ,'. " ,',',,-:: , .: ' ,:" ,,:,::, ", '.',' ' :', ' " ,..,,' ,,:. '"",, ',',. " ",:: " " " .- "',' :, ,':..'" -- .-:: .... " ' ," ;,' ", ',,'.' " .,>.-.'. ...' i\, " ,,' '..,'",'., ',"',..,'.<"": ,:,'" ,':, , ' , , ',' ',..' ,,:,', ',', ,,' .. ".- ,,', ',' ,,", ",', ", '".. , ' ,.-',,, ',' " , ',. ,: ,':' ':, ."":,' .- ", ' " " ,'.' , , " '" .." ' ,:, ......,', -', ',:,': ,,' " " ;'r', ,',. ','..,.", ' " .' '. ,> '.,.,>'.', ;, " "; '" :,' ,'.-;"",." ',,:> ";",,", """ '" "'. .', " ,',' .", ':',','..-' '"." ' ',', ," .. '-',' :"i ,'.. " '....::, '-- ','.: :, .-" '",,' ',' " :, ',,". " ,,' " ,... . ',< "':,<::-. 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" ,,':: ',:.-' ::, ,::', :.-'.", , :':, '., ',:, ~-",,~,.,., .~ . --,-~ --,_., " '" ,., -,~-_._,,- " .'- STATE OF WASHINGTON Department 01 Labor and Indu.trlu Employ., MUI' CMlpl,'. Thl.. R,porl by FllllfIg III and SlgnlnQ'EmploYlr'. S.ttlo" Bolow. Thu Moil a.pori 01 One. 10 .' O'P,o,.trn,nt of Labor and Indulin.., Olymplo, Wc:uhi"glon 98501 ---.._-_.--._~ --~ -----'^"LO"'L~~~~~~F~ ~u~iR~~:J~H~~~1bS __ - _~~~;;'~ll63U"iv NO. EMPLOYER'S FIRM NAME ADDRESS -------r~~ li< Jefferson County Dept. or Highways Courthouse Pori; Townsend, Wash. ~8 2w NAm; OF INJURED WORlCMAN -~--'--'_._--F=WORKMAtEMfWYIDJN:'YlHE.DfPARJMlliIL.~ IF WORKMAN HAS FINANCIAL SOlE OW;::;;--~ ,,_ H W d ICONSTRucnO,N OPEaAIION1REF.A'R N lAUNqtED BOAT INTEIIEST IN BUSINESS, PLEASE PAMINER ~. Ill: uuorgo . ee -~:{ ;zit, ,~~ ~i:l CHECK APPROPRIATE CIRCLE. CORP. OFFICER (,. en WAS WORKMAN ENG;Groi;---'-yes-vNO--~Ho~iis-"'--'--l'DiDAcc'DENiOCCUR--YES N{>" : IF NO, WHERE1 ~ ,,~~fr~i~~~~~R~~_~:J_~,..:"'~:?.?..,___~ ~~~~-'~~~~__~'; . , 9 IN WHAT <lASSIWllL THE:; , ~.t \ - '. li'F INOY TO BE RE~ORTeD,~G1VE REASON ~ - .. I ' (I ~. ~ WORKMAN'S HOURS SE REPORTED? 8 - 3 1 " W LENGTH OF EMPlOY~ENI BY voU-roc'CUPATIONW-HEN"iNJUREO~TEidovE~NE'SS'-"--'-'--~-''1;-----' CCAIIQNCi'i>'i'ANTOiJOA-wi1~('U~R( t: 22;years ----J~~-~~r.----_L~~~.t.9~Q..!!"-~~~-,~~g~~r,i~!!.!~~"CYtA!r'! F-'--=- q:; WIll rHIS WORKMAN BE YES NO: . l!N!lR WQRMM",n RATi Of 'AY IN ""'UCAllU r--__~..JWL.Pf...A!_OJ. lAST DAY WORKED AlE Ilf!URf\LO IOWORJ Gw ~f;l~~~~l~:J!!~!._~~,~_~~~~~;l:~~ [L~;:ro~~~~..~f.~~~~r::I~~~~-==t3~9.=n~~:'~ N9-1i..~E!_~~L-_ -_~~~~!.!f~~~~H~i:.:::-.--.fiOWHOM REPORTED POSITION r ~~ci~~~~E~;Oc'tAIM? ~:;~,~ ~ ~ IF YES. WHY? _..~_.=t=__~_.J~l~d Be~~~._~~~ Enc:~_______~Z: IAnA~~~':'" . HOW OlD ACCIDENT ~tAPPEN? . !.e~~~~~RE ,'::eE 1~;~~~~N~E~~g~';~~lll~~WAS_~~...~~E~_~~l?ain _~~~~. he. worked . . STRUCK, ETC., AND All !HE FACroRS CQt+ ; JR1BUJING JO THE ACC/DEM. IF NECESSARY WRITE A SUt1PlEMENIARY lEflER.) . 'i~tiHEFORrooiNG--'-'--'.:EMPLOVER~-~~..-~-_'~..__e....~_.~ '~-~-':"---:--- . i1A~~::;b't!l~~~~u~~ ~~l~E~~ST SIGNED i iBY ~OUJtty EngLneer '. AU OUESTIONS : " 'MUST BE ANSWERED ADORlSS GEORGE WRBD Rt 1 BoX 88 Brinnon PAiEI~~AiEF;SiIREA!MENi-'-THiSioiiY'oF-'iNjuRY'-.- -----.~--._-~--- ~___.____"L~_.~.~_~~.~~~~._~l(~_!~~.';.~~'~~;~.~~~~~E~: l~ ~,~~~ ~~.:~9h t_.elb~o. HISTOIl'Y {COM' "~1 ,.. . ~'-' .....,...N..'i~f;:;':-::.:.' ...~.:. Pl-IYsiC'il'fjr::i)iNG5"iNOOAit-~----'~-- ----.~,-._,,_....--,-~ -,-- ..-,.-,.....--.---..--.-----.- ; (.' ~... . ..,..,.., .~- lQ~~;~~1~~~w~~~J..__~~_._.~~~~~~~.~.~_~~~ .~~~_~~~~~.~~.~alp~~on ~_O~ l~tez:~l or lIed:~.~' co~~.~ has Lull range of motion g{@!~;;:;~~;i;.~.~rT ~. [...-~.~"t~=i:-;-~C-. o ' It....~ WO~M....t~ IIA(I ~ \ ~~'..o.':". '~'''':~O~'~_A~ e L~'Mtlt MN I'Mf-I.JI"ht-l(~ H~ ~'~~llf'~~~~I~~ cg;:-If~~'::g'~ CUMI"LlC"'I! tt l ~_J~"~""\.f. Of lId ....tlf A_ IN'~Jlfffll , I IRur....p.' Oil H IA"D III(O\'tll"1 ~ I 'Iff tlO~PlI""lU'''IIC)~~ IItQlJIlIll\ N....Mf /'O..PtIAl AOO"fSS ..: ,,"., ,:-.,;"'.", . -~~,~~..__...:...-_---- ""V.'y['l::-ii.;'liiAI.,:j' , ;.,. 1 Wll,1 IH~ lffo.U.'o\N liE en ~ .,n .t<.O ; J:SnMATED TIME lOSS t ~o~.... OUt ,IOf~II,\ 't'J~Ull", ,,~DUE TO INJURY I AllrP-f.)ING "H~\ICU.N trlfAH PRIN! OIllI'1P( r(XIII . ! John M. Donnell, M.D. =--+ tn ,<i-- iiHO/'ri"lcjNn',AG'NO~iD' Y[5 ,. 00 ~,II!f. IIfsun or ."'."'1--- ,i....,'?I'"Ly.-..iio~.~;o,~~,~".. , '.:,'UIJ.~ ,NI ./lI5(.II~.f 01_ _ < -;... '..'1 .l';P'coop~'-"~'._' ! ,- ,\ -, '.1 ~'ll 'Hf'~~.- ~~. ~~;~~,. yes hO-".U~D'[TI';MiNi"D~:~' 010'1\1 ,"UMANW' OISAIUWY? ,'.:.'.." ,'t'l ;;.:;, lD4~. I~' 'I '~'::;,;~~;~~I;~~~= ruu Ofn PAnE ACCOUNT NUM/l{A STIWI'I PAGE !';:'i;11i1 . · . .. ':;;.1t)9 EMPLOYER'S' COpy ", "..,' /c.:'::I'})Z:i(> .,..". --'I,t """',.1,:,,, .: ", <:/ "':,',:,,1,;," , ,', "","',, " , VoU'IOVEt, COMPLETE PARr I.. "EM OVER'S REPORT," IMMF.DIA TEL V AND MAil !liE ORIGINAL fO !tiE DF.PMTMENT Of LABOR & INDUSTRIES, OVtMPIA. WASH, 9B501. WE PREFER TO ftAVE "EMPlOYER'S REPOR'" DEFORE IAKIr--.G ACTION ON CLAIM, 2 \I. 1~)ll.(V, HOI -..,""".. " ." -" "" ".. " ....." - -c'''''-,.,----...,""".,". ,,".::' .....'. ..:J...." .. 1IiII_,_= III ..",..,<-- -,"" -'-,'. ...- ,-, .::.---....:::..~--, -:.....-_..-...................:""r~........, ':" ~ .- '~...-.'~..i.-l-~ .. ~ r'--'-- r-'-'''-- -......,..., .... .... --~-~-;~""~t"~:..~~~"r-.~'/~~, -,..,.--', "-""';'__~;--''' ~ CLASS EM_tOnE NAME TO WHOM PAID CLAIM NO. AMOUNT 8-3 GEORGE WEEO W 8 CARTE F453421 15.00 8-3 EARL A BUTTS HARRY G PLUT F519979 2.00 8-3 LOUIS 8UCHILLO ONEILL PHCY F370217 12.50 8-3 GEORGE WEED EVERGREEN DRUG F453421 46.37 8-3 GEORGE WEED P S MCCULLOUGH F45342l 35.00 8-3 NORMAN TAYLOR W J SCHEYER F534313 38.78 149.65 I fiRM NUMBER JEFFERSON COUNTY HIGHWAY DEPT I CDUR THDUSE PDRT TOWNSEND WASH 98368 4,360 01 5 30 67 L _J DEPARTMENT OF lABOR AND INDUSTRIES. OLYMPIA, WASH, THIS Off'AR'....ENT ""ADf AWA~DS AS SHOWN A~Ov[ HOM Hit MfDl(Al AID fUND NOTifY THIS O(P',~IMfNT AI ONCf If 'OR ANY llfASON IN YOUR OPINION AWAao IS l~j HI/OR OR (tiAt.'GfD TO IH( W~ONG CLASS , , . ~ . ,-;~,:,~ ----,,', . .. -'1 ~~-.-.c"~ ~, r----- ~-'".,...-,..~ - .., ", 1II1111LJlilliii -- w.nTt pr-",',',,'.".', '" ---......---, . _w,c " '"', - - "- .. ------ ~ "---.----..... -~'.-- ~ ''''--- ~ (,;J' .;:';:~. :-- f"--- ~..... -~"........" .~>~ ,.~ ~ ~ ~, . I_~ ~-" _..._~"..............."~,," ""'M~'c' ~'. ~,,__ .. ~.- '.. .. .- N:o'.....,.....<"""'~,,-"".,~, _, ~...' ~, _I ---"" T.... r--- ,~",~""",,,,,,,_'.'_~~"~n,. '_M P_'~_I . . -", ~-..- -~ ..-.__ __ __oii- - J"'"':' ;<,;,,:;~,; " "'lr., .. - -~ _IIC!IJ~ "" -- __I -...--.<.--.-" -~ I-~:i .. .. ' OF ANY MOTOR VEHICLE INVOLVED IN AN ACCIDENT WITHIN' THIS STATE. IN WHICH ANY PERSON IS INJUREO OR IN WHICH ANY PERSON'S PROp. .. SUSTAINS DAMAGES IN THE AMO~NT OF 'I1~O.OO .O~~~~UR:ElsTgFg~I~~n Jf./g~~~~T~HT:'~()~~r~~F;6r~F:R11$?:AMrc~'~'~ ~~g- $~~~J ~P~R:;~T~~ ' ...-- .., ,. .-,. - --- ~ -I-L. _._-'...,-_.~_.." -A:..._ ;:: . , ,'-'. . - ' , " ~ I .. +', ,-. , . . . ~ I . . . ' ,,' RALPH W LAX BOX 700 DOSCWALLIPS RIVER RD BRINNDN. WA 98320 . PHY BLOEMKER WILLIAM K MO PT TOWNSEND MEO CLINIC 1136 WATER PORT TOWtlSENO WA 98368 EMP JEFFERSON COUNTY HIGHWAY DEPT COURTHOUSE PORT TOWNSEND WASH 98368 STATtlF WASHINGTON DEPARTMENT OF LA80R AND INDUSTRIES DIVISION OF INDUSTRIAL INSURANCE DLYMPIA. WA. 98504 CLAIM NUM8ER H262584 TYPE TC CH ECK DIGIT 8 AOJ 6A MAILING DATE 10-20-80 UNIT 6 INJURY DATE 12-30-77 SERVICE LOCATION: B REMERTON EMPLOYER ACCT ND: 4,360-01-2 CLASS: 15-1 ORDER AND NOT! CE **************************************************************************** * ANV PROTEST OR REQUEST FOR RECONSIDERATION OF THIS ORDER MUST BE MADE * * IN WRITING TO THE DEPARTMENT OF LABOR AND INDUSTRIES IN OLVl1PIA 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 COMMUNICATEO TO THE PARTIES, OR THE SAME SHALL BECOME FINAL. * **************************************************************************** COMPENSATION IN THIS CLAIM IS TERMINATED AS PAID TO 5-12-78 INCLUSIVE AND THE CLAIM IS CLOSED WITHOUT FURTHER AWARD FOR TIME LOSS OR FOR PERMANENT PARTIAL DISABILITY. THE DEPARTMENT CANNOT ACCEPT RESPONSIBILITY FOR PAYMENT OF MEDICAL SERVICES OR TREATMENT RENDERED SUBSEQUENT TO THE RECEIPT OF THIS ORDER. THIS CLAIM IS HEREBY CLOSED. SUPERVISOR OF INDUSTRIAL INSURANCE BY LEONA RACKLEFF ADJUDICATOR .~:::l r:: /' ~ I;,~ i', ! f,;; r" ~f;:,:(,...", .,-..... OCT 211980 JEFFi!f<St",. (;,:>'JIH ,'f ENGINEEr~::;" 01:,~i(;':' EMPLOYER COPY "":", "I, ':"':;:!,:' ~;,~';}." " \.,' ;~'I':; , ("t.' ! ','\H', "", I"~ ' r"~'---'-- "/ , " '" ':', ",>" "<i"-' " , ,',', """, ,:: ,:' " .',',.-:~ :,,', " ,,' .. ", ,,'," .,' .,'" ,;. ,"..,' '::; ,:, :' ,,' , " ,,'.',' , " , " ' ,:,', " '. ,.- -', ..,~, >: " :' ,."',.,'.' , "', : :', '" ' " ",::':"",', , ,....:': ." ' ':", "':-:; ,',", ,,', ' :;" " :., ,: ',"', ,'" ,;,,::-'- ..'- " ',', .; ""'" " ' " ' "" '" '.., " ,',' ,','., ,',' '",', ,','. " ' ' , \,", ,.,";:> ",:,.' ',:" ," ',,' ,,",. '. '",:,,' ' ",' ",' ", ',' ","',', '..',.,.," "",,', ',','.: " .,,',' :'1,>., ,>, ' ',.,:\ ,'':,<J< ,", "." ''';', . ,,',',',',',;" ': "",',,;- , :,;', : ,,'::,;: , :' ", ' ' ;' ,,"':" , ,'",',', "",' , , ",' .-, ::'", ,".- ..:' ',': ',.- " :, :,',' ' ;', ." ',: ,", ,,' ".,' '. ,; ,C <':::' '",' , " ',' ,".. ',' ,'," " "': ,', ,-_...' " .., ".. : " " ;', ' .. ,',',',',,' ,,',",,'," ,':, '.., ' "'" ',,' '" "." ,". ,', .':' " , ,.' :.; " ::'-, '-," CLASS EMPLOYEE NAME TO WHOM PAID INJUlfOAlf CLAIM NO, AMOUNT 1,,-1 LAX R "~S PH4RI~ACY 1 ~lI!!P2 17 H262584 5.17 15-1 LAX R DOW, PHARMACY 12 ~o 17 H262584 7.14 , 15-1 LAX R DOi~S PH4RMACY 12 30 17 H262584 16.56 15-l LAX R DONS PHARMACY l2 30 17 H262584 5.17 , 15-1 LAX R DONS PH4RMACY 12 30 17 H262584 16.56 15-1 LAX R DONS PHARMACY 12 30 17 H262584 7.14 15-1 LAX R DONS PH4RMACY 12 30 17 H262584 27.39 15-1 LAX R DONS PHARMACY 12 30 17 H262584 7.15 15-1 LAX R DO'IS PH,IRMACY 12 30 17 H262584 15.04 JEFFERSON COUNTY HIGHII/4Y DEPT 0...11 FIRM NUMBER I COURTHOUSE 10'7 24 781 4.360-011 PORT TOWNSEND WASH 913368 STATE OF WASHINGTON DEPARTMENT OF LABOR & INDUSTRIES OLYMPIA, WASHINGTON 98504 U.710.67 Firm NOh,,, Mud A.d THIS DEPARTMENT MADE AWARDS AS SHOWN ABOVE FROM THE MEDICAL AID FUND NOTIFY THIS DEPAIHMENT AT ONCE IF FOR ANY REASON IN YOUR OPINION AWARD IS IN ERROR OR CHARGED TO THE WRONG (lASS .: ,; ",. ':", ',' : :: '\. :'.., ':'- ," ,:',' ,,' .- ',',' "", ,,', ::,:',,',;:" ".- "': " " ,,::,':: .- . ": ::,' ':,:, -- ':, ' ,--, " ' ,'., , , ',', ", '", .- .' : " " , '",--:, ", .. , "'. ,,' '-: ",,' : ' " --',' ' ..' ,.,.:"',.- " "',;. " ',' ::'.' .'" '-' " .' .,":,:, ,,' , ':::" ' ,.- ;', '. ::."<:' ,,' .-.-.' ".. ""..,.",',;',:, ',- ),:,'.,;' .-: '" ' " '.':' ,'",;.-",: ,', .. : '"..< "..'. ",.. ,.': ' .,' .,.. ,:' , '; .', '. :-'" '-','.., :" " " ", , ":": ."'-','. ::,.", :",", '..' ,,'... ',',: '" (':' :;" ,.' ,,".-' ',' " ,,,,'. ..,' ,,:' .,':: ':, ",' :,,' , .,., " '., " ' '.. ",. ":' ,:', ," ',' , '" . ,'i'< ..'. ,..,. " ,,:,:: ':"., ", ' " , " ,-" ",. " ::: ,:, :;'", ,,' .. ":', , ":,' ",\" :':"):(.i,::;:~ ,: '.-':' "'. ' " ,', .',"',\1;, "',..' _tiUll ;:" '; )';., ':',Xi ,;.' ,_ ~!Iii..lif,__ ."lU~ ',:D71.,..;,.. " ~ ' : :,'H'..ti ~ ',,''-'' ".. . ',' ~. '.' 'J , ,~~ )' :'-,1 I: 1 iJ: 't., }o' \\ , : ;::' ... , ': ,:", ':" '. ":" ,."..","''''[.....Un..,'''''~'''_ ~~ " -" U,III -1iiIIlIIl ~-_.- --_....-.......~.~.,~,._.........~. - --- - lIiIil__ ~ W ~""-- -.----""...... "". ..," --,._, -R~ --4 _W1TQ[U.JI.Jl1;~... _~IlIDiIJII1!lUI'""111111l1l~ "1' ,. . , 'I , ' ',' , , ,', " ',' ' , ; , ",' '," , , , r- ---~-~" . , - ~~ .~ ...-__ lll...>.tlllf~~ J.-AIi E -----.....-.., l1!!IlI.I ,~',..,: ,~,'':::, .', ' <, ,,: ,:' ,'" :, ",.,,', ' .,.. ',' ,',' , -.. ;:;', "":''- ..',.-' ''-:,': :' ~'~ "," ",' "",, ',., ,,' '.". ,..',',-' :,,' '..',:-.;, ' ','", "..:' ,. , ,I " , " i .-",;>;' ",',.. "..' ',.', ,'., ,'<, ,,'." ".' .,.,,'.',,' "." '" ".' , :.' ",' ," ~ : ,,: "', :.,' :,' " " ,,:: , .',," ',: ' " '., ,', ,'" ,'.,' '," "', .. ,,',,' ',' , ',..., " " ' '.', '.' . ",' ,', ",;'. ',', '. ,'.-' ," ,', , .' " " , " ,:", '...', ..".' " : "";,,",.-,,..,'., , , :: ,,-', " ' '" " ", ',,'.,.,': '<, , , :,' ,',', ,:.. :,'.-'. , ,,',', .',,', :.,,' '" ",' ',: ,," ,: ',' , .,',,',' " .. ,;, --:,':', i,,' .- " ,.::. ,.::;, ," "'>,,, .,.: ,",,' ,'" '.",' "", ,',:' , ',' " ',: , ,", "'-"", ,,:.- " " ..' ,':, ;" ',..: ".", :.'''''':, ': ":", "".: """"'::,''-'''1 "" , "." SF80SO.jR.",lI/nl INFORMATIONAL NOTICE } .7 ..' '--1/, ~(:l,/ SSA No --5'(,,1 -(,() - ,f'/6,O NcmeJ.a:.L.o ,/. ' / This is to inform you that no written determination has been made with respect to claimant's separation from your ~Ioyment for the follOWing reason checked below: ~ Claimant does not have a valid claim. If it becomes valid, you will receive a written notice regardmg the sepora tion. o The period of possible disqualification has passed. o Claimant filed on application only and has not claimed any benefits. If he later claims benefits and the separation is still on issue, you will receive 0 written notice of the decision, o When separation is caused by "Compulsory Retirement" cr l'Unable to meet employer's work standards through no fault of employee," there is no issue. D Separation from your employment is no longer an issue. EMPLOYMENT ,SECURITY DEPARTMEJ"IT / Initialled (\.""l!:r'- Date t L:i!..?/..-J/" c . ,;- ',; . <,:'!',: :::0 .'" . .'." ..., ," ',': ,i' '" .." ',' ".:'., ',. " ':' ' "." ,,'.', ''-'' :,:.-:'. I,:", " , ".., .. .... '. if :;(~~:::(j :~: ":>;,\;,,, ",'.,i, ,,':-.> ,'..' :,:::" '.'. ",': Ii i';':;');,: "..," ,'., ': <':',' ;::'",..,', : < "', .,',',::/,:./"'~' : ',,'->- '- ,'- ", ' " " - ,,':t;",.,,"i,:,~'r!,;,'~:I;: "c: :,,', ',: " ",.., ",.,i,:,.."",,:,,. ""',,",,' ',')'" "\},:::" 'i' ;;'":":/ ','" :;)":.""'" , "'"'. '",",I,'"',,I.~,' ,.,," I" ..",::",/ , . ", ,',',",' ",," ~,:,;":.::'::,': y,. /' ",'.' "..'.' ,',',:,:'"','", :<':::,\'::~:::: '. ,:',\",:, ',',',':., ,:,' ,', .,' :',i: ".':::~:('.:,I~t:,::":i,,;:;< '," '", ;,.':' ",":" .'., ":', '.', "..' I, '''';/;'1'':'.,,',:';,:,,;:,:,.',/,:::,':,:,:,::; "'., """ ,,' ..',:,::' "" ::', : ;'" "''',, ,,: '":,,,', ,', '::'-', :'" , "':,:,":: '.-,:: ':.' ".,'., .". ' i ,'" ,'. " ",', '". ,..' ,"',' ",'".',",,:)!; " ','" " ',,' ,,'..,' ',"," ',.', .,..' ..,," ,,),:,,:, ',," ,'",',' ' ' ,',",",','..,::,,',,:,',,':'... ""..," ". " ' "',,,,' , " " , ' ,,<,;,:',;'\'::/:::,~I "'" ' '," ' ,.-,' I.., ,""';'<,1, ',,' "," , ", ,'.""",,',, ,::., "'--:::'1' : ....... ..... .:. ;'>'" ,,' ,-': ':, .." i', ,':'-"..',:", ".',c.." ,- ,'.':...' "", ,.' ' .' " "~'I,:',' ,':':,',), "",,'. ~"",..,.~,i '~ '~", ".," 1-{':' '" " t':' " '..:. \'" !i~t '~"f,;':~~~~::\ "~':\" ~ ,;,.,;. ~- _"" 1.,,,,,,,. ~". ,~ .__. ._ ._..,~ . -'- .11lI11t ""'WI ~..l_~... '''''''''"'lll r--~ ___,,,_._,.,,,,...0' . .- ".-.., -\ ---.- __liIiI1ll'- ..-s; r----- - '''h'''''.'_ ,." .,.... ~ n ,.,~_. ". W iLlU _..._At_. __ ____._ l1li . ~ . " j ,., . ~", '\", ,~':' . -"-,' , . ... -..-.'. ,(.,,~':,. ~ .. '-j'''-'' -, - -- . ",- """ ,":!.:..~;..'I"" "i.I:',:;; ~'i','. ;I';~" V_ . r '""," ,~ ~ c' "" I ' "_' '.,' : ',. ~. - "'~. ,,,...... r~ , . .' ;; ',' (', ~ <-,.-. r- --..,. '.." '.' ~]~il!iW::':-:1liI.iiilflll1 ----- -, ji'JIII TO WHOM PAID INJURYOHE 15-1 LAX S PHARMACY 12 77 H262584 5.17 15-1 FRAKER OLYMPIC PHCY 01 06 78 H264445 7.66 15-1 FRAKER OLY PATH ASSOCS LTD PS 01 '06 '78 H264445 6.00 15-1 FRAKER ST JOSEPHS HOSP 01 06 78 H264445 ,861.75 15-1 FRAKER ST JOHNS HOSPITAL 01 0& 78 H2&4445 1819~33 2.297.22 .. JEFFERSON COUNTY HIGHWAy DEPT COURTHOUSE PORT TOWNSEND WASH 983&B 04 STATE OF WASHINGTON DEPARTMENT OF LABOR & INDUSTRIES Ol 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 WPONG ClASS CLASS 15-1 LAX 15-1 LAX 15-1 LAX 15-1 LAX 15-1 LAX 15-1 LAX 15-1 LAX 15-1 LAX 15-1 LAX u :110 81 '--""'''-"'''''" " .., ....... ~ R R R R R R R R R TO WHOM PAID EMKER WILLIAM K MD MILLS E H MD DONS PHARMACY DONS PHARMACY DONS PHARMACy DONS PHARMACV DONS PHARMACy DONS PHARMACY DON PHARMAC CLAIM NO. 12 77 H254056 38~50 12 30 77 H2&2584 S09.&4 12 30 77 H2&2584 5.17 12 30 77 H2&Z584 11.07 12 30 77 H262584 5.17 12 30 77 H2&2584 7.35 12 30 77 H2&2584 11.06 12 30 77 H2&2584 5.22 12 30 77 H 6 584 4.13 JEFFERSON COUNTY HIGHWAY DEpT COURTHOUSE PORT TOWNSEND WASH 98368 STA TE OF WASHINGTON DEPARTMENT OF LABOR & INDUSTRIES OL 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 10 THE W~'ONG CLASS ~ . , "'- ,~~ .,. ,'-~''I' :";"~,:""----:';:t..:,:_,_. .. .- ., ~ .- , ....,.' -.. ,I: ,,->;-"~'" . '. ","'.<, " . .... I', I " - ,~- --- ~ h_ -". I" - , "'. _;> _ V."". 1rIr-. "'.. "" w". --- '"''l!1:.IilJ,~. "'~:,:.'.:' .~~ r"~'''::'~.': .."m::,::.;::- HIlTOn' ~;'~ploy., MUll Compl.I.Thll Report b. fllllnlil'" and 5111nlnll Empi",... hellon hlow. Thin Moil hpoll ClI On,. to Depa,tm.n' :~~~~: :;:N:~~U'hl.l. Ol,mpla. WOlhlnu1on 9850". "'TTACt:~:yT:Es:~~~ORE 5PACE,PHOED. . IlPCOOE , . .~'?~t, T~~nd,' !I,,~hi~on tMPLO'flaS BUSINESS (S'AlllYP( OM N"'UIlE OFl 9t>368 ' lEMPLOYlISf,IRM; , LJ,:,,~,:r:,oll..Cou:ltY,.. . '. . ... Court House !EMPlOYfn LOCltTlON If DlfHR(Nf FIlOM MAIliNG ADoafU i-~'"' PAIlINfRSHIP, -'OIPOI,\lION: NAME O~INjuafo {MPLOYll j ~~~C:JS'fT~N .f Ra.lph W. LaX ? ISl REO PL U NO IfYE5.5,,,nWHICHANOGlvtrlHE IMPLOYEIISL"B,&INO FlaMNO tNWt....'CL...SSWlll tc !~~~~~gRE!tE.bi:rcu? 4360-004 ng~w:gm~tJEO? 0, t.~,: ... ,. ' EMPUjYU'!MPLOYEO IN WHICH OEP...IlTMUlT? ADOIlESS OR LOCATION, INClUOING COUNTY. WHfIl[ "(ClOtH! OCCUU!O = rCON~~~CTjON' ".c)PER~:!.ION ,'U'~,IR ON L"'UN~~W 80"" Jefferson county ~ i~iJ~l~'li~~~:s~E' N~ IFYU....TT Ct.O"',TtOf"jCIOINT TIME ' o"'TdVOnEOTOYOU ~lNO~EM~LOYED8YYOU? .X~' UPL~N~'I~N. '3-28-78 19:oo~' 3';'28-78 g:;~~STDAnwoIiKEo o...nRftUR!"EDTOWORK 'f~W~~~<1~fU~~~%~OH.I~ YES NO 8:30- ~. ','... ~;g~:,,:,78 .. EMPIO'r'MWT WHEN INJURED? X W ,Will YOO""Y THISIMJ>LOYU tFYES, EKP1...IN ~~W'(~r:l~.YH S ~ ,1.~~L~~~L~~~.g~~t81\l811~:? x lNOOVIRIIMfJ <I( ': ...VU"'CE w...CE ~ N...ME SCHEOutEO o...n Off A.j,~~~~~~11:K.._S Sat. &' Sun. EMI'IOYU S lEtEPHONf tlUMBER SOCI"'L SiCURITY NUMBU 569-60-81.60 :010 ~~t?laYU OIV.OROtPI.WHtRE INJUREDPERsaN 15-1 'Wt~M~b~ CUrrent Expe l~~~r~rE E,;,,:m:sEE~ S JOB SHE OTHER OCCURRED X CHECKIIERE '. ftME Lon DUE 10 INJURV ...,M I'...(CIO(NI " 'p M ,NoI ,mORI~O" ;'.'-." WORKDAyS YfS IFVfS.WHV? 9:30 e~lrgN-?~nt.~w'\? (EKP~~':~nON) HOUR CHEC~'::PROPRI"~E~~RCU PER' '!I n~~\1li~oYf~ ...NOIHERJ081 IFU...NHElUO WltlllllE X PERM"'NENT1 struck right hand with axe handle. COIllIIlent: This CETA Employee has ~d four (4) accidents since. 10'-21-77. It appears that "the cause of. the ;.. accidents is a desire to be reimbursed for not working; 4-12.,.78 1'0511101'1 ~O"'lE Edwin A. ,N.uu. OF INJURED EMPlOVU !(H~if::~"'T),,: Betl..oh 'M....lING ...ODRESS' If , flo,f3(),?, 700 TEl9q~M~E4;~~ ~ Wi)' ~VISJ"'TE l5;-tr>Flon ~A.'.'.~ci'.'.""(.'.i'O.'. ".'.' r 3..a-7if .... ,:c'iVlOA.ffL",srWOlllcfD" ~! 3-J.'6-7g fh ,NiVolf01 l.lm.,Vlil , " 7 ::: ') e \" ~<"(:So" L", rFu, f:: .IM~lOYfIl S "us.,.us (iMTE ,;;" OR NATUR' oil ".1 ' gl;. ar '~HOUR ...CCtDEN1 OCCURREO ~HlfT HOURS vaUlt JOIT1TlE WHEN INJUIIEO :C.IV(O"'TliRETUIINEorO~J(,.IFSO ' "WUE YOU OQ!NGVOUR REC.ut.... WORK...T TIME o,,o,CCIOENf? m ':<_1'/_'13 STAIEWIiERE "'CCICENIOCCUUEO [MnOYrRS PIIEMI5ES STR[(T"'OOIl[~S CITY 1i1J" t "Hj (.udl,,,~,, PI- J(; {JJ" :'C" "P , "'OD~E$SOR lOC'" liON. INClUOINC, COUNIY..WfllIlE ",CCIOENT OCcu.RCO HOW lONG H...VE YOU WORKlD Fait THI$IMPlOVun ,...tlNCo I' YOU un 011 ....,,'" $tRue" "fD, NA"'I ......CHINt AND OUCllOU H'NG PU\U"'c. I'USHINc. 011 c,.III1Y' \e.'BIO AS ,..DOOIIS 011 OUloooll$ SIlOUID lit ",......to. ......"'1 CHU.I'C.M Struck ri9bt hand with axQ hand1e whiJ.e at work, .. ~"'''1l1 ...(CIOW' IN you. O'I1OION CAUUQ IN "'NVW"'Y .VSO....IOllE WlJ IM'LOYIO"" YOU. IMI'IOYERP O"'lE 'OU.(I'OIl"O.~CC'O(NIIOYOU.EMPIOY(Il rOWIlOM REPORTED !N"'M~&TITlll 'f IMP(QVlIl WAS NOT . NO'lFlO TIlt lAM( DAn "'$ {HI "~f;lDfNT G,v.:,ItfASON , X 3-28-78 ,..TI' 'OUII 'All 0' ,..,... .,.to(A.,I.o"I\OW DO ..01 ,,,(lI/DleVII""" PUHOUII f'IRWUK 'UUNMMO'.Wln OIl..Ust...ND ...,11.1,11 0' INIUIIV IF OlVOIICIO,GlVlFIN"'\OEC'E10"'lf IF OIVo.ao ""10 YOU H...VE MINOll CHlIOIIEN SUBMIT'" COI'Y Of THI caun OIlO'" 'HOWING (fG"'l CUSTOOI...N 0' SUCH(HI(O'IN ...150GIVT I'RESIN' "'OOIl(SSO, SUCH (USTODI"N o...n THI rOIl,COIN(; U"'HMWn "'liE IRU[ 10 TIll MH ttl~gfl~U~~~I~Ps~f~~~~~~UO~UIl~O::1 M"'V IInUIT IN CIVil OIlCIIII,IIN...t.(tIA\!IU ..~~ ~\1-r ",. right Iulnd ,with lIXe handl.e .while .at ...,rk. ~:E'Y~~~\~~~~~:?O"'"("'? ~i'J;, l~i~ "n N~ "'HUI"'NYPUllll,tING OIU"'U O. tHI ..."" INJUIIED' ,,;:,'~ ~~e. W'(l TlU' O."'N'I' 0"''' tr ;:fl~\I'~n~?E~~t:gWt8~~V~"'1I ~,,~ ~i'}. COULD fill CONonlON vu' 1'1I0.....l v 1'0Ulilv' ~at g~"'g,~?~~PD~~,N'J,~~~~:[), /i:, it'} right Iuuld 1 !'\'OIVII.i...i.....,:nu,ilil :hI ;:: :;..~ation, treatment I right handx-raya, ~;" No aUvo fo frac:t g: rll~'..Wr;-~Yl~~t':.':J: r, ~ 'NO tit i "';\1"" Of Slur-a.u (O~i1.()toI' <.;, ~,iJ' f' r..c:.-U'lm..tD'O ',.lofOl11U 00(10. l)IVI "'..lilt "'~ ..OO'IU ..:,( = ' II toOVlfAIUtD ,..""'10' HOSPlIAl ~ (I~P~',~' 00"0'101'. ::: ; "'''IJItOItfG"nlICIA''' I"""''' "IN101 ,,.;,.,0:.,1 "'''''''1 A..O"'DOtIU ~ X wnl 'HIIIMI'IO.,'I U 0" WOllItOlJlf01HI'INJUlln vi, ESTIMAYED TIME LOSS DUE TO INJURy.... <II Will IHE"lIf ",.v N'''''''''(N' oIS....lllTV' ;y}1' ~~f; X (li 111'(001 'II' COOl IlllflIONINUI,\.11I stroot, IMPI.OYIII COMrtETE PART I.. "EMPLOYER'S .(PORT." IMMEDIATELY At-IO MAIL THE ORIGINAL TO nu OlPARTMf.NT OF lAl\OR & INOUSTRI[S, OLYMPIA, WAS~t. 9B!lO". WE PREFER TO HAVE "(MPI.OYER S RrrOp.T" B(fORf TAKING ACTION ON CLAIM. N 2 "l;'(:::~:'('~~2):;~~~1:~~i~{mWVl1f-:\ LI,'IO,I,Q "i':::"\'L'~ ,,::;'~',~:i/;/<:'<;:,':r ; ';i,,:i,:-;rt.,XY:i"i:i,~,',;;;" i>:.'.'>>r;"'i~:;::i,~,:,':::'/.'<' ',',( ".;':',,;i,/,i, :,;,':;,;,~~r/: of:, ", ,~,,/<<\;;.:;;:W;-':':' :t:!;",..,;.", ":'.','~:~'ii; ,.",:)' ':!;S: r'''-'- ~.. ~.", ... ---'~!&"Illlll!!'!P'_. .. ____ ,~~i "oil" lU __.._.____ ...1oIjj1li11'o Ml'ItI. "',.. TO WHOM PAID CLAIM NO. 15-1 BE../IV IDEZ JOHN C '1D III n H233521 17.50 15-1 KLEMPKE F: DONS PHARMACy lJ 17 77 H245147 A,70 15-1 KLt:MPKE F. JE"FERSON GE ~ERI\L 11 17 77 H245147 6R.00 94.20 .. JEFFERSON COUNTY PORT TOWNSENO ~I\SH 98368 ll.'l061 4.360 STA TE OF WASHINGTON DEPARTMENT OF LA80R & INDUSTRIES OLYMPIA, 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 70 THE W,",ONG Cl ASS _.-.-_..,~ ,. ,~,.~. .,," . .~.~ .. ... . - -.____..o;_.X__ 1 ... TO WHOM PAID 15-1 LAX EYER WILLIAM J ~IO Ie 17 1-12&2584 15-1 LAX PROVIDENCE HoSPITAL 12 30 17 H2&251l4 15-1 FRAKER CONNLEY M ESTELLE MO 01 06 ' 18 H264445 15-1 FRAKER ClALLAN CO HOSP 01 0& 1Fl H2&4445 .. JEFFERSON COUNTY HIGHwAY DEoT COURTHOUSE PORT TOWNSEND ~ASH 993bH 1I.1I0.81 THIS DEPARTMENT MADE AWARDS AS ~HOWN ABOvE FROM THE MEDICAL AID FUND NOTIFY THIS DEPARTMENT AT ONCE IF FOR ANY REASON IN YOUR OPINION AWARD IS IN ERROR OR CHARGED ro THE WRONG CLASS I " " ;' '." . ," :' " ,.' . "., ' " ' "" ' ----- -" " __"' 'O"~ I:~'-' (,,:i~;><0~ IIINl " .. ':;",:'" i,',!,:, '~:\',:;~2" .... ;,..'.' >';:;::. ", <,,". .... "","': '.,', ";,'/, '.',:,. " ....;. . .,.-... " ", '}" '; . :.'.... , ; ',;, , ,,',, '"" ' '/, ';> :"; ."'" ;" ,:' ...... ,.' ..'.'.... ,"." , .... .'....... .;,' /"/,,', .... , .'.' .' . ..., '. . ..; . :.,'.'i~ ,........ ~'. ,"-" '1'" ";".,,, , " ,,', ~ ' ' ,.;..: "'-':-,: :-." "",/",", ' ; ", , ,". , " ;'1' " -< .!i :;;,,, '~.''''.'..,'iil : r ).,'< ',,:~, : j". ",'",".:,'t.,::, r-- --'---' ,," ,,", ' ... ",", ,:'.: STATE OF WASHINGTON DEPARTMENT OF LA. & INDUSTRIES Ol YMPIA. WASHh ON 98504 '"ie' .. RAt PH W ....,,~~~~:~ '; I I ~.;':~~'~;~ I~J H:>5"O<;" 12-00-77 1llliB.1~=-'U.'U'..1:a.11.1*;f.l'II:U""61~r U(el._ ~"""'"'''' :' -;. .: ..~,.,. l '? -; d\\"~ i~~';~......,:? "" ,', , , ,,', " " ,,'," " " "" , ',:. " ."" ...:..,.... ;, ";.': . '..... ".... .... . .'. .:..' " ',; ".",',"':' ',' ';,:.," '", :. '; " .": ..'........,... '..... '.. .::',\,:',,',,:,::' . ' ".; ," ; ...' . '. " "," '. " ,:' ',', , " .':,' ''',' , , '. ,."',,, ,,>,'. . ,; ".. .,,'....' .. , '.. ;'" ':',' ", .;'. .,/ :.', '.. "" >, ',,; ',"' ",.' ' . " <' :", ,', .... ,.';. :'. : ,"", "','.'" ", ,:' ' , ,,,, ,','..,i::, .'" ,," ,',,', "," '," , ;: ,'", "" '" " '. ::: ,<. '., ':>:, ,', , , :',': ;:,,'" " :", ',: =~ -~~ __i 11 _,__Oil.__~ " " .' . .' .; , ',"', , " , ' , :"":" ". > ,', ' , ,:' ,',' : ", ,,"., ,', ',', , " " , ,,:,' . ., ..,", ,,; ..... '. , , """ ";' .: ". ,''",: ",.' ': ,,',',.i' . :. ',.""'(" ,'"",'"::,"',, ", '': ::';,"'" "', '; " ' " ' " " : , . ~I ." I' ..Ilm.JIRST CLASS . POSTAGE PAID .. PERMIT 11312 .. OLYMPIA WA ***~o*~oo**~o~** , " .. " ,.. , , /" "..". , ,',' 'I." ' : ,", ~. , " .' L, ~., .' .,.' " j .... ",,' ;; . ,',:, ,".,':' " ':, ':,' !::f;' IlMHOVH JEFFERSON COUNTY HIGHWAY DEPT COURTHOUSE PORT TOWNSEND WASH 983&8 , t<: .'. " /.', ."," > I:> ' , .', .,', ':,1 " ,;,' '..,' '. , ,,', ," , .' ..' ': ,"." ' . :, ,'"."":,:,, ., '., ,."" ',,", ,: >:. ,': ',I' " ....::',' ',; ','. :' ,I"~"~ :: , : :';' ," :.' " ,'.., ........ ". ........ ./ ,.... :':.,. ':.:": ,"" ' ",'" ',..., ",',"',,:' .'.........', . " .' ,.,'" '. , '. ":<.- ",::' ,;'" .,', " : I"~ "' , " ,", " ..' ,.. ..... ,,'.: '.. ."..' " ". '.',.;.,::: ">,, >." """'"' ,. -:: . :!(\ ':; : ){ , P":; -- ""'P" ..........~_., "".... .~ _. ._ ----- - .._--"-_.,, ...;oW ",' ,; ',. ','" :~' , ,," : , ' " " .", " " "" ' ,,,:,',.,,, . ",. " .' 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D!:P'\~"'\c~1 ;~, \ :,'H):r!{\lJsrll,,', ~! 1\ 1f '_'., '."1 f.',l-lI:',C.1 C,U , " , ", " ' .. ',', " , '.', ., -I, r,..' >>< ,I" O~~OER AllO\:JIN;:~ /d,w (I U:"r~(, : ",' " l~/'''r:DI(/1L TREATMErn ONLY ,: :: r--'" '___n ::f-',.";,,.' ",' ,,' 1'~)t;Il) )'''..1 tho' " '" . "''' . """"!':'''} CJr:('pl .,. ",; ,\ '>''':n! ThtJ ,101m I~ ,,:, ',':, ._, "k '<'.'J I ,"'" "':",,,,,,^,,,, i ANY- PR"6lf- i I <""11 IHi)iJFS T f- C "~; C;'~.:S!{)~ "i\' J Y, \:1 : 1"", d"I.'~R MUS T l~f 1..~A[)'r I.'~ WI<"! fIllG-' TO THE DEPAI?TMfrJT Of- lAflOti ,.ND Jr,(.'l!<;,;;lf', '" ',',.,'1" ':.'j'lj/'j ~,(J [)A.':", ^ fURTHER APPEALABLE (HlD!:f<Wllt fOlLO'," (1J,!~ A. ,\~~ '.~ .J' :';1, (.Frrl,i:-loi 1...,"<;1" BE MADE TO rt'1f BOARD Of' lfWU<;TRIAl JNSlI;<AN(f 'II ,'("dIN /d~ f)Ar", III()M THE DATE fHI<i ORVEtl IS (OM.',',UNI(AH!) 10 riH p,\ln,[", (J~' 1llt cd,I..\(:,H \.1 ;H(~.."il flt41<! " ',' '.i,' , , , ,', .i' , " '., :,', >;: ,'::: ' ""',: :,' ,: :..... i ..:< .' '. ,i... . 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C.~~oWr.dt.ro'llf', .!lort 'l'owIuIend, lfaehJ.nllton 90360 305-1300 "p/'V'~--r~.",~ OA~_9-77 PAYlli;4t~~'fI (OUlO h" CONOITION mAI1,';?~~?0~~~t<Jf~~\IIJ~:Oi 'ii~ , ~t:r WIU IHI5IM.tO"11 U Of' WOC""U'101H"I'IJVtJ. ESTIMA TED TIME LOSS DUE TO INJURy.... 0,," "U NO lmOIUI",I...fO Will hlln"1 AN' "IMA"'INl 011."""',. r,;?, ~~!t II' COO, lUlIO'" 'An.\e(OUN'NU.......If...;~GE flAl-lOYII, COMPl[J( PART I.. "(MPLOYUn REflOAT," IMMEDIAfrLV AND ""All TUE ORIGINAl TO THf DEPARTMENT OF lAOOR & INDUSfltl[5. OlYMPIA WAS'''' 9RSO.., WE PREHN TO HAVf 'EMPLOV[R'S R[PORT" 8[rORE TM<ING ACTION ON'ClAIM. p - ---------------- r----,.--".~- '" .. , '" .... . " I '.' .....,.,' "......... : ,.' " ... .", " ...': ',,'" "" ,', "',, , ,'" , .", .',' ,'.. ~ ':)' , """ ", .... ..' ..,.......: " , , "'" , ,", ' " ".'" ,. '. ". .'.'. . ....., ". ",.' ":' "i.....". : "", ,:,:,' ',:,., ': ','", ", " ',:',' ' ", , ',,' ''"', ' " ,,',.' ":; .'", : "',' , "' .,: :" ' '" ,,,',,, '" ,',"" ',",' ,,':,,: ",'" . 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'" ,'", " ' , :, ,;/.!~ :-" ,':;,:,' ,>':::':,;/ ::','.-. ..':::,:",: c.,,",' :.;::':,: .":;,, ",.' , < ;" ' " ' , '.' <:, " ;..... ",'... .;". .:., ... ..... ........ ..... . . ... .;,"., ....... . ..' <.. ,'.,.. ...I" .' , ", '.. ....,.. ........,';, .., "' , :, .', .../:, .. .... ... : .... ." .. . :....." .... ..... .'. ,.~. . ."';'1' '. , "':!<"~>":"~.,::,~':' .,>':.;..;.' "'~v' , :' , :) " Fo'm W-~ I (Rev, October 1976) DepulmentoflhT'l:Ilury lllllllnal Revenll.S.rvIG' ~f1~'" dtployee's Withholding Allowance Certificate (This certificate Is for income tax withholding purposes onlYi it will remain in effect until you change it.) NOTE: If you incurred no ta;( liability for last year and anticipate no liability for this year, you may file Form W-4E to claim exemp. tjon from Federal income tax withhofdjng, See Form W-4E for details, Type or print your full n..me !ZtHP;;. t./fJlt.Ae.1!: L 1:)':( Home address (Number and street or rural route) f3"lt:?O" ()d~eu;"./I.~ R,u~1f'. RJ, C;~'J,O';;WO',s.'.;.:nd ZIP "'~) I).::,J) , 4., ~ 71'1 1 Total number of allowances you are claiming .. ..... 2 Additional amount. if any, you want deducted from each pay (if your employer agrees) Your social security number <;: <; -hn . rtl.tt'J Marital status D Slngl. [;?"Married (If married but legally separated, Or spouse is a nonresident alien, check the single block.) I $ (J. Under the penJlltlu of perjury. 1 certify thd the number of withholding exemptions and allowances cl~lmlld on this certllicato does not exceed the numb.r to which I am .ntltled. SJ..,.w.. ........~...u......1f~~........................m................. D... .....~..~..?....................__.. 1:;~;:; ~-""_.^. . . ., .' ......"i,.... .i"::,, .:. ........... .'. ...... .'.~', , :, " " :",' .,'",' . ",': ,: ":"","'.",,' ", ,,,:',',:, ',',:,' .... . '" ",: " ',".".' ", ';, ',','" .:",;, "': ,:':'" '".' , .' i .' ',",,' ,"" ""'.,;' ..;.... ........i.,>.. .", "',:; 'i" ....... :'.' .... ..'. ....... 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"':., - ", .:. . i, :.":,, ,,:" ',: ',..,',J ,",':',".,", .'.,"'" "'",' ,,:< ': ':.',: ",", "',',", ,:' ',', ,<, ',": """ ':,':',:',::: ',:" '''; " :,'"," ',",' ,,", ,,; '":,, .', ",,', ", , " ,', , , ,'::, " ,', " , , "'", ,':,:", , ' . . :,,',,,,,,. ,:,," _."; , ., "~"":"''' .' ,:',~' . :>'\ ,: . "...,'::,:jl..', "'..,:...", ' , '.') ~ ' " ~ \ ,~~., ".,' ;,,' ~ ~ ;', ::.. ' ,.<.., " " .: I'~ , ~:';,; .;, ~'" ,:.~ " I ,".'. ~:'-, ,I') , , ."," ~ , ,c"': , ',',',,' " ~.! , '"m W-4 \ E'-Ioyee's Withholding Allo!nce Certificate (Rev. Aug. 1972) (This certificate Is for income tax withholding purposes ?:rel~~e~~~fn~~eJ~'~~ry only; It wlll remain In effect until you change It.) T,p. a' PrlO'!!A ,," "me Yo", .oclal ",",lty "moo' _ 1.1'.jL,Ji../JJJ_J..J:tL!tE_1Ji.'/. _5.tf:,'l-if, n - 8' U{J Home address (Number and street or rural route) Marital status t:L'J.,_a,dc7~_fMeu/f1L,(.';fS-,e,~r:Lj?JL._-'-'-'-'--- 0(, Sins, led !8(M.r1led wif City or town State and ZIP code f marr e but legally separated, or e ,~:,'::::,:, ;,::::: '" ,,,:~: 2 , ~::~~,' ._~~\t '''00, '~ the 2 Additional amount, If any. YOll want deducted from each pay (if your employer agrees) $ 0 I certify that to the best 01 my knowledRc and belld. the number of withholding allowances claImed on this certificate docs not elCceed the number to which lam &fIUtllld, SlI'''ulO ~..,..~,::.&.J...__.J!4f'--....--m..m'm------.... D'" ~j).F,--.L9.m.' "..7.0.,.. ~.~ ' r ,:1..>, ,,",' ',', , ::, '~' ::::: ,', ' ,",'" .".' ..' ..... '. , .'., ' , "::, . ,,', ",' ,:",',"' ", ,,::':,:' ' ,,:', ,,". " ',' , ,",:' " ',:' , , ',,' ,,; ',: " :" ", '. >: 'i,',,;, .... !! ..', ,':; , "', ","''''', "':', ,,:,. ',,; " ,:" ,,:'; :~:'q ':, , 'C;' ,,"': ",' , ,,: <,.' :', ',', " " "" '" " " ,: , ,,' ,: :'"", ,,:''.!''': :""':' .' ,", '",,''>'''''' ;':', ',: "" :;~',,'>'>"';:"';";:I' '., ,'" ,,' ,':", '';' ",:: ",'," , ,"".",' ',,:",', : , ,,', :""," '':', ',' , " ,:,',,':,:, :,:i",,' " " ," ' , "', ::',' ,', ". ", ' ,,'.",','> ',', ",', h..,::'>':,....... " ::".:,' :"",,' ,',' " ",:' "<': ': '; :" 'i,', ",": ",' ' ,,: ' '"'," ",:,'::, ",' ': ' """" ',"'::, "-::' :',," " ,: , " , <t""".}!!:" ,::. .... d', ":,' " , ''', ,,', ','r:: .',," ' ":':' " ."",' :" " " ',,"'- ':< , "," " ", J ',' ,",,, I'!'::'f{.'~~ , . ' , ' . , -"'",.. " ., ",", " ,,,., '- . ' II..". , i'_'II" ._,_ ..........! iIi_._'IIIIIII rr--'_.~' - .,"-,~,._"._..._, --, " .., IV II ',' , " ..'. . -, ;.!.1"': "~.~'" ,-iJW ...., ,f:';:~\ r--- IJlI': ;!' .~, '. '.."e k~:'( ;'::"': ; :';".,:,', "." :, ' " , ~ ~ , .," "::'. ".' ,:.'::',":" ';''''', :-,";; ...' < .'. :'., ," ,': :::' ,'.' :', "; " ',i" " " ' '. ", 'i ',":',,;'::' , , . ",,:"::: , "":i ':", ':', ,,"'. '::, " .'.. ..' ".:' . ": :,;.::, ", ................. ". / ",,", ': :" i, ...-......,,"" -~.',.,~ ",l'II --- 17~ ,"" ,," , '.:''', " ' '.' .......' ":...' . '.' .'. .' ," .,: :",' .' '. ' ','" " "': '. ' ," ' ',' ., . ::., ..;. .<' '. ". ' . . . ..:., '. '..", '.. . . .' ..... .:", ,", .' <.', .i. . .' .' ,,".. .......". > '.,' ",...,' ," , " ,: , " ,,' ,: ' , " " . ,"" ;' ,,>;, >..' ", ....'" " '''''' " ::, .,." " .' ;"',',,,," ,:'" , .,' '" """':':. ' .'" ,: ''" ,,' , , .' 'i:".. '".. "";.,,,, '.," .' ..'>,." , ." .,:, ..','.;' '" ::, ,,' c' :\ .... ,', ,'.",,'" ", ~~j . 48 411 Fillmore Port Townsend, WA 98368 January 25, 1980 Hilton L. Sanstrom, Director Department of Public Works Courthouse Port Townsend, WA 98368 Dear Hil t: ThIs is to inform you that I have recently accepted employment in another area and plan to relocate in the near future, therefore, I roUBt subrn.l t my re~dgnation, effective February 12, 1980. T have enjoyed working wi.th you very much. If 1 can be of any assistance in tIle future, please don't 11csitDte to contact me. Sincerely, " _../' ,.,.2>,'(: (.1:. ',,, 7'<O( .,- (~,'~~:~<'" ,;' ,.' " , " ':' ': ,'" ;' ", ,...,.' ';"":'" , ", ',,', ',,":' ,",", ';":, '. ,',,:, >".i '," '" " ,'" " :;",:,', ";', :\',:,>,. ':';""; :" '" ,,' " r-......,......,-_... 'ILl. ,__.. ---," ,,---, II - ~ """" ,"":' : ' ,i c" , , ':':"', ,': ': :': .:::1: <: il':':' '\ ";', ": , ; _'_M'~._._.., .,,_...'.. ~ ~ -- -'--- , _____" o.L lIK'llIIII -~_.>--., . .~ ~".. - n, ,,-.,. llllll - IJIIL - 1ft u-1 " '.~~~".._- .,_"~.J~~,_._." .?,~, , /O,~, ,,/ )"":':"" -. ":'~''-'1-'_! .. .',~. '," '"" ~.._ -' -.".- .'''- ..-..~ .. . , ~ \ " r --." T::,..........-.-,.........~_. ......, ~.- ... , - ~,'-'''~ . , .~..- --^f" ~ ~-......... ,-. "",r --r... -.-' l ' ,'.' ' , " ' ~,~, . < ;::: c.. '" :.l ... ei! => z '" "' ,. ." .. c:i z " '" 1 '" >- 0 ,., ~ '" ~*' ~ ~ ~ J q o ":l ..; I ~~,' ". .-:'-- ,_J, ~ ,-~. ---t' -,~\ .~, ~,_ \~ _,. . ,.,,: '" .. ~ ,_..".~ Employee Performance Evaluation Instructions I. When Required: Annual Review. to be conducted during employee's anniversary month. New Employee _ to be reviewed within 30-60 days but no larer than 6 months afrer hiring. Termination. A review will be prepared upon all terminated employees. Other _ when an employee performs in an exceptional manner, or when performance falls below srandard, II, Who Will Prepare: Employee's supervisor, III, Rating: "E" 1. "G" 2. "S" 3. "F" 4. "U" 5. IV. Overall Rating: V, General Comments: VI. Review: Excellent. Individual performs all tasks in an exceptional manner. Requires little or no supervision, Good. Individual performs many tasks well, and all other tasks adequarely. Requires little or no supervision. Satisfactory . Individual performs all tasks satisfactorily. Requires normal supervision. Fair. Individual performs most tasks satisfactorily, but not all. Requires more rhan normal supervision. Unsatisfactory. Individual fails to perform many rasks, requires close and constant supervision. A summadon, not necessarily the same as the individual's charucccriscics, This is critical, you must, in your own words, sum up the individual's strengths, weaknesses, and sreps to be taken to improve upon those weak areas as well as potential for increased responsibility and job promotion, By a person at least one level above the supervisor of the employee. (S);H REVlrRSE SIDE) . . - . ".--,.--- . , ... "",,~ -- ~ ,-~ "':::'-+'~" ,".4 ~ I '. ~ _~,.::... ~ .~ '.;; j ~ T ClI III ... CJ :J 0 Z u - c Z 0 Cl - c: <t t: 0 0 ... ~ ex: ..... ClI CO Q) Co .... t- o. >- 0 ~ - 0 z E ClI ClI C. - 0 - Cl lJ) 0 I- 0 c:: U In :J c: ~ 0 .$ ~ w c C> z :>. 0 CO I- !d: ::t: :~ ~ .... 15 Cl :::s en -, - 'Vi t) (/') "tl c: .... (/') 0 C 0 c: - Q) ell: ClI .... (J) LL. .8 0 c C) E - 0 U ......... c: .... t- "C :::s 'Vi ClI :E ~ Q) en 0 ... CO 0:: "C eo :J - (/l c. W ... III ~ (J) ctl ... 3 0 0 C t) ~ LL :E ... 0 ClI u :J rl Z co en rl "tl , C rl 0 rl ::t: U c:: ~ 2 ~' ~ 1 ~_~~~.._~.... _t~_ ..........,_',., r , '..:: . - ._ . oj " ""*"~ . ........."', ,.~ - ",,- '.,,- - ...- ~ .' ".-"-'-- l ~. ~ ~ CI1 <II .. " :J 0 Z u - c: Z 0 OJ "- c: - c:: 0 0 c:::t .. +" CI1 :j:j CC Q) C- eo - I- 0. ~ 0 h 0 z E CI1 CI1 Co - 0 - en 0 I- 0 W 0:: U II') :J c: ~ 0 <1> ~ W c: C> >- 0 - z eo ~ ::I: ,~ ~ - 15 Cl :::::s en -, - 'in lJ) '"0 - () lJ) 0 c: c: CI1 .9 c: - Q) ~ C <1> U. .9 (.) OlE (.) u ....... - 'iij c:_ I- 'C :::::s CI1 0 .. :2 h Cl) en eo CC 'C a:I :J "- W Co W .. <II ~c3 ltl .... 0 () ~ 0 <( u.. :E .. 0 CI1 u :J rl Z 00 a> rl '"0 , c: rl 0 rl :r: u 0:: ~ 2 @J.. -w 1 . . f---- ........"""'~~>....,""'...._-, -... "',' ,I? '-"., "'.\ ,:,:,.,:"'",,, e', ,', :'< ;:;;:~<;,:~'i,,, ," :" ;" "~:;~:\ ' .. . ,. '~';:'~)(:;;-:" 'J ..' '",,:..';~ ":':~':'" '<"i :.,) '., ;,:<:,' -i"" 1 ~ f CJ Z - Z Ol Gl c: - c t'! 0 <C - ::l :+:; a: C1l 0 ca (,) ..... l- e. Cl ~ 0 E c c. - 0 '2 en 0 () "! c: ... C1) ca W >- .. F 0 ..... ~ - C'O ::J ~ ..... '0 - CJ) (J) c. ..... () (J) CIl C c: - C1l .5 0 Q) u. 0 z U C ..... en E - - ~ U 0 c I- "C I- ::J ;: ..... 0:: (.) :E ~ Q) <C CJ) CO a: "C ::E: 2 en c. .. - ~ W co :z "- CIl Q) ~ = 0 C C () Cl 0 <( -, IJ.. (,) riA ~ 'i - ft HI 1""'1 'I,',"~, F-- [ TO: FROM: )/~d ~, lift) INTERVIEW REPORT NAME OF APPLICANT: u,J,()Zz':'n/t'/~'nn'm'nn'm.n'nm'.'n..' PN~1~~~0~I~n,~~tfd.munuuunu ADDRESS ~~uj'f.0,ug;..I&,":~ PHONE un..1I!e?~~n'?']?f I.t INTERVIEW 0 CANDIDATE FOR: uu ,:~~r. "" THIS IS: 2nd INTERVIEW ~ t:!f -/ y (Job ntl.) 3rd INTERVIEW 0 INTERVIEWER: ,u/f/;,n".,,(..u.' ' ,~~ PLEASE REPORT YOUR INTERVIEW IMPRESSIONS BY CHECKING THE ONE MOST APPROPRIATE BOX IN EACH AREA. 1. APPEARANCE o . I ft// Very untidy: poor -fute indreu, o Somewhat cllfelon about penonal appearllnc~, SlItisfoctory personal appearance, ;d Good taste in dress: better than average 4ppellrance, o o ~en~'~:~r: ::~eYI~on~med: taste in dress, 2, FRIENDLINESS 0 0 ~:!:i~~rry distant Approachable: Warm; {riendlYi lairly {ri!.~~Jy. iocillblll. 3, POISE-STABILITY 0 0 llIate"e; Somewhat fe",.: About 41 poised is "jumpy" and is easily irritated, as thllllvllr"gll .-..!Epear, ne,vou.,. applic4nt. 4. PERSONALITY 0 0 Unsatisfactory for Questioneble for Setisfaetory for this iob. this iob~_ , th_is lob, S. CONVERSATIONAL ABILITY o T.ns "try little: Elpr.ulS himu!' poorly, o Triu to upren him"lf but doel hir job at b.~t. A...eraga fluency 4nd ..prenion, 0 ~ 0 Very sociable and Eltremely friendly outgoing, and sociable. C ~ 0 Sure of hims.lf: Edremely well composed; appears to lib crises apparently thri...es more than a...erage person, underpreuure, 0 pi( 0 Very desirable Ouhtanding for for this job, this job, 0 JiQ 0 Talh ....ell and Elcellent elpreuion; "to the point:' oltremlly fluent; forceful. 0 or 0 Quick to understand; Exceptionally peree;...e, very well, keen and a'ert. 6, ALERTNESS Slow to "cote I, on." o Rathor slow; require, more than ,:!ora9.!. tup]..n_~!ion, 01 L=rups idea, with avorllq. ability, - ' 7. INFORMATION ABOUT GENERAL WORK FIELD Poor knowl.dg. 0 I F.i, knowl.dg. 0 Is 4' inform.d as of fi.ld, of field, tho .....ra90 applic.nt, r No r.,.tion,hip b.t......fJ I Fair rel.tionship b.twoof? .ppliunl" b.dground .pplicent's b'c~9round =~~J1'~__~~_~~1!..!_~!.n~'~.._-=t= e_~d jol?!!_~u~~~menh, _ 9. DRIVE I o 0 .Rf 0 He. poorly d.fined go.h I Appearl to ,.1 go.ts too I Appears to h..... ....er.9. Appears to ,tri.... h.trd; ~_;~~;~~~1._~~__,__._l~,~~!Io.~tto3~~~:;~~~~~~J~t~~;;~~1~;~~._ t~~l~~;~'i'O 10, OVERALL l' I o 0, 0 /liJ _._~_.!i,~~2:.~;~;i~t~~2.=--.~:~b~~~~r~::.=~-",~=~~~1~~~;:,_.-;.:~:07:_:c,,=-==:-..:..__~~!~;!~!-:;.~;~!,~~',-'!.~.=-_._.2~lt."din9' o Fa;rlyw.lllnformed;kn~ mOil th",n .....,ago a_e'plic:ant, o Hal e.celt.nt knowl.dg. of Ihe field, B. EXPERIENCE o KJ" A....rago amount of &.dground ....ry good: meanillgful b.d9round consid.rable uperience. _~*2~~n~..~_=--=-__ = =---- E.cell.nt blldground and..peri."co, o A'jeers to lOt high 902 ." to.tri....lnc.".ntly to_.~hi..... th!!!. o E1MICKE ASSOCI^HS. INC.. (PLEASE SEE REVERSE SIDE) . ~ - , .,. .~ ~ . -.. , , , ,... ,,_ I . . PRE-EMPLOYMENT APPLICATION nD"///Ec/?4V/ 7ffc#,v/C//1A/ 7r (Position Applied for) Jefferson County is an Equal Opportunity Employer and encourages applications from all persons regardless of race, creed, colDr, sex, national origin, marital status, age or physical, sensory or mental disability unless based upon a bona fide occupational qualification, (State Law: Chapter 49.60 RCW and WAC 162) UlPORTANT: Complete all section. Please use ink. Print name only. 1. Name: ,M.-PT..w' uP /Y/f/ v: (las t) (firs t) (middle) 2. Address: /?t?.cb..r #9 "aR4M~ M. 9"T.?fd" (street) (city) (state) (zip) 4. Date of Birth:~~;' (age will not be used to discriminate) 5. Home/Message phone: J'ff -ZJ229 6. Business phone: 7:. Education - Total years of pre-university schooling: Circle year completed: 2 3 4 5 8 9 10 11 cfi/ 8. Have your passed the General Education Development (GED) Test in lieu of High School Graduation? Yes No Year ~. -- 3. Social Security No: c7f? -.7?-d9-Z/ 9. Colleges attended ~L,.c- ~"'~-9?;Y Years From f' /65'" To .r..$' d Degree d? 6'. 10. REFERENCES: (please do not list relatives) 1. ~E.r/47 2. ./1/"1' U4j/w_<"U 3. /.;:>08 #.t.<EA? 4, 5. ~fT&-.#CN /PA hA',(~R' /?A . ~ ~RRV'a..-f~~A OFFICE/HOME,PHONE c::f/bA'dMA4J ) .J'Tf' - / Lf3'~ NAME ADDRESS " 1/ :J,?"F-.:rn<r Form 100, D.P.C.C., Rev Dee 1974 ~' ~. -. ,." c' - :'~ ,. -'- '. ,...., ~,:. 1~ iJ. 'A. Company Name: Add ress : .inning with latest emPlOyment). Phone: City State Zip lmmediated Supervisor: ~alary: Beginning Final (Monthly) Job Title: Dates Employed: --'From Specific Duties: To ************************************************************************************** B, Company Name: Phone: Address: City S ta te Zip Job Title: Immediate Supervisor: Dates Employed: Salary: From To Beginning Final (Monthly) Specific Duties: ************************************************************************************** C. Company Name: Address: Phone: City State Immediate Supervisor: Salary: Zip Job Title: Date Employed: From To Beginning Final (Monthly) Specific Duties: ************************************************************************************** 0, Company Name: Address: Phone: City State Zip Immediate Supervisor: Salary: Job Title: Date Employed From To Beginning Final (Monthly) Specific Duties: Form 100, D.P.C.C., Rev Dec 1974 ---,., ",' ". ,.. . --. -F -- '1. _1I;,,___,~ U fll "'Ililllllllj r.~'"" ,-..,...--.,,---. __,n=~7'-, ,>,..,~... . - ~ ~"....--.. -.. - - WI' _ __ ___ "IIlIIl ~'--- . ..,..,,-_.....~ ~~ ~~... ~- ,.,- '-'"" f!iiiI' ~_ II i11i1-1Ml :)i':\'. ~"".,.. ,.....')}"""...""...,' . ",,, r,,,, ' '..............,....-,~ ,"- -' , '.. ......-'..,.. ~,;:'t,: ~IIU~ ".'.....,. .~,_,__ ',r~''''''''''''''''''''''''' . ~~ .~ ~,",~, ,,-...., '.'''''''''- - lU 1><frr l_ i"',/' ';,,;:,, ,..-'- -~_..... . ~ , e.. -'~.'" ""'-.., , . . PRE-EMPLOYMENT APPLICATION >>,R//.cy AA"TY~E/:' .4#4~,.p (Position Applied for) 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 Dccupational qualification, (State Law: Chapter 49,60 RCW and WAC 162) IMPORTANT: Compl~te all section, Please use ink, Print name only, 1. Name: /7' - ,10#1(/ 7/"f'77A/ (last) (first) 2, Address: /? c7. .6"0 Y /'Y7 M/i'/.JLiJUd (street) (city) .J. (mid dIe) M. (state) 9?.7..>,? (zip) 3, Socia 1 Security No: Cl';r-]'?-c4'-Z/ 4, Date of Birth: 2/.Fh-;z (age will not be used to discriminate) 5. 7. Home/Message phone: :;,8"S-- 2.7-Z"9- 6. Business phone: 8. Education - Total years of pre-university schcoling: Circle year completed: I 2 5 6 8 9 10 11 @/ Have your passed the General Education Development (GED) Test in lieu of High School Graduation? Yes--==--No~Year 9. Collc~es attended _.~~ a//.'Ed/T.Y Years From To Lf- /f/l'~ /'Y....? DeRree /.? 4. lO, REFERENCES: (please do not list relatives) NAME ADDRESS OFFICE/HOME PHONE 1, LEf ~A/7 5'nfT&"/9aR~.-e/?t?w.rmvE 2. 0A C~UAW",-Ltt r?h/c~ ,1"?~R/f1:1/V.t'I"bPE 3. &A #u.c""" 6.r7/.::If.>/P/P/)'<'f;-at~~ /, '/ 4. /.1A>V..... d.>?/t"/r' 6/C"~""/7/Yf A- ~ :.>" . , 5, c::;.;,~& .IoNA;'f'CM ~~t"~A",;f;j /" '. , :J?F-/9-,?iZ :J?..r-/~?..r .J3S- - .iJd"/f .),r.r- /..rP,f" Form 100, D,P,C.C" Rev Dee 1974 '-'- . .. " ,.... ... "'- ,-~~--- , ......" ',: " , ", '^ ~ '. ,,'. ~ ... }I....t~ ~ WASIIINGTON .UBLIC E~rpr",OYEE'S RETIREMENT Sy.r NOTICE OF SEPARATION Last Nll.me FIrst Name Middle Name Separation Dnte .\ciiiillen o Resigned o Retired ~cceascd o Ineligible Position o Granted Leave of Absence without pay until...................... Dnte I.lo3d :t:l'nest; c-~u- IT ENTER GROSS AMOUNTS "pAID BELOW GROSS PAID FOR: Amount Month to be Reported Salary 1,1118.1.0 AUlr":lt Ternlinal Leave 260.80 AcguGt Sick Leave 612.88 AcgWlt Other Jef!'Cl'SCln C""r..ty Ilept. H1eh:r.~ " .............................'.......Empioy~.r..Aiiejjc.y..................,...,.,...,........ . ' 7"'j /" ,,'(, . X;~~~~:jj~W~~~~iiC"b.o.~~ro'm.ccr...........,.. ',' ~~~wl~~~ ~~~t~h':n~II~~~IO~dC~~~(!SnJ~lt~I~~lnreJ~'JI~fl~~ ~~~r~;e/i"r:i~I~~ Er.-rvcr.o~~sttO l~c~~~;..,rfnl:;J~n?eTy~er, ~ :J , , '. " ' ~'\ ' . , \ " " " I ' , ,." , " .~. ...... ~ . ,'" "j - . -. " \ ' 'I ." I, ~ --','-~"-'~. -.. .~ r , ". . " ~ .- """"'! ," -.' .. ~ ..-- '. """d"M , ,~ . ~ -, ,""'" '_ _,~, ~ . _ \". , . , _.1 ot ,.. "",,~.\ I ... -- ._~- "', ,'m" ~ r-~':"~';\.."'i.:"" ",,- , ... .. :a "'O' s: wC !- o~ ~~5 q)C;1i ,~ '" !-.<: . :z: ,,~ won. ~~Ji ..O~ t-.- 0 Wn. ~~,2 CO+'; I- . U % C.... ~.~~ ~~~ o~ ~~ 11 c ;t f . _ '.!l ::r z ... o ~ oS ~ ] , - 'll I !- $ 1;' M ~ .~ .. Ifl I-n. -' . u ow :z: 0 w '" ~ ::> '" i t .. ~ .5 0 .. 0 J: " ~ ~ ~ . L ~ .E "0 i z " L '"' -ll . . '- .. 0 " L ,5 " ..<: ~ " ~ ] 4 0 -a 0 . ~ I . c ;, ,2'; .., ~fi "0 C "e i c'"' ~ 00 n.~ . en. . E -a uo .<:~ . " ';;. '" ~ "'t=. $ . ~a " > o e ~ u 0 .~.<: ~ -au E co j: = HO < y .~ ~ ;j1; ~.~{ .~.J, .g - ~O'- 'J ~E ~ \'<" ~lY) bo ;J l,)::r "1 F :: ~ ~ ~I '" g ~ ~ ~ ~ ~ :: 0 ~ 0 ~ v' '"i ~ -- .. u u u .. -r::- I~ .. -- _u \" ~ t'... ~ ;, < z " . . ~. l- n n .. ~ z w ~ " ~ ~ ~ u p, ~ 4 ~ Z :; ~ 4 4 ~ " ~ E ~ .- < " "t I~ &; ~ I- "- ..... 0 :,; j ''; ~ * i1 ! '" " '" g Iii !;; DI- D'" .. .w ~~ ...:~ .. :rS U~ .. .. ~ .. ~ Lllllut- o~ ~ ~,.; .. 3+: ~'f ~ ~ f ~ C ~D GJ lllO'" S L..c ri ..~ ~ "'.. . -a~ ..."O:;J....,.. III L fl... 4- OL:JO'> U'" Clri . . 0 III L"'C AI . ~ .., Q, : ~.e.... g- o ~'" '" ~ 0 i'Z fr-{i ri t.. u > U'" tl...... "0:0 ~._...... ,.... " 11'1 " 0.-.0 Ii.~ II.... /I >to otN ~... er. ..... -a. u "~.. ro4 .5.tJ.5 '" tt ~ :to ....,.... 0'" a 0 C II U 0 ,w:......... 0 's ~:;~ ~ ... L III '" 0-.0 ... GJ 1.1... N "u.... 1..- . ~L5" :;! . . ~~,~ ~ .~ ,..... r. L C ... Cl l:I 0 . 0.... l,.... c.... "',. IIIQC1 L'" '" >0 lU ex III ,.. III P o......r:. IU 0 ..........'U III >0" C l/I'" c:.c... &I'" " 'II(,"ouu- ~ ~ . " z " . I- I- '" .. '" 00000 . . ~~ ~'" .0' N ~-: lQ ~i l'<)G-j! , , , G.~l c ~' . , ~ ! ~ i c , o , u : ~ I ; : L' , .. , -- '" .. , ..~~ :g ,; ~ ">J '" '" .. " ~ ~ E ,~ ~J ~ ' "- E " ~."" 1! ;' ~ ~ /1; ~ .., . . ;:- ~ Cl ~ -a ~ c ~ ~ ] ~ :z: '.,. ~"O o ,~ -a. Ln. g ~. "t=. :;: +'~ 5~ ~ "0. .'" ~. ,re: .". .S lit 1Il:E l: ~... '.'1 ."", ' I I' ,I " . " ,,' ,', ," . ',I, ' I ' , , ,,' , ,~...........~_.....--,.-.~'"'~c_'~' ~"' -~, :.~' '"'-".~~..'-;""-""-'r< r---.' . ~'<,~ - I,~ '._,._ ....~-.__,_ ~,_~~... "., .'.. \, .' " _,'. .v."" '. , "'__ ~ ~ "_~' .',_.' ., ~_~~' '" ",. ,_. \ . , I,,, ~ :<_' ~:''::'" Employee Performance Evaluation Inscfuctions I. When Required: Annual Review. to be conducted during employee's anniversary month. New Employee - to be reviewed within 30-60 days but no later than 6 months after hiring. Termination - A review will be prepared upon all terminated employees. Other. when an employee performs in an exceprional manner, or when performance falls below standard. II. Who Will Prepare: Employee's supervisor. III. Rating: "E" 1. Excellent - Individual performs all tasks in an exceptional manner. Requires little or no supervision. "G" 2. Good - Individual performs many tasks well, and all orher tasks adequately. Requires litde Of no supervision. "S" 3. Satisfactory - Individual performs all rasks satisfactorily. Requires normal supervision. "F" 4. "U" 5. IV. Overall Rating: V. General Comments: VI. Review: Fair _ Individual performs most tasks satisfactorily, but not all. Requires more than normal supervision. Unsarisfactory . Individual fails to perform many tasks, requires close and constant supervision. A summation, not necessarily [he same as [he individual's characteristics. This is critical, you must, in your own words, sum up the individual's strengths, weaknesses, and steps to be taken to improve upon those weak areas as well as potential for increased responsibility and job promotion. By a petson at least one level above the supervisor of the employee. (SEH RHVEIlSE SII>E) . . '_....M..'''...._ .. .. - - .~- ,,- t ...-::-......,..--""" II. ._~--.. _.......'!IJIIll... "". ...TOU - 1II~.m :,.""".."1-.,,;,,,< .V," ~ EM~YEE'S PERMANENT RE<8RD FOR DRS USE ONLY. ',',';;i AGENCY NUM81R EllREMENT SYSTEM CHECK ONE: .;,. . .: PLAN-CHECK ONE: DAY YEAR PUBLIC EMPLOYEES 0 STATE PATROL o TEACHERS 0 JUDICIAL o LAW ENFORCEMENT OFFICERS FIRE FIGHTERS o PLAN ONE 1iJ~--PLAN TWO ms MEMBER NUMailt lliD m .....,.,. ".',~} Zr NEU 0' j:;'. '" '" z 0 .........'...-, ii:: .0 ~. t=: /Z. :f;l 0 ..... 4.5 'Ul : a. U> MONTH O'AY YEAR ~.:.,.",,:" ,-,~,".~._- .. . . .. . %:'. "';~" .~ .. .~ ),;";~.:e" ~.;'~;',.; z. . ", Z! .:.1 0."0 1= ..-" u -D,.. .w .:e :0 ::.~ c!HMLES H E1\J R. '-I - S CIAL. SECU MBI! A COpy OF THE SOCIAL ~ECURITY CARD SHOUlO BE ATTACHED. 664- 64-4475 ...:~{ _,~"'PLO't!"..~.:.~;,""":IY," "'J::';',,,,,;,;' -r..,l'......~.':.~....'l.;.,.~...-.:t-.,..........~c..W'<>"...;,'\".~::,:..t-:I. ."DATE 0' EMPl.OYMENT IN CURRl!Hl' POSITIO""~":'.""'-, 10 81 JEF'rER'S01\I Cout-.)r( {;I\lc, I f-JE€R DAY YEAR kAONTH .EJiIGlt.O't'llR'S ADDAIS$..,-" ,~,,"":~~"'~'-:""l-,I""I...''',:.!' ::;~...~..:.....-~:...._~,...;,.~ '." ......at;.~....'...."';. ~. POSITION. TrT1.1! -..:.-,: CDDRT/-lCIJSG.; JEFF€:.RSOl\J CoUClry' ~AFrsMAI\I STATEMENT OF REEMPLOYMENT: I was previously a memb... of the Ue.~/i:. EIllPL.oYc~.s Retirement System tn this statEt until I separated ample ment on ~)tJW 3L lq8D CONTRIBUTIONS REFUNDED :yes 0 NO Month year MILITARY SERVICE. (\/ A- ~:~e~t~~~~r :,:.o~~~~~I~~g ~~~~:~~e~~laW:~~\~~o~ ~~:~: ~~~': DATES FROM TO FOR THE PURPOSE OF DISBURSING ANY ACCUMULATED CONTRIBUTIONS STANDING TO MY CREDIT IN THE EVENT OF MY DEATH PRIORTO RETIREMENT, I HEREBY DESIGNATE THE FOLLOWING BENEFICIARY: ~'_'-'~h -REUj:rp",-".,,,,,,{:o. . ~'. ,....~"k~.';;:~q1~..'.- ~'I':ro ;:. P>;ClTY ....;."7-..,...i:..~t7I.~'J., j ;r'J'Io:'STATE'("...~-''! ....;,'.......;.;.,..~.;,.ZJ,..COD!.',.....,...::..:'~,,(':r- . PORr TCW/IJSi:7J WIl. ~ ~ ~nELAnO~SHIP~~:;: '.: "f:SE!X~' :';.1 '. ~..:~..~>{>. "DATB'OP BIRll4'~r.";..;.z..~ . 061-l1E1L r:- ()cr :a, (9&{., . .:'Z"'''h~ :';;'..;JJ.ObOl'~ ':-, cnY':..-' 4 ',- ~r.-...::.t...'~... " -....\ STATE~'...';'k '.\"""'rl'.,.~":':;JW'l-ZJP' COD!lI:y~1 ~';' .~ Po~r r ()W,.$eI WI!- C(8';>G8" NOTE: t.aws 01 most Stata Rellrement Systems require that the baneflclary be related by blood or by law or have an Insumble Interest In the lIIe of the member. Do not designate a beneficiary who does not meet the a!lOve re- quirements belore consulilng your personnel olllcer or retirement system. A member may change the beneficiary or. beneficiaries by requesllng nnd complellng the proper lorm Issued by the Department of Retirement Systeme. , ~>~ ,"5'1 ":1 . ":~1 I hereby certify that all 01 the Inlormation I have ~n~d on this lorm Is true and complete. . _t1b~t:J ~~2&~ 610n'I"",oIEmpl07" ~ll- T'ILI=.-e C,T ~;X;...' TWM.."&lI)-1......tll ~~~-L-_ .. r'"") ell)' Sl.t_ lip Code . <l~JnAJh..-_ (.;;z../ /~)/ /' / $10"-"'" ~ Tnl. 0' "enon,," Of' P.yroll. Uoc" 0.1. COMPLETE AND FORWARD THIS FORM TO DRS IMMEDIATELY UPON EMPLOYMENT oj I ," I ,~\ -' ,",," ~ -'.....~ \. T""'"l - - ... ~u"'..._ "'" ..- VIllI ", . ~ "'-;' <, ~ ~. .,~" ., - . "\ . ~ ~ - . ,~ ..: , ._~~', - .,..,. - ::-.... _, ~ '-.. "" I"' I ~,. _.;1 I .,. _ -~~-~. ....-." . . ~--, ":' - . ~ ~ ~- , .., ~., '''', . ; "'- '1"'" .~ Ia. ',\ .' .' '.,'. '.' '. ". .'.- . .: . ...... '.' ;',: ,,'. ..,.... . , '. . '. ...., ." . .....,. ;" . ." , ,- . . ..',' '. . , ",:;:.u '::.'~~}~~~~~ .'..... .: . '., "/~IT=::F LABeR & I~TRIES ~.'.'.'.'."_'" ,';":: 6 OLYMPIA, WASHINGTON 91150.. ~ :. '. I; i., - '. ,.-; ~..~---".."- "'n, ,.."..". f ~ .\;~~~ l,~;~: l~~~~>: :'i;:-;-;":>;,L<~<.' , ' '. ',:~; '.. ',', ,:. '. .'. .: . ",", :,: ,'.. '-". . ~i" ,,':': '. ,- ......, " ". '.. . ,'. "', '.'.; .; . ..... , . :.. " .'.',.,; '.", ':". = 1II!Iil:l'l"ln..'1:a.1I.]:tI~.J..:t4:.i1J''''H(.]~- Cl.,......f~.....' -~ -pon T~.dl" I :~',~~~,,~ ~ 5 I ::':~::':',':::"~~-j, :~~j uf-"1- '" 1 1-1 0-. :r~~ ; '. , ,;$~11,; ".',;' "'; , ,'. " . ..' .,'.' .... "',""" " ',,' >', .'..' ,,' ".,' ',.,' :.:.....,. . ';",,' .' "....,..,.,'.:;'. . . . ,;' ",:".' ,,::.';;... .:, .'." " .: " ci:. ',:, :';, ,i.;' ,:', ' ..:;': ...... :: ,'< '.'.' ';',",,' ." ";', ':: " ,.' ":"'" ,'.,' "::.: ' ':;::' : >.;, : , ' ',';'.: . ;';, < ,',." , ': ",'.,' , '" ",.".... ,,".; '. ,', -:ii":' ' '. ': ..,.: . ':.;. .' .. ;',.,':' :.- , .;:" '",' , . ';.' " ~' ,. :. ~-_.- - >. , - C1"MPI fl~5TClASS'lAH 00" U5POSTAGE PAID I 0' Ii. ",," PE~Mlr NO ., 96'> 312 -~ M 'N"_ _..__A".',.__._. · """'1 .-- ,'.', '. . ,~ .f: " .. "..-.' ",' . ; .,..... '........... ...--...., <<, I" '. ..,'.';,......'.. ....:: ." ,;.: :.... . '. ':,:,.. , :..>,.' , . '.':'." '" . .,' :<"'<'. ....,. .,:',. , ,....,'..., ',. ....., ,c' '. .:, '. :.-,' . . .,.... .,'. :. , ': ,.- ;' Ii' .':, ",' '; ",.; ::i. '. .,' , " .' . ',' . ;' :. ": : .' ,. ''-;''', ,; ; ''', .' J : :: r- .~ " ') <', I l. _, l; ,\ 1 r (.:... [; ! T ~! ,-:, ~ .- 'f, ) t; _ ,'- 1\, T 'J" ,\:.', (:, .. i .. . , .' ..,' . :. ". . 'i '=' 5 a f. ; "',.:'., .' ',." . :',. 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'.' . ..' ,.. ,. .'; ,:.,':':. :. . .' .'. :'," " ",'. . . ,-I . ,,::.'. '::,: t . .~~ ':: . " .....-,.:.,.. . :..' ",," ;"." ',"'. ."...' ':," ... ""', " . .' '..:,:"" " .; '. '. , ...':....:. "', .'.":":. "'; .<" ..: , . '.' ,'. .'......,. . .",.' '.. ; . .: ; . ',. , ,,: .' ..' .'. . '.' '. .:. .'. ""..:': .'~ :;1" . .'.' ; \ ,;.L": ,i" .,j, j ,r:-.;:r,l Itl~U~'HJ~ , " 1\I~l: I t.J() Ij'; r i{1[S .;~,lr" ',',I:~Jh!r~G\c:rJ . :",;,. :: :'..," ", ",,,.1,-, )'('11 " .' , .::.' ORDeR ALl;)W!lic. ;;'[>lU ~:;"l'.:.\~..jG q,\jM rCH Mi::tJ1CAL iRl::AT,'IIENl OI-..,lY (t. ," ~ " .' ;',' MH' "ROTEST OR R!:C;Ub1" THE DHARTME~n OF l;'~:I()(1 .';:,~J';~-' :..r3lE ORDER Will F(HLO\', ';l;';"l~"t' THE BOARD Of ll"ot;<,ll.?j,\\ THIS ORDf:f( 1') COMr\~ut,I,--.:.\l::) ,:,.,'].' " .r ORD::-:R MUST BE MADE IN WRITING ((, WI1HltJ ')0 DAYS A FURTHER APPE.t..L FRO,',1 THI'> ORDER Musr f)E MADE IU .,....ITHIN ()O !)AYS HOt... lHE OAT[ ,,\.'M 51-11\11, ,,(;'COt.\E ftHAt i i '" :i " . '. .' '.'. "-::-'~": ,', .. " ....,.. .'.' . '.' ." '. :... ..' , , ", '.',.,.'<.." '.. ..' .... .... '." . . .:.'." , . '. , .,,' '...., " .'":,, ....", .... : . '. ",' '..' ' ":, . " ". .. ,,:' . .'.' ,'.:' "". .,. . . "" ,.... . . ..' ..';'.,' .'...., ':. .,' ....,;.:...,. '. . . .:"..,'. . .<1 .':.' . .".:.. '.". ",.' . , ,,"i,',,', ,',: , ' ',': ',:., ..',' ", ':',' ,." .". ',::,: ,"',':': . "'.' . ,.'... '.,' :'.:' c..,' '. .. '. ';'.' ':..........., ,....'.,'.:,.,'. .... .'.' ".. .... . .'.' '.'" :. ,';".">.'. ;,':, ;]: , ' ;.",' '.' ;', . .... ..'. :":":. . ": :-'. ." ", ..., , ,.' . "'.,;, ,',:', .':'::, ,.." " '. ",' '., .' . '.' '. ";-.' .., ..' :' '.' "'.:, ,. '. ,'. ",~' . . ,"., ,. ;". '.: '. " ., . :...:.. , ',,': ., ,':" ." ",', ' .' . " .. "." ...... . '.. ..,....:. .: ',.. ::,.' , , .,',.; "','. ,'" " ' '. .':. ".':.", ,',".,; . .' ..-: :'. . ;...- .', ,',. .". '....., . ".." .',' ,,' . '. ' .. .....'",'.....i.: ':,::,'.': ,',,'" ,', ,', ",':'':.,',,''::',:> :.::.:-,;,:",.':: . '",:,], " '. ., . ,': ;'" , . , ' ;'''. '. . " " ,."., ',: ' . .r. :" , ,,: .", , . ",'" ," \f ~ :.( .,'. :.'. c....:. '-.. " ,?' :,' J ", " .:. .:. .' ,',' . ',' If, ;"; " ,::.'. ~\ :,".' . .;',):':::, ..,..', :.:: J. :: ' '. .';:,;:' .. ,; C." '. .'~ : ",', .' .',', :> .,( "::.'.' " ~;. :. . '.: ,:1,', '., ,.,',',;-" ']t!l I', ",' . ........",.'.'...". I, ',1',:'.::",',":.",::,' ., r.'" " " 'I 'J'" , :"'1' I :,::'j/f!f: for your files and promptly moillhe bclancl~ of the form 10 the employer (this includes the bottom portion of the Original ~':':\~j~~:~:".. ond 011 of the 2nd copy). : tMPLOYU<'5 COpy . . GREEN TREE COMMUNICATIONS 2326 SIMS WAY PORT TOWNSEND, WA. 96366 RE: RADIO FREQUENCY LISTING THE FOLLOWING LISTING GIVES THE FREQUENCIES AND RELATED AGENCIES FOR THE SYNTOR RADIOS INSTALLED IN THE WEST END VEHICLE AS OF 6/29/65. VHF RADIO, (CENTER MODULE) MODE lA GRAYS HARBOR REPEATER MODE 2 A CAR MODE 3 A FORKS DNR MODE 4 A UNKNOWN HO(l[ !.i A UNKNOWN MODE 6 A UNKNOWN MODE 7 A UNKNOWN MODE 6 A UNKNOWN (DO NOT USE) MODE B JEFF. CO. ENGINEERS NOR. MODE 2 B MODE 3 B JEFF. FIRE SOUTH RPTR. MODE 4 B LUDLOW · MODE 5 B JEFF. FIRE CAR MODE 6 B LEARN MODE 7 B SEARCH RESCUE 156.910 155.910 151.415 164.625 169.550 166.525 155.970 166.6375 154.115 SOU. 154.115 155.115 155.115 153.660 155.370 155. 160 MODE 6 B STATE PATROL (DO NOT USE)154.770 \' n f:'" ~ iF" E ~ ~II f::., ~~":u ~p ~~~-:~~ n - SE? j: C:',':. -, ~ ::I',i(";lN~S.~~S QFPtC " ':;,', "', , ,: ," , , I " ',' ,,,', , ":., ' I,"' , t"-.. ".-~"'~- ,'~-- ., JlI .. , .. -. - .. j, " .'\ . ~ - . .-,....,......"1.;, ~ f--- -.",.... !1titJlMl ----- ~ ij, Ii!llII r---'- ,<"-.... ,..", ,- -- ___,a ""' . ""'-'-r---~ '-l -'-,'.-,'--"-'-- - l.!!!It't, , " - ~~'-.~'_.. ._-<~~. ~ '" - , '/,\.~_......-""l'.." IIIP4 r-- : .~\.f~\.t!:~~\~;,,\ <' ,';" ~,',;""" .' ---. "__n'_ -~, - ." ., ... '" ~ '""1, - ,~,-_'~ ,_ ,,'-- ..'~ _ '. .. .... " - . ._. ...!... ,... ... II!!' '. r---"-"~"'-'---_. ~--- ;;;?lV, - ,-, '... "." - ".~ ;".,> " . EMPI@jYEE'S PERMANENT, REC8l0 . .,7:..:FORORS'U:SSONL~~ AGEI'tCYhUIll4ilIt. ~:C::y~~::::2J:~ o TEACHERS 0 JUDICIAL '. ' o LAW ENFORCEMENT OFFICERS FIRE AGHTERS ',-:- PUN-CHEClC:ONe;:-':::, , ""'NT>< o PLAN ONE B"PLAN TWO .... Tfl3 MIiMU" 1tUoIH.C" I ~t;Jfu Vld "-~ . 0 "_' I f?;:~\O ~'\\ _ rL\ ,I.U a ..:) I ~ -:",: MONTH OA.'!'. YEA>t '<H .-.... .' .:- ..-........~e;:;.~. -:C.AT2.OfIo~O~'t:D*~~,.,,,=~~..o-:_,... Co.' I 6 78 '-'ONnf CAY YEAR ---.~-- ':P;...i~.~~- 1:-u '0' SerVI C e fJa(} STATEMENT OF RE3.lPLOYMENT: 1_ preylouoJy a memb<< of the Aettreoment S~tam in ti'rb state until I sepan:ted empJoyment on CONmIBUTIONS REFUNDED, 0 YES 0 NO _'" Y_ MIUTARY SERVICt: ::e~:~~ t~O~=~9 =:e~l~=~c~ :~~e ~~=. TO FOR THE PURPOSE OF DISBURSING ANY ACCUMULATED CONTRIBUTIONS STANDING TO MY CREDIT IN THE EVENT OF MY DEATH PRIORTD RETIREMENT, I HEREBY OESIGNATE THE FOLLOWING BENEFICIARY: :~ST~ .- z:P'~ NOTE: Laws 01 most State Retirement Systems require that the beneficiary be related by blood or by law or have an Insurable Interest In the 1I1e 01 the memb'Jr. 00 not designate a beneficiary who does not meellhe above r.... qulrements before consulting your personnel officer or retirement system. A member may change the beneficiary or beneficl.rles by requesting and completing the proper lorm Issued by the Department 01 Retirement Systems. ~~-s~ I hereby certify that all 01 the Information I have entered on this lorm !s trtJvnd complete. ~~ '.f? " /:(,7 j 7. (/,___ s.~,..tru,. 01 F."'~loy... .,... ~.~.) ::: o o ;:: < 5.~ ~'~ u c: L:J L:.I '" U Wltn!!9sed by: /; /"'7 " ~""'.J~.~ _ ~ f' ~~~!~..... 5'~",,~. tftl1t r.r<'Ol ~.,'..~ P1)ortJlIOt'Pt(... /-C.-:?-"..- OJI" COMPLETE AND FORWARD THIS FORM TO DRS IMMEOI.\TELY UPON EMPLOYMENT -- PRE-EMPLOYMENT APPLICATION 5IULJ{~t maJ1. -CCLr:e+O.K.e;-- (Position Applied for) 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 occupational qualification. (State Law: Chapter 49.60 RCI, and lIAC 162) IMPORTANT: COIl'plete all section. Please use ink. Print name only. 1- Name: RAb"DALL !JiJARK ' (las t) (first) 2. Address: 538 Tyler Port Townsend (street) (city) 3. Social Security No: 550 02 5189 4. BREliT , (middle) wash 98368 (state) ( zip) Date of Birth:S 10 II 54(age will not be used to discriminate) 5. 7. Home/Message phone: 385 1132 6. Business phone: Education -Total ~ears of.pre-university Circle year completed: 1 2 3 4 5 6 schooling: ~ 7 8 9 10 11..(-J1:\.. Development (CEO) T~=~f in lieu of High School 8. Have your passed the General Educat~on Graduation? Yes~o Year 9. Colle Res attended Years From To Degree 10. REFERENCES: (please do not list relatives) 1. Irene Stancik 2. 3. 4. 5. ADDRESS 921 olay 385 1506 Lawrenoe 385 1227 OFFICE/HOME PHONE NAME Ted Yearian Form lOa, D.P.C.C., Rev Doc 1974 lW'_ -~--_. - - - .", ,...,., 1.l1li'1;7....'11 - ~ 1J1...~r- ,-',_ '~",;":,': i;C"'-:" ' 'r---.,:,," ',.,', " " , ~...........,,,,,,,.._....-,,,- .~-.., _.~ " n- ....., r';\~.,,!;/fl';:R\!,'\' . -- J . 0) '" !i :ri " '" "'" o " u ~ c U~ "f< " '" .... ......'" .... " 00 '" 0 " t-~ P. ~ '::T- ~ \~ \' \~,u \'" '-' 'd .;; "-- 0 c:. ~~~~, z:.~'':-ll.:t. 8ft ;; ~ ~ ~ % , '" ~ . '" z f< .. 0 Ul ~ ~ i % u C ~: z .. - z - .. w. $ f< oJ . 0 '" w. H .. ~ ci "' U u c ~o: [;! ~ ~ .. ~ 0 . ~ ~ ~ ~ 0 ~ ,.. ~ .. ~ ~ 0 ~.l'i""~'''''''''i''t~ p-----';~'-- -,- _~_~<.~Io.o.~"_ . i'~' ~ 'j~. ....., Il_ ,. """'~h'I:.1 i ._,-_...., '.' .-i >--, <t ., .0 zo en '" 0 .. ... " . ,; . u . ,,- z 0 l- e> z :I: V> "" 7- 3: 0 " .. f- 0 ~ UJ " "" Vl I- ot ~ ~ "" ;: l- V> g UJ ~ ;: 0 f- f- er 0 c. .-i <t .a CO '" rl .. .a CO '" W~ " -, " ~ >" " " - "'- . ..,..._".. ,_..._,~,...~ 'JJ>.. 8 z o l- e> z :I: Vl <C 3:: ~ ~ ~ W :r I- ';) ;:: ~ Vl C >= ffi I- Ul ~ ~ o re .~ Vl a: W Ll. Ll. W ., 0\ _, M ~.~ cO \0 M ..; .; on .0 00 "' 0' ~~ " U , o "' o !: u , o u o o ~ z 0 < " .0 ~ ~ ~ to ~ a: -< <" i= "':> o '0 ~ 5 >- UJ '" z '0 f- 0" 0>' z ~ z E~ -w ~cr >- ." "" 0\ ~ .... cO \0 .... " 0\ , .... ~ cO w \0 .... u ~ >< ,:~ " '- " . , ----,...., '.. ....., .. -... .. $) ., r- w< <i H (Q C$ v " .; .. . . <' v' .... Z . 0 u f-- 0 " 0 Z :I: Vl <C z '" 0 II. ... ~ 0 ~ W or ::.'.: f-- Ul ~ ," <C ~< f-- Vl ,; ,: Z OJ f-- Ul z Z ~ :J g 0 ., ... a: :r VI cr W u.. u.. $) w r- -. 0 <t' 0 " ro C$ $) r- <i <Xl C$ ",3 , < .: ~ . < , " .4 -- .. .. , ---.............--..,..."..~.,..,.... ....__.,...'T.......~--:;-. '~ - -....... _ilD ,~-~.,..,,,.~,~ -.. ~-.~- ..........;:......... ~'''7-. :.~~ ~ '''1'811 ,.-...- ~ 1"" -~,...._--~ - '-"",""''-''~'~'" , ~, - lIii -~ ... /. ~ ..-.,' '--/----"---, r---- _~N._~~_,__ ,,~ -~- - "'--.-,.~_"""',b. .... FOR EM. P/"OYER USE WASHINGTON PUBLIC EMPLOYEES' RETIREMENT SYSTEM r:4JPLOYEE'S PERMANENT RECORD FOR RET. BO. USE: TO BE COMPLETED BY ALL EMPLOYEES 'I IN ELIGIBLE POSITIONS ,:) PIOQ!O Typo or Print Wflh Pon . AS A CONDITION OF MY EMPLOYMENT UNDER THE REOUIREMENTS OF THE WASHINGTON PUBLIC EMPLOYEES' RETIREMENT SYSTEM, I SUBMIT THE FOlLOWING: 50e I" L 5 I!CUlllTY Ii 0 ~ L"ST ".....Ii: rlRST N......C ...lOcLe:lI.....[: ""IOCN U""I! , -:S;:>, ';-.A C \ \ ="0=- I 53'2... :36 i <:fi\B I D"TI[ or lUIlTH 1;:~~;~~~cN~\W~ Ii': I "^:,^"M' 0- 10- 39 o SINGLE o WIDOWED o DIVOACED F' MARRIEO ~IlI!:II:NT 1"'~L"TeR LOCATION tlATEST"'''T''D IIO,.ITION TITL.!:: ~"'-_....~;"U eo"",,,,,! '2....c..'l'\~ ~Oe:., \O"",,,""L"E."'-S> \\-"2.'Z.-~ c...T\l>.''''''''''~ I.... ALIO nlPl.OYI!O BY 'POLITICAL SUIlOIV'SIONI LOtAnClN O.o,TE:: 5T"RTED POSITION TITLI'.: ie',,; '''''' ....1011:..111:11 0'" THE "OLLOWING "'I!:TIIU:.UNT PLAN (II< "LIONS STATl:MENT OF REEMPLOYMENT; I WAS PREVIOUSLY A MEMBER OF THE WASH. INGTON PUBLIC EMPLOYEES' RETIREMENT SYSTEM UNTIL I SEPARATED EMPLOYMENT WITH THE FOLLOWING EMPLOYERl - - - - - - - - - - - -- - I'I<EYIOUS EMf'LOYE:R ,Uil'''''''T'ONO''TE: r'N""""N' '~""'" DYES D NO FOR THE PURPOSE OF DISBURSING ANY ACCUMULATED CONTRIBUTIONS SU.NDING TO MY CREDIT IN THE EMPLOYEES' SAVINGS FUND IN THE EVENT OF MY DEATH PRIOR TO RETIREMENT, I HEREBY DESIGNATE THE FOLLOWING BENEFICIARY, I'fRIT N""I!: .. I OOL 0: f~"" II: ~"'IIT N"""" ~~'::~:',':::~L~~~~~ , I'I~L"TlONIII'lII' O"'Tr Cll' IlUlTll 12:tii t<\ "( ~\I..E:- ~ol>..~\4'E:: ",?", "'S W\'\'-'C S-7...CJ-....O [;~fl!'i,l 0', IF THE P<>SON, so DtSIGNATEO, "EDECEASES ME, I HEREBY NOMINATE THE FOLLOWING BENEFICIARY, OR BENEFICIARIES, TO .iHARE AND SHARE ALIKE, OR TO THE SURVIVOR: r'l'lrNU'1[ "'1l0L":"""'1[ ~""T """'1 ,,"ooltr.' ,INCLUDI 'f1I'CClOr.", .:I.~~~<l. '-""-'Eo.. ~ \M "-S .:.~ ~.... Q,,~1<'Q ";R."'..... o..:'''''~' ... "!>o'-l. '2..-~"'-Co\ ;-'." ";,il< ~: I ~lfUBY ~ESE"'VE THE RIGHT TO CHANGE THE BEN!flCIARY, OR BENEFICIMlIES, AT I.NY TIME BY filiNG WRITTEN NOTICE OF SUCH CHANce, DULY ACKNOWLEDGED, WITH THE RETIREMENT BOARD. i)., I HE~EBY CEll:llFY THAT All OF THE IN' O~MA nON WHICH I HAVE ENTEF~ED ON THIS RECORD FORM ARE TRUE AND COMPLETE. '''?7.0:'"'~ II/lo,....'''... ,,, WIf""" ..- '~'-" _.."~ l!, ...\HI...."..ClIiM",I'(QD..1 IUT, \ \ -"Z.:Z.-lc~ ~O'i. <,,\6, , \-\~'t>~L-~ \ W I-l ~'C..");~<'l r _ f.lo I, -. . ,...-- ~, ' ;rlJ" :' :u::: " . '\-'',':, r-- '. . . :.' '......... , '. ,,'. "::...,,,',..-. .," '., .-"'.- ,:",,",,':', ',;:, ': , .,,:., I:: ---"-"..., ..,.' "" .dJ ..- ,;;1;," ,'".'; . ','i:', .. I . ' ", ',.: " ',:: ":, ":.' , ' ,"'," , : -: " ,:,.:, ':'., ' .:: ':, " :: .' I.':". " "', ,'., "" ' , " " ' .. ',.',:", ,';, " " ",:'. ';.:;: .-',.., ,:,' " c'. ,,'''' ,', ; : " ; ,~' '... " ..: ,',.', ,". ,:,,' , , . ' :, :, ',I: '... '.,: " '. .., , . . .."._..____._~..__.~._ ~"_:-_.....~~M'. "lit -"----. --~ ~ .." ,..'.. ------, \ .. II' I , WASHINGTON IlrAD DEPARTMENT OF HEALTH STAn: aOfl20 CERTIFICATE OF LIVE BlR'm REGlsn:;:~.: :~:"'," --.;;'-;.;'-;;'''--'' II. V8UAL aEsmt:NCI or MOTIIEa Cl'rl'JeT' c!o., ,"OC .r II"" a. BTATE Wash. ':tcf'ffflo 1:. CITY, TOWN OR LOCATION Qullcene d. 8TREICT ADDRESS REO. DlST. NO. ... ..A: I 1. PLAOE or bJaTR .. COUNTY Cl....l1am b. CITY, TOWN, OR LOCATION pn~+ """a' aa eo NAME or lIfftOt.,.~..,...",",IIMN"J ~~~~O~R Olymnlo Memoris1' c1 IS PLAd: OJ' smm INsmJ: CITY IJMITSt .. 18 RESmmcz JN81D1: CITY I r. IS RP.8mEl CB ON ^ FARM! Yea ,.... If. n LI1ofIT81 Y.. [jI: If. n I Yea n If. r1[ .. HAMa.... Il1Ul4r Lout ~:::'''' Ben 1amln Robert Prl tcharo e 4. SEX 8.. THIS BIRTH TIb. i;WU-~ I. DATB HoN" Dq Uft' a BIlfOL2ln TWIN M 'I'lUPIJn'M lot n IIId M .;;r:;1 BY~TH 7-23 61 T. NAMt rtno - IMf I, ,COLOR OR RAfB ~ R1chard Orv11ls' Pr1tchard White 1 '< t. AGE (Alttmnl w.~, 10. BmTHPLACE fl.... or forftrA eo-err, 111.. US11AL OCCUPATION lib. IUHD or 1I00nNUa oa DrDUJTaT ~ d~ nwa MlsBOula Montanal Malntalnance w~state nep~.ot_~1~& 12. MAIDEN -NAME '*" JnUIe lMI U1. COLOR OR RACK g , F.-ancss' JlUle . Ri~lt'IIav' White' S .4. AO_"'."llM"'''lttrtr''I' 11. BmTHPLACJlflftUeor,,,,...,....,, 18. IHI'O&MAH'I' I 1I! 7,7 nwa '3snu1m . h Mother 1 h""bu c<rtI/rt'11ltJt ITa. .""~~'" (L. c:::::\1 NI I'/b, ATTl:NDANT AT smTH i lhlt chllCl """ bonI '-\1. .J ~ II. D. 1;1 D. o. n 0tIl0r """"1 oU"" 011111. daI..tol.d ITa. ADDIIEIlI '" 1Td. 1;)ATE BIOIll:D obov.. Port Annele II Wallh _ __ " Ill. DAn 1UlC'D.~ l.DCAIf 11. ~~'11 SIOJ1ATVR&" ......1 t\, 10. bAn: ON WHICH OIVZft' NAMB ADDJ:D ,,/,-.7/. .::-/.....' ,iOAt-':/(.o(.,.fie'''-;.!~_~J Q... ~ ~ .. ol.-, " .j ". ,1 II . .. . . . " . . ., . , . n , II - . . c... . I:: ":'..,'. ~ "'...,' ,,', ..', ':: "."', " ,; ;'~ ;, "';";,:, ',"", "',,', ...... '",' ; ':,: ',I, ";",, ,'" ': " ' ":i, ,",',: ',' '"P . :"...... :, 'I' > ,', , ',.' "" ',:,: " , . . ","..' ' " '. '.'." ',:',;,:.. -'"~I :"" ",' ',: ",', .,' r... '. , i ! i I i I I " i I .. I I ~. ';, ..;.".,':' .':,; '," " ::,"', , " ,":; ""'.' , ,I';::' ,,' :.'!"',,' ", ' ,.',':,:':': , - ~ "! - -' -"'--' '~---~-'''- . - - ;,~, ~. ^ ,"),' ^ : - '.', ~ out", L 2 OCJ-R 0 tll AS dF (,5/3,.1>36 WA5~IN~ CEPA~TME~T UF LAOU~ A~C~~DLSTKY PAGE 217 ME~L INFORMATION PAYMENT SY~~ RUN-CATE 05'25!8~ FIR M 5 TAT E ~ E ~ T C F A~ltROS FUR THE MUNTH OF MAY EMPLOYER ACCOUNT NUMBER 004360-00 .. b,;W )If/ / JEFFERSCN COUNTY AUDITOR I' 0 I:lOX 563 PORT TOWNSEND, WA 98368 C LA HI RISK DATE CF A.'ICUNT NU;'lBER CLAIMAt.T NAME CLASS PR OV lDER NMIE SERVICE PAID J497352 0 KRU L I CH 1501-CO K IT SAP OLYMPIC VOCATIONAL 04-'22.'Bb- 203 . 20 , J491352 0 KRUll CH 1501-CO K IT SA P OLYMPIC VUGA TI C~AL 04/15/86- 620.64 .",':,J5B7525 T KRULICH 1501- CO I'.ASCI GEOFFREY DC 11/19/854 37.76 :::;:J696620 C IH1-'BERLEY 15C1-CO CLnlPIC ME~ORIAL HOSP !TAL 03/25.'86 166.48 '~:'->J &96620 .. C ,11 M BERLEY 1501-CO BAKER SAMUEL R MO INC PS 03/20/86 18.88 f2,J696620' C'WI MOERLEY 15CI-00 BAKER SAMUEL R ;.'.0 INC PS 02/03/86 53.57 ~ J 696 &20' :,..C ~11 M BERL EY 1501-UO OKEEFE JOHN J MO 04/09,/86 96.50 J696620 C WHIBERLEY 1501-CO PENINSULA RADIOLOGY 1I\C 1'503/25/86 71.95 J696620 C WIMBERLEY 1501-CO SCHEYER WI LLIAM J ,.10 03/03/80 63.40 J70 1203 W M,\TIlESCN 150 I-CO RO~E JOHN C 1'10 12/27'85- 14.16- 'J706936 ,S THONAS 150 I-CO MASCI GEOFFREY UC 03/07/8& 56.64 J706938 S THOI-IAS 150 I-CO MA SC 1 GEOFFREY DC 04/11/86 94.40 J7069'3a S TIlONAS 150 I-CO MASCI GEOFFREY DC 03/03/86 264.52 / ..~ ,'. 17 '_ - =;= ,_Hiiii ., . ~-~.""''''''''''''''-'''''.': -.. "'""'7-' -~ r-----. - '. ... .. ,-., _.~, II . I " - '- ',~'-'~'" ~ \ . \ . ,"I,,~ ~'i' -- " ,. '.,- -.- ._~_.... .... .' ~~ 'r K ,___1-_ ~ fiJllii i ...._.L.___ol\. ,...._ rr---- " ' , ,",..<-- '~,." -' -.. ~, (, '~/ ~t ..~ .--. ......-< ~ ~"A ~ {.~ ~ ~! f , {.-- '~j WASHINGTON OEPART/~F.NT nF I Al~f1K ANII 1""11J~IKY /lEDICAL IN'FORMA TIDN PAYMENT SYSTEM F I F M S TAT E MEN T o F AWARDS FOR THE MONTH OF JANUARY EMPLOYER AccrUNT NUMBER 004360-00 JEFF~~SO~ COUNTY AUDITOR P 0 I3')X 563 PORT TOW~SEND, WA 98368 :;LAIIl RISK DATE OF AMOUN WiHIER CLAIMANT NAME CLASS PROVIDER NAME SERVICE PAle J470B60 D BATES 1501-00 PT TOWNSEND LABORATORY 08'28'84 41.0 J497352 D KR ULI CH 1501-00 HAHN FREDERICK L MD 10/24/84 49.C J497352 D KRUL ICH 1501- 00 AUBURN GEN HOSPITAL ASSN 10/24'84 360.C J491352 D KR UL ICH 1501- 00 VLY RADIOLOGIST INC PS 10 '24'84 104.<; J505500 D WORTHINGTON 1501-00 JEFFERSON GENERAL HOSPITALI0/22/84 43.~ 01 MIE M KRULICH POBOX 553 HADLOCK. WA 98339 STATE OF WASHINGTOH DEPARTMENT OF LABOR AND INDUSTRIES DIVISION OF IHDUSTRIAL INSURANCE OLYMPIA. WA. 98504 HAIIH FREDERICK l MO X35 12TH ST SE AUDURH WA 98002 JEFFERSON COUlITY AUDITOR POBOX 563 PORT TOWNSEND. WA 98368 CLAIM tlUMB ER J497352 TYPE HII CHECK DIGIT ADJ 6E MAILING DATE 06-20-85 UIIIT I INJURY DATE 06-12-84 SERVICE LOCA lION I BREMEr.TON EMPLOYER ACCT 110: 4,3(,0-00-'. CLASS: 15-1 ORDER AND NOTICE **********KM****~*********************************************************** * 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 INDUST~IAL A * INSURANCE APPEALS, OLYMPIA, WITHIN 60 DAYS FROM THE DATE THIS ORDER * * IS COMMUNICATED TO THE PARTIES, OR WE :3AME SHALL BECOME FINAL. * ~**************************************.****************~******************* TIllS CLAIM COMItIG 011 FOR FURTHER COHSIDERATIOHl IT IS ORDERED THAT TIlE CLDSItIG ORDER OF 4-22-85 BE SET ASIDE AIID HELD FOR NAUGHT. Tt/IS CLAIM IS TO REMAIH OPEN FOR AUTHORIZED TREATMEtIT MID ACTION AS It/DICATED. SUPERVISOR OF INDUSTRIAL It/SURANCE BY ARDELLE BAY ADJUDICATOR ~3'/I EMPLOYER COPY y '."~)':',;/~:~.,I,. .,... ..~-~ - -",,- , . , ,~,..,- r , ~ I ~ ~ _' . ,~ . ~___ rl l" ,~ r--"'-'-"~_.'''-- ~~ 1 I ~ '~,..i(' :"..;, , , , I ~::~~:'::~':'I r~~:: ~~~:Ii~:'d I brphy>lc:iaro, 10"'.' porlioll 01 I pag..ubmill.dbremplar.r. ~ ------------------- i EMPLOYER'S COPY \ _ . . _ ,J ._, .:.~. _ _:. _ :.. _' __ . _ r,'. , ,,' , . ,.-' -"-~'- .II[JIII illJ1"'_~_, , ., . ~r I~. ,. . _ , . ~ .J. " ".', ..e , , 11,l1li1 . " -.'~-"--.---- '~r~~~...__---;:~;7""'~... ~ r-'-"-- II. ; \ :, ~ Yo;!'.< " "!Ill ----....~...............;.....______ .,.,....~_ '~_~"-<';.-~;';""':;'J:......_. _ J&:1MIiIii 1 -. :.;~~;"~. ..' ~; 1:, :~I:?~" . . ~.. '" ..... . .... .... ." '.';, ,; . . ' . .." " I . . .. ; .' '.' ...... . .. .... , . .' '.' . 'J ,.,".' .. ;,.... ',' >:','..," ;..:.,....... .... ":,'. . ." ." " ,.; .'. ," """:. "". ;' '. ",' ,.." . .... ." . . ".:. " > ".. ',- .'. -:: - , '.' .. ,-- . . '".' ;' , . ,~~ .. . ,.', .. I",: '. " "".. '>'< .....,'.' '. ........ <. ,', "',; " , . '.. '..' , .' ,'. "",. ';"..'.....:" . . . ,.... " .' " ' ':..,';, , ':,,'; ; .' i :.: ..... ,....'. ,:,\,.' " '. ' ';,:.... ;'c;" , ,," , , " .,',' ,',..,,"", '.',". ,,', " ";,:. "'",',',,',.:'/,';,; .', '1 " i I 1 .;' ('. . " :: SUi'ERVI.SOi.' OF iNOUSTRIAl INSURANCE DEPARTMcNr OF tABOR AND INDUSTRIES STArE OF WASHINGTON 01 'rM~~A '>VA ,HINGlOr; 98~Ool '. ,',t. ',rro~< ll.f .... ", , " "~.',I' .:" r, lor /1.(. ('-"'d J'''11 " : "'"'<1''''''' ... / Ih" (In.! 'h;,1 ! ";"'r.,T Ib'l (I.:;"" ,"'(1 r'1,. (l'lI'TI I', .; , " ," " , < .', ' ': ~ " . ORDER AllOWING AND CLOSING CLAIM FOR MEDICAL TREATMENT ONLY " ,,' "I '" 11;1', .." M/Y PP.OH5r Of? RfOUEST FOiC{ RECONSIDERATION OF THIS ORDER MUST BE MADE IN WRITING TO HiE DEP/dH.....IENT OF LABOR f,NO Ir.JDlISTRIES IN OLYMPIA WITHIN 60 DAYS. ll. FURTHB: I\PPEAl. ADa: O,QO[f,> Will FOllOW SUCH A REQUEST ANY APPEAL FROM THIS ORDER MUST BE MADE TO THE BO,'RD ("~ !~iD~Srr.lf,t ItlSUltAI"rCE t,PPF.AlS OLYMPIA. WITHIN 60 DAYS FROM THE DATE THIS ORDfI{ IS COM?...1IJNlCA TED TO THE PARTIES OR THE SAME SHALL BECOME FINAL ~: ~' ~.... . , '.." ,. :c. :~\~,.' .... . ',' ',':' '. ," '''.'';. .: ' , ,. .,' ,,' . " . . "'. ':., """ " '. ,'",," ':"',.' .': ','.: ".,"., . .' ..' ..... .... '.' . ". ': '. ...... ',' '.. ,>".: '... "<': .... .' '.. .... . ,:,:...... : ........ : ," :,.",':, ,r ..i.. ... "..': .' ..:~'..' 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'.' : >:' : '," 'I; :t : .'; ".' ii" I 2;.:;' . .'" ,,"', " :'i:.;i!i'i.\ .:'''0,'' :,', r.-........--.-- .~,~~,' '=--^-~~'~')~''-- '" -. ,"' ';,'~' ~~. ...........: "'.-""-' J :a: '"' 1l~1' U,",,_ ,._,_."".._~_ ., .,.....,. ...,,, -" .,.R i'l"._~..._ ~-""''''''~-,}~;;"''''-'-- , -",,- ~:/ .. '! ;' ,.: :',', " ,,',>. ,.\".: ' /, " ':' :,. it;'.. " , i:\'/ "~;:;t;'::~. '.... .: ' , '.:' ":". " ...'.... ,i ......,...,... ... . . : ':: '. ", .....', ' ,';-;{ ~',.. " ::', "., ',: "," ':, "',' , . i . ;..". ", ' ><:~ 0..:<:..:.:,:,.,::.,':,:;, '/ '" .' ":",:', ",,,' .. ;,' :,' '. . ,.... '," "", ", '. '.:.'.. " '. " ":,' '" "', ::', ,',:' '",.', ',' :" ':.':'" '" '.,,:, "" ,.,..' " "..: -'U~,~"" - ". ~h~",,,,,~, ...... ,; . , .: ," .,',,: ;:, , ..' '.< .'" , ;':;,; ~ DEPARTMENT OF lABOR & INDUSTRIES ~ OLYMPIA. WASHINGTON 98504 ~ ~ -."""'...".,.11.'''"'.''..,''"..".,,.....-, "- I ",..",,-. DelOH"" ~,-J WORTh IN" TON,."",,,,,,,,,.,,,,,,, "I ;)~.; . ~"~~55C~. ,,;;,-:.~!,f.-y.~~~.~~!:~- "",.""",-- " 1'-1 1L-,2-c4 v~-11-~) ~ .' " " . ',:' " : ,'",'.. ,". ., ,," ,.','. ::,' ';, ' :' , '. . '\,,: .... , -::,':-' :M<.' '. . .. " ',,' ,',,' ,',"" ':, ,",' ,',', , . , . .' ,.:', ,,' ..:: "',: :,:" :::'" ' ',.'.. " " ,.,;. ,;,.'.:..'..... . ..,'.., :';';:<: ':, . . . ".' " , .. '," :..'';,' ", ":' ",:"'... ": , :'.':' '. "" '''''''"'." .', :.'. :.":,','" ',', ',' "" "-'. ,; , ' ,', ' ,', ,'" !i .' ',': " ,,' ~., .' , !,": " , : ,,' >.' ..,. , . ,'", ,'; , '...;:", J"i rc.~ol." '~-'t-;'~,; \~i,g .':, ':, :,:, iJ'1 T~'..\-,c" ','. :'" :.. ......',.:,....: '<. , ,,',',' .,' , ! ....,.'.,.::' .." " ",."'. <,"" '.' ,",':: '.,: ." ",' "':' ", " , ,;,'. ", ,;,',:, " .", ".:':.,': :..., :.:. ': ,.' " . . ,.....> :.. ': ,,' ,'...:.' ,'" " : ", ,". .. ' '.' .,':' , ':,: '.' ",.. ,',,'.",......:: ,.,., .' :.".,'. .',,/:i',., , . , ,: '. ',:, .', " " . ,', " :' ,'': . . 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PHMIT NO 'l-.., 911"<:> 31] ~ ...., " ,"I',' , .~ , ' ,..",' ,"1: -,..,..,.. , " , .~ :' ",~( 'i' ,; l',: : : I:;\,' T _ ;R":"":":,';< ~<", ,<",.! ;(.:":,:: '- '~ .,"", .::,:::'.~"':;: :,~.>.::~ ':".'" , ""w: ;:;<'.';,1<,,'. ',:;,': ';,' "J,': -"',," . ",~' ,/:: '.':/\<:. , '. ,: " . --.. -,,,.... ., ;<rr=."l.. ," , .' :':" 'I:: ,,'..' , 0" '~ I "'" .. " : <" I ",: " ',:', ::: .. ",' ,"" ::'.,......,... .,'.'.'. .,' , ',,",."'" .' " ," ,. "'> ", ''', , ' . "'.: ,::",: :.: ,',,' '::, , ," ,,:',":',', ':' '" " '..' .' ,: ", :-,;,.. ',.::?,:,~::,,:;. .' " : ., ,... ",::' :' ,", , ':':'/',:: '., ,.",:' ,. ',.,.,.,..,', ' '.." ,.', .,.., ,.,',' ,':. ~':', ':' .. , """ " F'.(":'......" '.' ~': ~~"..---- .. THIS ORDER MUST BE MADE IN WRIiI/',," .....i'~A 'N~THIN 61) DAv:; A FUIITHH ..": ...,...,...., ;;;.: 'C:':C ." .. l {';:;'~,;,"~~';f:,;~S O~"~:\\t'~:~,:;E ;~~.':, fHIS 0"'''" IS CO.',IMUmC,\TED JO ",: '.\C "" 0' 'HE 'MAE SJ'All BECOME "'Ml ."C, " "i :,>" , ,,'. ~_.... Ii ____~__l"",.....~ _ :".A.\.~ :--"": "..,"",' .., ..' " , , ':. ~.' ~ ...., ":'. .....' .':"......::,...., , , ' ,," .. ': - :'.: .: ';::,': '};J;~~: II '~, ".:: :"",,:.': " ," """ :';;. ' '. :", ",',' ',;' " ':..','. " '" :,'..". .,' " '. .... '.: , ,',: ," ,', ' , .,:. ,".:',' , ',' , ,'. '," ',' ,.,' , . , ., ". ,: ,,' " ':' ';',: ,:;, , .'.:, ',' '....;..'...,. . .' .''', .'. .....,. '" '. ,: '" ::,: .:.,'.. . ,:" . ;._:.:.,,''''''""~ ~;~', .'. .,..,. ,', .. ~L '.,' ',:.. " , .: "', , ' ,. '" , ~' :; ',.,', ,:, "',"J;) .;, - ::':'.'"?.',\.C:: , .: [ .'.. ~"...,'" .'. f' · .: :'. :. " [' t: '.> ~ " .', .... ',"', ': .', .' .' .-; " ';:: ,,, ,.. " [; ~,' i ; , , ' :'. ,':" ...',....'..,' ,.'..'...:,....,.. .,<:::' ,: ,. ,,' '. '.'. ":"::':" '" ,'; :', .,..' .' .'.. . ',,: : "", .'.,., '... ".' , " ',' ,.' .,,: " '.,' 'i :,' ,,'''' '::" .' ;:,,',,.,, ",', :', '., . '. '. .' .i::., ,; , .., ";.. : "....::,: :, ", " ':',:, , :: ;/':"';' ':".. . '... :. ,', " ..' .... ':'.' , . ':, ::..', '''':'''', J .. ',:,'".';,: " . :, " :":., '" ,"',: ,:::", :,'. i:, . '. .' . ',:" ,. ,..,', :;, ,";1 :' :",\ .;,: ',: "',:,,' ."( 1 'I ,.11 ", " , " ',", ,,' ~ WASHINGTON OEPl.R mF.NT OF I ABOR AND 'NOU~TRY ~1EOICAL INFORMATION PAYMENT SYSTEM F I F M S T ^ T E MEN T o F AWARDS FOR THE MONTH OF JANUARY EMPLOYER ACCOUNT NUMBER 004360-00 JEFFrRSON COUNTY AUDITOR P 0 138X 563 PORT TOWNSEND, WA 98368 CLAII! RISK DATE OF AMOUNT 'lUI~ BER CLAIMANT NAME CLASS PROVIDER NAME SERVICE PAID J470860 0 BATES 1501-00 PT TOWNSEND LABORATORY 08'28'84 J497352 0 KR ULI CH 1501-00 HAHN FREDERICK L MO 10/2'./84 J 1.97352 0 KRULlCH 1501-00 AUBURN GEN HOSPITAL ASSN 10/24'84 J497352 0 KR ULICH 1501-00 VLY RADIOLOGIST INC PS 10/24.' 84 J505500 0 WORTHINGTON 1501-00 JEFFERSON GENERAL HOSPITALI0/22/84 --........--.........-... -. -. " ,,, ifill Ba""T . - WORKER; Before completing section below shaded area, READ LEGAL WARNING on r."" PHYSICIAN' l.9mplele Physician's.RecOfI. Detach lOp pt,"lrtion of Origi,n,t .~,.h"'."'I-A' _. Lobar & Industries, Allenlion: A..:.nt Report, Claims Section, Olympia, WA 98504. Detach the Physician's Cop;.-._u Copy) for your files and promptly moil the balance of the form to the employer (this includes the boflom portion of the Original and all of the 2nd copy). DEPT. OF LABOR & INDUSTRIES CLAIMS SECTION ~L YMPIA, WASHINGTON 98.504 ,.,. ~. ~ I' ,~....--- r-"'. . , ,- '. . , ~ \ ",.~ - .~_.~~^..~_. -. {... ,- ~ I~J - f~., '. 't., ;"_"", _.__ __ _, ...Iot!I., - r1Mlfl' .....,.......... ,""- .......'1~~..".' ~ 'c~.",~.~l .'f'.~~~'~~'r:"', ,i ,:'/,;: .,;:: ;:,' :.-',::- ~ """')~"'::'::";i-('''i:' ":.:".,,,'" f---- . , . - . . .' ~. "~-7 .__.,-,-~.~. _!".. .~, _ ____ ':".' ;_~_.,. _"', ~ w . ~..--~.-._--- , "......" ~.,~, .- ..:_..--,:....,."'~:_-~:(. '~." -'.'- "'~-;-.-,... ,~ .."-'~ . ".',_.'..."., . . , . . .. PLEASE USE BLACK INK OR TYPE STATE OF WASHINGTON DEPARTMENT OF RETIREMENT SYSTEMS 1025 E. Union, Olympia, Washlnglon 9850...2511 (206) 753.5283 EMPLOYEE'S PERMANENT RECORD FOR DRS USE ONLY AGENC.... NUMBER RETIREMENT SYSTEM-CHECK ONE: PLAN-CHECK ONE: MONTH 0",'1' ~ PUBLIC EMPLOYEES 0 STATE PATROL o TEACHERS 0 JUDICIAL o LAW ENFORCEMENT OFFICERS FIRE FIGHTERS o PLAN ONE ~PLAN TWO TRS MEMBER NUMBER z 0 < ~ Z U 0 ii: 1= 1= u z w w f/) c z 0 1= < :Ii a: 0 u. 0; ... lD Z W z :Ii 0 ~ ~ ... a. .:W :Ii :,0 w De.. bo~(l...k.. ~ I ; oz,...... ~ +i-.- ~\~<'"J MONTH DAY YEAR A COPY OF THE SOCIAL SECURITY CARD SHOULD BE ATTACHED. $oct- 0~- foo'lO OM F ,,3.-~t-s.;l DAY MONTH /0 YEAR f"(p ~.....Io\iCL V:>o...ks; - -;:rc..~t.c"So"'- ~. a.7 :::re '("Sa", Owl\ t~ \'\.d ~a (., ~ STATEMENT OF REEMPLOYMENT: I was previously 8 member of the Retirement System in this state until I separated employment on . CONTRIBUTIONS REFUNDED 0 YES 0 NO "DNYH YEAR MILITARY SERVICE . ~:~lj~s~~o~~~eOff~r~~~~:I~g~,,~~~~~i:SwO:s~j~grOn~it~~~1i~ '~~~~~e ruture .s -ro. ~~ A-c.c"OI.lI\{...I\+ DATES FROM TO IMPORTANT:' .. q' ,'Ud f." ",", ~v,,"'E" BEFORE COMPLETING THIS SECTION. CAREFULLY READ THE INSTRUCTIONS ON THE BACK. FOR THE PURPOSE OF DISBURSING ANY ACCUMULATED CONTRIBUTIONS STANDING TO MY CREDIT IN THE EVENT OF MY DEATH PRIOR TO RETIREMENT. f HEREBY DESIGNATE THE FOLLOWING BENEFICIARY: ,UU OIWN NAIIE OF BENEFICiARY DESIGNATION .p~m~\"'- "i""o" .5iS\-t.-r ~-13- o 0 .. o !1i z u o ii: ~ ~ w w ,f/) lD o 0 iTUI NOTE: Laws 01 most Slate Retirement Systems require that the beneficiary be related by blood or by law or hove an Insurable inlerost in the lite 01 the member. Do not designate a beneficiary who does nol meet tho above requlroments beforo consulting your personnel officer or retirement system, A member may change the boneflclary or boneficlarles by requesting Bnd com latina the pro or form Issuod by tho Department of RoUromant Syatems. z o '" ~ z U '" ii: 1= 1= o a: w w f/) U I hereby certlly thet ell of the Informallon Imed on this form Is true end complete. ~ C LU~ :::2o~ ~y-'?,d.. - ,~,~po f:.t ..::s ....: l~ "'- c.,~~. 61.'. 9 P3 b- l.p COde Witnessed by: ~~ /c::? -aa-P~ O"e RICHARD J VICTOR 115 ALBERT ST PORT TOWNSEND. WA 98368 . STAT~F WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES DIVISION OF INDUSTRIAL INSURANCE OLYMPIA, WA. 98504 BLOEMKER WILLIAM K MO PT TOWNSEND MEO CLINIC 1136 WATER PORT TOWNSEND WA 98368 EMP JEFFERSON COUNTY PORT TOWNSEND WASH 98368 CLAIM NUMBER H717ft05 TYPE TC CIIECK DIGIT ADJ 6F MAILING DATE 09-17-80 UNIT IIIJURY DATE 06-24-80 SERVICE LOCATION' BREMERTON EMPLOYER ACCT NO: 4.360-BO-4 CLASS: 15-1 ORDER AND NDTICE **************************************************************************** * ANY PROTEST OR REQUEST FOR RECONSIDERATION OF THIS ORDER MUST BE MADE * * IN WRITING TO THE DEPARTMENT OF LABOR AND INDUSTRIES IN OLYMPIA WITHIN * * 10 DAYS. A FURTHER APPEALABLE ORDER WILL FOLLOW SUCH A REQUEST. ANY * * APPEAL FROM THIS OROER MUST BE MAVE TO THE BDARO OF INDUSTRIAL * INSURANCE APPEALS. OLYMPIA. WITHIN 60 DAYS FROM THE DATE THIS ORDER * * IS COMMUNICATED TO THE PARTIES, OR THE SAME SHALL BECOME FINAL. * **************************************************************************** COMPENSATION III THIS CLAIM IS TERMIIIATED AS PAID TO 7-06-80 INCLUSIVE AND THE CLAIM IS CLOSEO WITHOUT FURTHER AWARD FOR TIME LOSS OR FOR PERMANENT PARTIAL DISABILITY. THE DEPARTMENT CANNOT ACCEPT RESPONSIBILITY FOR PAYMENT OF MEDICAL SERVICES DR TREATMENT RENDERED SUBSEQUENT TO THE RECEIPT OF THIS ORDER. THIS CLAIM IS HEREBY CLOSED. SUPERVISOR OF INDUSTRIAL INSURANCE BY GENE FOMIN ADJUDICATOR EMPLOYER COpy WORKER: Before completing section below shaded orea, READ LEGAL WARNING on reversC' side of this page. ! Sub""to,ig,nol to l & I O~ : {ollo....~.lopportlon of PHYSICIAN: Complete Physician's Repor!. D~ top portion of Original where designated o~bmillo Department : peg" ~l.Ibm.ttt.'d by of Labor & Industries, Allenlion: Accident ~rt, Claims Section, Olympia, WA 98504. DelcW"';1lhe Physician's Copy ]physidclIl,lowlIrportionof (3rd Copy) for your files and promptly moil the balance of the form 10 the employer (Ihis includes the bottom portion of I page submitted by the Original and 011 of the 2nd copy). ~e~.?~~y~:"-______~______ IEMPLOYER'S COpy R - - ';"/ .,'.' rr-'~'- 11d;!of f;iuAi ~ , 2/,r//1) . . PRE-EMPLOYMENT APPLICATION -;171<7'A:lI-t;"ut,'?'-<./ <hl1!:f:_kt<~<--~ (Position Applied for) 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 occupational qualification. (State Law: Chapter 49.60 RCW and WAC 162) IMPORTANT: Complete all section. Please use ink. Prin t name only. 1- Name: Y; ?-TcJ Y ~j8;- c/ AJ7?ld. (las t) (first) , (middle) 2. Address: //5 &~ 9tf3Gf (street) (state) (zip) 3. Social Security No: ,6.33 -/{, _/(/0 s- 4. Date of Birth: 5./P-Z/ (age will not be used to discriminate) 5" 7. Home/Message phone: ...d J',_ 50:? 2,7 6. Business phone: Education - Total years of pre-university schooling: Circle year completed: 4 6 7 8 9 10 11 @ Hal(c your passed the General Education Development (GED) Test in lieu of lIigh School Gradu.:t~ion? Yes_No_Year " /' Coi~ttendcd Years From 36 1'0.5;7 Degree &~.~yt,..t:?~ ({e.r!?~ ~~,,:<,L,.<::U-k~ A-,7Lf...,-~&'- ~..4~../r____r'A .<J Au o>f ..!:,nL.i "u~u<_ - "f "'/.j-,~..,o(' .4~ 8. 9. 10. REFERENCES: (plcnse do not list relatives) NAME 1. 1..,. /7-,,,,..-,..- .1:.." 2. a, t&;:~_eu...~ ,- J.~, 1;)~,.tae'/ 4.~,.. /~..c~~~,.~( 5. 6,,::f/q 'lJ"U c.a.~ct, ADDRESS OFFICE(1I0Mll PIIONE . 1J.,';i :}I.,,;.;;:;;; .?l 1',( . 0000.. ;{ >",-: Of"'f'O /.Sl~"i ~t~- -3 J'I- 2.. a. <. G- ,eM.ie~ ("'~h,,"'NU. .:i.Pr- arid-' ,-,,,,......,,t; 3J',-~ /r4 / c.~,t: ,? S.l - O'fl: I .,_...............--~, lJlI1Il III~ ~ 1" '. ~"~--,~ -q..~,..~ ~, ..~... -- .~ - .. ~. I' ' --- '-'_."'~~ - .. .., ,'" ~- - .... 11' . ~ ,," """. -., --- l!II!N' ~ - ifilL w rilll_. , 'U,__., . :..,- - ,..' :...,.~.,."':"-..., ~ ;1- .,.'"..,." < ,":" ,'" ," " " , , ,':, ;, :....',' ,,'. ::', , :':: '. ' ..." ..,. ': 0: ...'.........,.,. ., '.... . ,.... . ..... ....:, ...,..:,., ,,', '...., , I.,: ,.':, ' ,,', ':',': ",', ,',"," .:', .. , '," .., "',' .. "..,.,.' , , " ,'" '.""..... ,: , ....': .",..,:, '...,.., ,:,'....,' ,'..,', ',"':'.',;: ,', '..""':"", " < ':, ::"'" '>~ .. ., > .. .... < :,':":.'., ...'. ", ..'....,..'.... ''':'u ." ,', :.. ...., ,..,. ,f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i, :, ,','" :. :;11 ,.11 ,"':' < ': ...: :... .:..', EM5~J""1 ^'~lV ~1tJ, STATE OF WASHINUN. EMPLOYMENT SECURITY DEPARTMENT WJTICE TO EMPLOYER - CLAIMANT'S NAME / ORA'~,? ~~':i~~~N~KED UNDER ~~<Z.- MY LAST DAY OF EMPLOYMENT WAS 9'-3,-" ILAST WORKEDASA eOU/~.-#'P.t..-7 (l,P"~~""'A> t BECAME UNEMPLOYED BECAUSE L ~ ",J 7'-e A/f'/N'P IflRSl1 CLAIMANT. DO NOT WRITE IN THIS BOX mr:=><J,.........,v IMID!)lEINIIIALI SSANOJ''Il/ - '/6 - /'J'6(_ DATE OF REPORT 9- /5 .19~ JSC NO I '3/ 8 YE ..a. cO -.1 c..... EMPLOYEE ,19....a.J....LNUMBER MY USUAL LINE OF WORK IS Gt"J.OJ://hP~'T (!}}?.pA"AI; 1""r1/"_ BUSINESS NAME AND ADDRESS OF MY LAST EMPLOYER '1-~_ ~ INSTRUCTIONS TO EMPLOYER THE ABOVE NAMED INDIVIDUAL HAS FilED A CLAIM FOR UNEMPLOYMENT BENEFITS NAMING YOU AS HIS lAST EMPLOYER, PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM AND RETURN IT AS SOON AS POSSIBLE OR NO LATER THAN TEN 1101 DAYS FROM all.5;/1\ The U,S, Supreme Cou,' has held thai once 0 de",'on i, mode allowHlg benefIt" the claIm ani i, entilled 10 Ihe prompt paymenl of benefil, even though Ihe employer appeal, the deci"on, To Insure PlOp., determinalion of eligibilily, please fumish Ihis Depm/ment with 0 detailed factual statement of fhe ,epormian, In the absence 01 a reply Irom you, Ihe claim will be delermined on Ihe ba,is of ovadable infa'mo"an, If Ihe cau,e of unemployment" alhe, Ihan "lack of Work" or if you have infalmalian 10 question the cloimam's elIgIbility lor benelll', and you w"h to be plesenf when the applicant" intelvlewed cegarding fhe 'epara, tiao a, ellgibdily, check apprap,iale block an reVelS. "de, and you w,11 be Inla,med of fhe tIme and place 01 Inteevlew, Hawevel, you a'e nol ,equired to attend such 0 proceedIng and may 'ubmlt wntten Informonon wh,ch will be gIVen full can "deration In mak,ng the determinatIon of el'glb,'lty, You, caope'atlan may help to prevent Implaper paymen" of benel'fs to be charged 10 your aCcounf. .LLL '\~ "50/'/) tUr.} 31 r - Q'"'...fli:.., o ,'!:' , r/, ...L..~ j l --'L ClAIMANTSSIGNATURE 2W.., .z.. ~ 1.') EMPLOYER COpy. RETAIN AS YOUR RECORD ~""."::" "I' (SEE REVERSE SIDEI " :: i.-, >~?:"':' . ,,' '...' '," ",:"'.. I,' ' ,', ..'" ... " ~. \ " .... >; ,,': ':,', <',: ,'. ,..',. ' >, ,,' "',,':,i, "~,';:' ,:<,' :';' ,..," :' ,",', , .: ,." .' .." , ',' :,' . '" . ~o:<,'. ,,'; '; " ' , :;,."" /",',', :':.' , ' ' "':':':":::.':',.:":, ':' ',," .i"..,:","'.",.: :' .,.'" ':" :" ,:.. :,': '.., ,i,' .' ""'" " Ii'.:" "..i ",""',, ''''", "":" " '. ' , " ',I: ",',,',,:,:: "'.',: ':\,'..' " :' ,'::" ',......":,'::' : ", ' ", ,':", " ":>""', ... .~'.'" r---'--- ~_........'~~"., -' ~~" " "', .~~" - .. flCI'~~ - .- ~_. '" .1iiiiII . , ._....._~- ~! ~ ., ".-,. - ", " ,. ,~,- ", .- -,_._..~,.._._.~,._. '- ~ .- . , . ". " , ...-~... --~. ~_.. , " ., _':: ~ '. . M~~'...,_I.. " iij:\ 'r--;"':'i.!';!ii'~.".....,.,. " . .-.-.. " ------, :,::.: ~.':j::: :;~. :;.::.; r J I,"': J,i'" 'f.."""'" ;,~ " , .... " :.. 'i, ',f..,' ',', ',.' '" ...., . :','.' , " ,,',',' , , ::: ,.,,' ,( ',", " ::.....',',, "" '. ';,,,,' " , ,:,', : " " ,"'" ' ''',,': "..' .''' , ',:, ,,' <, " "",:,i '. .. ,.':,' :' '.' .. ,'" , ";"",,, , , ':/ ' " ',': ',' , i " '.'.. " ,....":';;: 'i"", ", ': ,;', , '. ", -' ' : '., ,',' ,.--"-- , ,...., ""- . '."""_''':~.'":'''''-'''''''''"''';':t'''''7~.~:: ,. ~ ., ,;. ." .,"....'..'. " ,; " ',," , .. , ,;: "",," ":, .." ';', , ' , ','..., ,.' ',". ... ":,,.,', > ,'..'.<:. .',"', ',...., ".... ...'.., ....':. ':,:' , . , '"," , . ,,,'" , .. :,' " , ",', ,,", "" , , ,,:,,' , '::: ; ,'..,. :" , :, "P:~ >; ,.,., ' .. ,',. ,; " " .. '.:, . ,", ,.'., , ,.' ..,:", . ::, ',.. DISPENSE AS WRITTEN u_______ i,:,:/ , ", ", "" "", , . ,.," ',' , '.,.,. .,,' " :", ':> " ," ." '" ",.::.' "'<'.. "".,:,:":: ," , ,..., '.".:i" ':i .,:,' . ",' '""" ,,' " " '" ,',..' .",' , ,':, "'" ',' )' '.,..,",' ',"......,.',."" , , ",,: '" , ,." .",,1, --I,: " " ..' "', , "'," ,',' " , , ;: " ...,. "i ::. , ' ,.,' " "" ':':' ''', ":', ,""j ",'," '" "', .:: ,ti" '- , , , , ,.;-:;,":,....,. ..'\",'. " ,", ",;' " . .,','..,' :,' "'.'" " \,' ..'.".: " ' :", , , " " ".'. ,......' :'.' ,", , .' ,:>> '. ...,. '. .,'. ,',:! :"': .' ,', ,'.. :' ,'.. ,',,' "" ,", ':....", , ':,",;: ADDRESS ---__"'____~n_~_ " ..".;".'; :" ..'.,:.:,i '. "'" ,;, :... .<~, """,; ',," ",.. , ," . , ",: ,..", , , '.' ' , ',' "",",,:, " ......,:', (',:,:, '.., ':, ,,':'.., ',,' , .,..,:, . ", , , \' ",," : , .'.', '.':Ie, ':', . ," , J, PETER GEE"S, MD, J, RANDALL JACOBS, MD, FAMILY PHYSICIANS 631 WATER STREET PORT TOWNSEND. WASHINGTON 98368 OFFICE 385-3500 DEA REG. NO. AG 6069769 AFTER.HOURS 385.3501 AJ 6287761 NAME___,"_",_~__~ I' ~___ DATE /J 11 7 /';;0 R X 0~~, ~~ ~ ~~~ ~~\ \rv- l 0 h'-'\(' SUBSTIT :n 'J\...A M D PEA ITTED M,O, ---.-- i " " REFILL : , ':,' ",' ...., ',.., , ',' ' ...... , ~ -- ;' ',' , , '.. '.., "... " """ .' ,', .' ';'", "," ,~' ;1 .:',...' 1,' 1, ,'1 >:i "i ", " , ::. ':,1 ..., i ,', " , r, :;,', i, ,'.. . :...__ . ,.J.... .:.,~ _' . " '. ,.' . ' " .' . I DEPT. . .HRU 'MAY 25, 1980 HIRE ~ VACATION SICK LEAVE f.L1!. ' D. TURNER 1-6-75 2.72 21 1/2 0 R. SUCH 1-6-78 ' 13.96 22 1/2 '1 D. BATES 8-3-78 13.47 11 1 F. HOHE 2-1-75 3:15 8 0 * BRUCE TURNER HAS USED 9 DAYS OF MILITARY LEAVE ,HE HAS 6 DAYS LEFT. _ ~ f/t.,,'n <..___ I +/; / ~.. I ( " ( ~ .... . ~"'''---'---~-'''''''' , . b J h. . lOepl. ofl& I copy ORKER: Boforo completIng secllon e ow 5 oded orea, READ LEGAL WARNING on reverse side of this page. I Top POtlrOn ~ubrnlrlt:d PHYSICIAN: Complete Physician's ReporAJach lop portionaf Original where designoA"':mdsubmilloDeporl-: by phy$icion ment of labor & Induslries, Attention: A~enl Report, Claims Section, Olympia, Wo. 9bJS4. Detach Ihe Physi-l B 'b ." d I o1lam pOlhOIl 5U rrll ,Q cion's Copy (3rd copy) for your files and promptly maUlha balance of the form 10 the employer (this includes I by cmplol'ur the ballam portion ot the Original and all of Ihe 2nd copy.) I 1--------------- I eMPLOYER'S COPY EMPLOYER'S BUSINESS NAME ONl V "Je#f'1"""'" r;",,,>? y fMPl.OYEIl'S BUSINESS!S'Alf TVi>EOR tlAIUREOfl WAS THE ACCIDENT IN YOUI! 01'11'1101'1 "'fS ~S:e~No~~ri 't/y"o~YR ~~tg~EER? X b.d IfEMPLO"'UI WAS NOT NOTIFIED IHE SAME DATE AS TtiE ACCIDENT. OIVE REASON DESCRlaE ACCIOENI fULL"', STAliNG If "'OU FEll 011 WEllE STRUCK. rxm~~~rJ~1~~~~W~;s~=:~~~&~!t:~~~~i 010 lj Oe7f/~.l7' ..IfJ OBJECT SIRUCK; SH0010 BE NAMED. NAME CHEMICAlINVOlVEO, IF ""I'PROI'IlIAT( .. .V')<-,-:1 /)/..1 ~I"(,('" I w"".eLc. ;,;-r I(I;!, 7'" ,4..( I< e"vc";',,,c c)'u l~olP""':} rr"J.....tp/'J(7-0t<- .,., ( to'" S:-v .,f'.,r.p IF SEASONAl EMPlOYMENT + 00 YOU WOIIK MOllE THAN.O HoolIS PER WEEK? IF...ES,GIVETQTALHIIS,I'EIlW[EI{. IODA....SOAT( 0/./ r:::,"'f'r!rl /.) , GIVE NAME AND BIRTH DATES OF YOUR CHilDREN UNDER lB SUPPORTED BY YOU BIIITHDATE If DIVORCED AND"'OO HAVE MINOR CHltoREN SUBMIT A COP'" OlTHECQURTOllD{lI SHOWING leGAL CUSTOOIANOF SUCHCHIlOllEN. AISOGIVE Pll:fstNT ADDIIESSOf SUOI CllS10DIAN FUll NAME CfSPOUSE AT 1!M10f INJURY (WORKEIrS SIGNATUU) 06JECllVEfINOINGS (~I~I:I~~lb~l~r~LVED, ) HAS EMPtOYH EVER BEEN TREATED BY AN"'ONE Fall: PIIESENI 011 SIMILAR CONOITlON? ANSWERS IS THEilE ANY RECORDEO TO THESE P!!E.E)(ISTlNG IMPAIRMENT QUESTIONS Of THE AIlEA INJURfD? ARE win ltHSOQANY01HEIl . YES MANDATORYPRE.EXISTlNGCONOITlONCOMPlICATE . JREATMENIOIlIlETAIlOIlECOV'fIlY?' . IS THE CONDITION VES PIlOBABL Y POSSIBlY NO ~~~~~?oTrJl~~:UlED? / ,,-,,-~ p_ \ (.,.,-U, IF CASE 111'[1111(0 '0 ANOll-illl OOCtOli/, GIV[ fUll NAME AND AOOWlS!. NAMlOFli~lrAl H05l'l1'" Ulff'HOtlf NUMIlEIl UIUSEONLY ltPCQOf L.Jr+ Cj,f 5 (; Y (un 01''''. "AYII ACCOUNT NUMln SlAM!") . . !;,I~IM" ~'C"~-'N.'0I.v....t1:' ~~ .luu:.Ol.U'-UllNG.lNIUllAND SUBMJ1 TO llll'ARfMtNIOf tAIlOR /I. INDl):ill.'lfS, MHNflON- ACCIOfNI I.'[POIH '1,',~N~:~i:2,5~~f5N3M91.l' 'J' EMPLOYER EM";~"IA'fIIlMN"""'f MAllING,wO"I,"S '~~STARrHERE JetteraOl1COUDty Dept.. Public Works Courthouse 't;j,,,,~,.....ovUr$IOC.AIIOfltr OIUfllfN' Iii/OM MAIlINO AUDlI(S!. .;- :::~~ r.~;:.~;,~~~:~;:,~~I:1 . ~r.idl.':,~ ~~:::'~II~I:7~:~g.~i~::.0'i~':J;r.~ ~~~OI"$~I.oA"~CI~ r;j~ t:r;;':O~i1~-"'~1 o':rt"D~;:'"' 01 ClAIM NUMl1ll1 Clrv<<.SI"U,. '" . llPCOOE Port Townsend, Wa8h~n 98368 (M"Oj~~~~!fUMRt; 'M'YI~~':.ol N"~I or INlVIl1Dr"'p\Ol'l~ Bruce N. Turner IHOI'lI{lU"'-I P"'Io'I"I~""IP C()IH'OIl"rl()'l (.rrC:O:1Y',.Of ~':'NIJA"ON W"lllfCl,U IMf\OIIIt~ X)lJ!~1f Landf'ill, JeUerson County ~~~1;~'1I f'IIIMI~!. x x :t:r~;N"l:~1 ~'iiALLii:~ OAltllU'Ll6/ltll It) TOU I'MI IA~'y^r~YKlA VAil III 11lllMn lOW04lJ . 5-28~_~J...:~.1 "~,, 6-18-80 ~ ~ ~ o-.u.-ou . /xs m ~~~~~:-----;T .;)1:;;~-;;~ -6-J::-'~:;:~~';"-:- +'iY-;;iJ7'I-;;-Wii.'I~;;;'~"'~-T'!. ul'\,'.111J ~~~;'';~~~!~'I _~ __: 1";;;-~YWI~~~'~~~:~----,,,j;.'~I~:~~~I~~w,~,;~g!:~~~~~~Y~___. __~__._. S ck eave pay "..j !(""-I 'H"I' "~', If''''\lA ~".. 7 75 '''.i~ I'",Y MI' "'C"JII,r~--YJ~"l" WN,' E~~~"/jA~' _..____..~.____._.__"J.~.:::.::~fPl,""! , . .HI X , " E~~~ S li~.~~"?""HJ;m' :;j~ :1~1. i.:'n"I~~;,'I",,\;''''''H "'...~ t;"''''\lH~ "(~"IO'll<""1 ....."",.".' I"u~ ...."...,llJ,~ .AK'''''I(l "-S "''''O')6I~OIt UUT, UAM( :,otllltA.'U (JAT' UI ~:.,/~~.' ...,,~ ~~:;.~~/(~.U';I 'Z;r':~;III~;''..!,1:~~~~~,: . ~~~~.tJll~U~~~'I~I.~~~~:i',~,.~::"'J':lYIII~ Va.ried' '~I~"'<<"i"" ....,\.\I~.I"\I.'YIII,II,r>l,.~.M.;+i(. 1~)\l"'''.lO_ 1((11fJ '."''''.1. (t(NI("l UM.\VUlll AI'l'lltlil'VIAU:. A _l~_ vu sett1ng up to check engine 011 compactor and etntck hill ~" ..;' ~tfnA't tl'''' '''I fl"'I1(",o;'lG I -tl" ,I; 'i/l\olJf\.....1 OIlIf".I~ljll IOI.IOAI....''''(I/ON nIYW,,' D"1.rec~or ~~ >r'\II,yIl'.mAlt{tlll.lffl)l.....'\' ... . , . 1.. ijOON (lA1l 6 . eo .o'/f.r'NO'M{Y"AMJtl:I/t, ~ M.L.S4natrca. JttJ9D!I4 J:"'Ub e Wk. -19- .._. .!.'''. ~;~, . . .. ,~ . '7~,'--- ..._~;_,..., EMPlOYER: Too, off obovo Original all.., com 1000ngl f II d b I -. , '- ,.., eldon! RnporJ, Clolm'!'. S"ctlon Olympln Wo 90"504' 0 n I U lJn jU m I '0 DnPCJ, "mn~t of lobar & IndustrIa" ^rronllon: Ac~ pennhy, Irnmodiolo re'ponHt will aid ~loin; (onlroi. y ow emp oynr m1l1t fila oUldonl roporl 01 on co or bo Poubjocl to' a ,;. ......,_...""'.,,'~'...~~.., r~__ " 111.- -, ""--- ..__'l/III r'......<., "., -~ ; " . , __J>" - .. .-....... - .-.-,."..--,-.-.. lu...'llIIIl ., i ':sii{ /" ~, ',':,I,\~): ,,?-,," \~~ ,(\' , 'l~ J ~ -, ~ ,"'., . ..J' 10;. ) 'C l !{i).. ,'I. ' '0 \ , , ,,< I I t ',~,~'; (\ IV (~0" 0 \;\,(:;~7.7 5 · \ :' S(~{ 7.75 , .,~.\ 7, 7 5 ',;,~ r , ,,~ ," ',1 7.7 5 ! ,'. 0- V p1.0 0;' I, .~. 'J.:' J 1.0 0 \' " /""'-' ,Y\ _' ~ ~ JX62.00K , ;,,~ ,'2\~~ : '.'> i X · \ '; ~ I. '\ " 6 2. 0 0 . 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I,... j: '...'. , . , .. ,. ", " ~ al gj . 5 . ~ ili :Q.l' .a "" -0: . :" ',' , ~ t~;: _ s."" ,~F 'T.' , 0.; 61(' ST" ~T 01 , gl' tl ,: SI .1< II' . 01 o B ~ " o g t ' T ,~~:' '''''''~',' " , ,- , , ',',;...",'..,"'""';:,, . : /.!-;" ,"5':::;;;:;.U\~I{mE SERVtCE'WAS RENDERED SECTION B. APPLICATION FOR PRIOR SERVICE CREDIT for credit for service rendered as a public employee prior to October 1, 1947, based upon the following complete factual schedule:', . L~':". ,,0'.<> ,'.\".;' <",:':":',<'.'__.:'.;, ,\ "" Namoofrieparlment.cio~lon .:_i,,_; ,', ',:"'.'" orAiency ," ,"" , 1 ",,'" "', .::2.. . , 3' ,4, " ',,.i,, "5 , 6 ..' 7, '''8 , ,9 ,to ,11 ,12' ' ,.2:.:' ,,'", , 14 .... ',,15, 6, :,:'17, " ."18" ,,' '\' to; .:"26, ",' 21 I" ';22, '1",23 ";;Sf -;-:'25 , '.', ' " , .') . , "; :;:;-:-~., . ' ,':', " .' ....' " ~ .,.,'. '" " 1\'" ' :,:' ,,: '.." "."" r .'.' . '".' :., ,;, .'" . , ,", ;,:.: , ; ",: i:::.':, :' i: ',,' : :', :' , ,..', " ;' .":' :": '., ',"., ..' : ',.. . :.,,:, :', ' " ",', .'.,', : ro...,[~!l. i :0 ~~,;, '.:.'.\[..:'....'. S B !8, \~ ... _..~ '\.~k... .....f.f~><: (,A-a;ll'i 'I jj " "Ii , '." ~ !l \~,~,~.\ lloH ''f/ ~~ at IflloS' .. ( '-j ~~ ',,' ~ii 'I ~flr " ..-, , r , , " " ~ .'..'. if'" aif ~~ r~ ".i ~, > i,.!1- '.' e. '" "':1. ,"~ ~: 00 ~s. iJl ..,p. '" !!r !1-g s:... "''''' ill! ~o 8" ag it IJ , Address (City) , ~ I ~ Ii: Ii: '" I '" ~ i ~ ~ ..' ~ F! r! ,~ ,~ - 1- , ! ! I' i , ; I , i ! ~ ~' '< ~ " ~ "" !' N, i i i .. I it ! o i ~ I r ' i I I , i Name ot AppolnUne Officer or SupervJ.aor . , l 9 $ ~ I ~ I g I I '" " I p" I ~ r f I .. I g I I i I I I I I I I i I ! ~ I ~ I it I 8: - I S- O I ~ I !l '" r , i , , ! : ! , i , B. 8. Tltle of PasJUon Hcld by AppUcant .' Mo. Beatf,~'Vn'\-ear PERIOD OF SERVICE Ending Mo. Day Year Length of PerJod (Months) s~~~~ Credit Allowed by Retirement Board (Leavo blank) 19 19 19 19 19 19 19 19 19 19 $ 19 19 _ $ _---"-_ 19 19 ~ ~......'......, 19 19 $ ...", ..' _~----Wl'--- $ .~7..-r- 19 19 $ ,. , ' 19 19 - $ -:;:-:- 16 19 $ .. 19 19.. $ 19 19 $ 19 19 $ 16 19 $ 19 19 $ 19 19 $ 19 19 "-$ -" 19 19 $ 19 19 $ 19 19 $ , 19 19 $ 19 19 , . $,'" 19 16 $ ------ f( . .' ~ n !" 0 ~ S'~ H ~ f l: ~ 8 ff~s- il:~:;l~~!:~ ~ If ~ s ~ ~ t ~si ~ ~ ~ t f;j ~ it! II is; 0 C r' [g t;l. I ifir.:!l sa~. b:;;: k l g.~:;; ~ i I~ ~~\ ~[ ~~\ ~l! gj t:l ,.. ~'" fJ', ~~. [e.~ 9 ::: ~.\l i:i t:: ~l S'~!il: ~ d If p ~ tl t - ffg'g!"J ~~,r~ sH I~~e. ~ ~ ~ lr, ~ ~.tu'l :;.!1lff &l Cl ~ ~ ! P ~ e.;-:>- is llj~'&:. 1;f1.-: .~~~ ~ ; g,) i a ~\: f;; ~ ~ n ~'-r. L Fl ~ ~ :H 0 ~ ..' i!. ~ ~ - :1.c" "l ~, ~ L ~ 0'-""" ffi ~ i ~ &l f ~ ~[~ m Cl [i !l ~ J... a ~g ~ :!l CIl !2:'; '" .l'J i ~ ~ !i.S' n ~ ?, ill... 'C; .. "<T'a !i: ~ ,... i I I ~I jUg p, ~ -, ~ P' I ~g en ~ ~ I ~ tJ-- ,[ I~~ S ! K r' .;' r; ~ CIl :;;: i (I ~8 ~ I ~! I ><:oo~ t:i sa ! ~S'i .~, ~ I ~~ ~ ~ : ~l~' I .~-- $ $ ~-- -~ , , -.,.' ---'- ! " , I', ' I . ..' '," I ./ , - I -,- , ' -::c- , ,', , , ' , , - ;::,;,"y,:>;',";;:', :;.' , PERIOD OF INTERRUPTION OF PUBLIC SERVICE FOR WAR SERVICE , .-.,,:~){.. '.' .: " '", ::'." .-'.. ':~.-:"I ' 'D~t. 0'01".;". From Claim for prior service credit because of military or naval se,vlce must be supported by I ' . :;'<>):D~te:Of.~>tn1el.1t> " '":. '_Active Duty photostaUc .copies ,of discharge papers or records of service be!ore any credit ,can :be con- ,I ma.- . or J 1'::-5"'7 sldered. ' I~:](r< ,. , ..' ,,...., ,~:': , " " ", .; ,,;, , , .. :, ' ',:' "'.,:, , TOTAL Yr.r; I',>,' MOl. , '.- ~ ~s"'il ~~U HE~,~ ~.....,. 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''', ,','" , ' , ... '; '.", ,~' ,: :,;, '..'~:. ,,", '.' /i . /' ~l 7. , .')/ I. -/ /'"..' ',," ,," NAM,:>~!(":~ /t. -r;.~/tdACi /",L~ STREET _ ' '.'" l/-( ~<../'.....-e.- CITY. STATE(;2'z:f<::!~.:.->2..f.c-, LA'"f V f:j{~E: , " , ",: .' , , ,: ' , .. .. ," , " .". , .,,: ...',...., .':,' ','..' :",.., "",':, " ',;' , " '. , :." " "" ;,",:" :', " ' , ,,' """':"""" , {,: : ".,",: ., '., ,'. ':,,::::',: " .', ,'. ',', . ',' ",\ " .;," -:'.. '" "",....., " , ," .' " ';,' ,,',,',. '"," AWSS CARD . STATE OF WASHINGTON EMPLOYMENT SECURITY DEPARTMENT ,', ", ! > ", : + ;:", ::'" ,: . . "!- "', " " " , " :; , ' I ,',,' , I ,', ,I ,:,1 :e, ~'t \: " :~ :/ri :j -"'" -, - ~..... - ........ ...---- ", ' '-_r':\:.:,~'.;."A_";"'''''''-''' ". --... '. ""' !IF' j I lIiilli!"- ._.___..........'''' VlI ~..".,... ..,~..-._-. ,. .. , '" -.....-.: "I,'" ~~ - "~r ,-~.. , ~,'-"," '~_... ~ .'~___'M ~ r-'.,,' ... .,' ....,' -...........,. . ,""'--- , '( "t,J . "< ...~,.. F I f '1 1 l: . ... II A MEDICAL INFORMATION PAYMENT _ATEMENT CF R 0 S F0R THE ~O"TH OF DECEMBER ~MPLOYER ACCCUNT NUMBER 004360-01 JEFF~Rsr') UJIJNTV HIGIlWAY OEPT CCURTHrJUSf PORT TrJh"JSr.~lD W~SH q8368 CUI" RI SK DATE OF A~10UNT ~U'~[I~" CI.AI'lMlT N4.."f CLASS PROVIDeR N "'I E SERVICE PAID ,)44740? 0 SHEKIFF 1501- 00 DA VE S DRUG 07/25/84 11.95 J 452543 'I CU~KE 1501-00 CIlU H~Af\KLIN I~D 07/26/84 1 ~ . 88 )452543 'I CLA-.KF 1501-00 DeNS PIlARMAC Y 07/23/84 1>.12 J4btd 5tl R En\';4~ ,)S 1501-00 GEERUlf S PETER MO 08/16/tl4 48.00 J46615q a ",OWAR J S 1501-00 OIVES DRUG 08'14'84 5.44 J46q1n r) tJAP") 1501-()0 'HPS CLAI;~ANT NUl<! BE R 11/26/84 202. 23 .I5!l4U ?1 L .~ I 11'1~ 1501-()() CLALLUM COUNTY HDSP-ER PHYll!1O/84 23.60 J 5040 27 L ''1IW!R 1501-00 CLALLAM CD HOSP 11 '10/84 57. 80 liASHINGTIJN DEPARTMENT OF LAHoR AND INDUSTRY ~EOIC"'INFORMATI0N PAYMENT SYST~ I R M 5 TAT E MEN T C F A WAR 0 5 FOR THE MONTH OF NOV2~BER EMPLOYER ACCOUNT NUMBER U04360-01 JEFFERSCN COUNTY HIGH~AY OEPT COU~ T HIJI)SE PORT T~hNSEND WASH 9836R :LAIM RISK DATE CF A"',);)/IT NU,~BEP CLAI Mf,NT 'III. '~r: CLASS PROVIDER NA~IE SEf(VIC~ PAID JZOZI0.) W '~EYEF. 1501-GO 1'145[:/1 CLINIC 12113/83 28.,6 JZJ?I'C W ,~F.YF.F, 15IJI-IJO .'.1.11 S~!\; CLINIC 12'13'83 13.50' J 44 7402 0 SHF.F: I FF 1501-CO JEFFERSON GEN =":AL HoSPITAL07/11/&~ 113.0u J466158 B EDk\R OS 1501-00 JACOBS GERALD E DC 10 110/&4 85.00 J469187 0 WAPI) 15Gl-'~') ANG C'RTHO & FR tLI\ INCPS 09'26'84 77.00 J469187 D WARD 1501-011 ANG '1RTHO & FR CLN INCPS 10/10/84 ld.OO [RECEiVE]' DEe 10 i9o', JEFFEr'::SON COu..:"( ENGIN~ERS OFI"IC . 'M ". ".. '-",. - " ""'" ::";'Ir ~ .., ~' ~.'.Y''''''.'.'''' aT ....---. -------.-. ,~, " . ...."-~ - .. ."""l , ;,l~;jj;Jitl;;;i:i;;:ui;;iii$;iiit0;f"tr!.i:i1itJx!;ntiL;BC1;,:;at!J2.iill,'ni?0:tif.' , Jk{s{!02:!f!,j/!"i:&f~t)l~;5)2t'ii.t4k~<j1i;il;!i;,;,0;,illf~!ih~!;,;. WORKER: Before completing section below shaded orea, READ LEGAL WARNING on reverse side of this poge. j ., l~YSICIAN:,Complele_ Physj~i~n's Report. 'Det.IO'p portion of Original where designated on~millo Deportment t ~o"':~~::;:J,I~~~.' ~~~~j~:; >. of lcbor& Industries Attention' Accident Re _ Claims Section Olympia WA 98504. Delo~ Physician's Copy I by phy.j,j~". ;,,"'.. p",han 01 .. ," . , , '. , . . b . pog.'<lb"'''''dby.mplD~.', .' ",.,' (3rd Copy) for your flies and promptly moil the balonce of the form to the employer (this Includes the altorn portion of ~h_________________ ", the Original and all of the 2nd copy), . ! PHYSICIAN'S COPY OEPT,OFLAIIOR&lNO'USTRIES '~" ' CLAIMS SECTION . ..4 ; ~lYMPrA.WASHINGrON 98504 , _,_ '. ',",(c" .:"',<\1' "I. . . . ., :'-"'" .,'. J' 'i ' "," '.11 .,', "~1.~~.,.1 "",',1-' "'~~'llr..."./ - /'" '. Ii'" -..::./ii'.JJ...........;2(YL-..:-,--:L.'-C:1.._::.i.e....i...:..,;:_.d.:0..L_:u_i:____ " IH p--- ..:. '.t., _4__T~~_ ",.~.l_ _.,.... < .~" ti_, '/I"'~ ".-' ....'""-... ~~_,. "".- . "" _. ... ".~ ~.'->' ....~..-~j.." '.- - ,.,.. "'.~ ~ , ~ i' .-\:-', ,,-., > ;\-"'>1'- \,I,,'ii'_~",ci~'" - "'''',', ,. ,-"--,~ '"' ''" ~"". ,."" ;:).,t' ;';>~':'\: ".:'-- _.~"').- ~I' , . ", \._ _n"..~, "~ - ..._ ~ --''''-'''-'-'---'''''''''T-'--- . :,"~ ,'__,' . I, '. _ .' '._'~ ~__.......' .' , . :;." ...... ....... .... .' . , . ,...... '. '. :.,' . '. .. <c. "':" . .:. ..' ..':.....:. .,". i' .......... .,'. '.' :' '.: i....'... .... '.; -, "; .:. .:..... lIl'! '. . , 'C.::.";..:'.': ,', "". .,.,' ". ' .i... ,." . . ,::::.. "1." . ......;.,.: .......,. : .' ". .... ". .'. ':1 :." '.' . .;.....;.... ;", :,',.; " . . .',' '. .: .:,' ". . .,':' ;.i,i' . . ":>:.,',: '.' '., '., ' "":::. 'c' " "'. " ':., . '. ," ~ ~ Ft.. 'q" --_.... -- 17 ';:\ ' ,. ...... '. ,.:; ......; '.' :::::'". .: .;; ..' :. :, '.' .... '.',. , ..,<: ::.: ':". .::"., ..' ..... ...... ,. . ". .'.' "'. .'.' .....:.. . :. .... :' .......:. .' .:> '.:' . ." ..... .... . · ..... ~t~~1fl~ '. TO: PAYROLL DEPARTMENT i'. ..... '.' "LCASE ENTCH THE FOLLOWING CHANGEI.OUR RECORDS TO TA",e: ~-/2-85 . ' .3~/.4v ? .:i#t!~ roAl ...' .5'3/- 30 - 2985' 0EPl: If;tfL/c tW<kS THE CHANGE(S) (jDEPART,..ErH ." l)JOQ rJSHlFT .... .' URATE .?, 850.00 c;. ~o [] REASON FOR THE CHANGE(S) : .; " (JHIREO (J PRODATlON"RV PERIOD C~MPI.ETED o LENGTH OF SERVICE INCREASE .:-,...' ; ,'''' .:,i...:,;. ;.:,....' 11RI;'HIRI';O l ] PROMOnOl'< rJ RE.EV"LUATION OF EK1STlNG JOB I)OEMOflON MRE51GNATlON ! JlRANSF[ff L1RETlFIEMENT ..I MERI1INCRE"'5E ULAYOFF ~l UNION SC:A.LE (J DISCHARGE (lOTU[R lI.r,A..., CHANGf "UT'IOHIlro IlY _______ ___.__ OATf. <H."".....O. un -.EL~D~~__D.,. ~-/.s:-a.)" ~~- .....' .::::.' ',::-: . ," ,: ...., ..."...... ", ...........................:... .... ":.,<, ".. ....., .... : ", " '.' ...', :: .' '. ".' .' .... .,' . .... ':"'.'",:, . ,:: '.: ......., '.': :'\'.' :':';' ;\?:,~: c;-;. '. ',' . . '/'~(, . ........ ' :'1(':':"':" '. r----- ,.; , ,\li':':'O'''':'.''',',,:'::','', ." ,.:'i .... ., , ',:' ':":,': '.' ~ -=:. TT J. _ - --....--.; I IIlIL ]IIfIl ....~, ".: .. ;" , .' . . .". '.- . ' '.,: .... ..', .: ..... .', :.:' . "." " ':" . ...: '., :;':: , :....:" '.' '. .. ' .. :,. ',:. ',". ....... ::,:- .. .' i : : ..... " .' . .: '.. . , , .... .' :. '.> ;.'" i; :." : ;)!' :1. ',. '..'. :/ .' , " .... . y. 'f;? ,:1 '/\1 :';3 " ;.,::. ~, -..-., ,.. ....~.. ~ DlI1lN , ___'J6_....._... J Ii. iil<~ ~ ~ ~ ~ ;: ... ~ z :> 0 u 0 z ~ w u z " a: ~ ;!; " w ;: z :> 0 u z 0 ... " z ;: ~ '_~~D ],1'; " ~~) ;; ~ ~ 1 ~ LL ~~ ~ .e'......:g N ~C{f ' ~~ c .~ "i; :> '.;) \ ~ ~ ~f\ ffi ~ ~ ~ <3 " ~o ffi ;;:15 ~ ~ l\ r-> 0 ..J "0 " au frl J: ,f~ (J ] ~:.' 1l t:i;,:;~ ::;: , ~N ~f\ ~ \ ~o~ x X I( ,><., '0( i( )( ^ )( .... ~! ~ C ""~ C l'i - ~ u HH .~ 8'2 tlI'c 0. gjri~ ,~ me tlI : igi~ :J 3: '5.c 0 o g~ ~~~~ ~~~i~.s .c CL Ql '~1'l~ B ~ ~~ ~.~'~8 ~ ~~ ~t~~ c:5 = ~ ~::1 E'a o H ~U; ~ ~ ~~ ~l~~ ~ IIHnil I ~.i ~~~~ 0 ~ ~! ~ ~g:: f .. ;li ~2~'~ - ~ OC C>!l:JV ~ ~:~~c.~o -c HHH i ~H.:~h ,> :: :5 ~ ~ g.E': .s a. 8 .~ ~ ~:;;; ~.~ ~ g 1i & = ~.\,l a ~ .c u :0 e ~ ~i ~ ~ ~.~ E e~ uoc; 8..5 I ~: iHH Ii "tjw ~s;:.:~o>.~ "'" ~ 'C..c 0 is CL 5 ~ ~~i.~~;~ c E '" ~ "::.\ l \2 ~ ,j.j :~q :<i '1- ~ -= \..: ~ I'~ Q ~ ~ \, '1 <:(!9 ,,~ '" <.. 'f( \ Q: ~ Ell: 'I) ~~: .- N ~Hf ~ ~~ t? ~ ,<ill ~ ~ <J i'\ ~1 ~ ;...; ~ .. i ~ ~ _I ~ 'W z &! '} ~ I '- \ t\\ 8~ .~ i "u wo '< ~ ~ c ~ ....1".......'""""',.,.,._.._. --- "........- ---- ~...., i.--..,:.~.:;{'n:i, . .. ---~- -~...- -. , ., "'~ 0" . , .-- -- ,~. - .....- -.,.' , - '" . ~ ' --., . '-" ,-", F- _._,~- - .,~ -,~ - . ..- , ,- ,. "" "." [ TO: FROM: ,............................,.,~,...,....I ....................................................... .. ;.:-~-'.,.., . . , -'---~l ~ . ~ ~ ~'. .. . ~ .... " . '':.i> - ~-'".!; INTERVIEW REPORT NAME OF APPLICANT: ..,A~.......,~..&~../d...............,.. ~~~~~~~~~~....../.~.:.p?-.,.......... ADDRESS ,...,.............,......'..........,..........,............,....... PHONE .~.B.3...~..,"-Z,:;:.4.".. CANDIDATE FOR: ..................,.........,..............,....... ,....,......,......,.., ,.......................,.... ,.. (Job Title) I sf INTERVIEW 0 THIS IS: 2nd INTERVIEW 0 3rd INTERVIEW 0 INTERViEWER:....,............................,......,........,..............,............,..,................................. INTERVIEW IMPRESSIONS BY CHECKING THE ONE MOST APPROPRIATE BOX IN PLEASE REPORT YOUR EACH AREA. I. APPEARANCE o Very untidy: poor taste in drOll. 2. FRIENDLINESS o ~:!:i:~/:.ry distant I 3. POISE.STABIL~YI III at uni is "jumpy" .nd "p ..u nervous. 4, PERSONALITY o Unsatisfactory for ~ob. o Somewhat car.leu about Satisfactory pllnonal .pp..,anc.. pllrsonal appearance. Approach.ble: fair!y friendly. Somewhat ten'lI: is usilyirritatlld. Questionable for thi, ob. W.rm:lriendly: sociable. o About as poised .15 the av.rage .pplieant. o Good tad. in drllss: better than ....or.g. appearance. o Very sociable ud outgoing. o o ~::;s~:~r; ~:~e11~on~m.d: taste in dress. o Sure of himself; "PPUfl to me crhe. more th"n .".r"ge penon. o Edr.m,'y friendly .nd .oci.bl.. o o , 0 Eltrem,ly well composed: /tpp"rently thrives under pr'nur.. 5. CONVERSATIONAL ABILITY o 0: T.n. "ory litll,: Tries to o.pron himll" II Anr.go flu.ncy EJprl..e. him'llI poorly. but dOl. I.i, lob end e.preuion. d best. I 0 0 Vory duirable Ouht.nding for lor this 'ob. this job. 0 0 T.lh well .nd E.eellen' e.preulon: "to thl point." edrem,ly truent; fotl:elul. 6. ALERTNESS Slow to "c.tch on." o Rtfh,r dow; r,quirl' Mor. th.,.. ."Ir.g, ..pl.natlon. S.thf.ctory for this job. o Gr.,p' idu, with .vI"gl.bility. 7. INFORMATION ABOUT GENERAL WORK FIELD Poor ~llowlld91 0 I F.ir knowl,dgl 0 I, ., inform.d II of fi,ld. of lilld. thl nlr.gl .pplic.nt. B., EXPERIENCE I No ,el.Uonlhip betweeP ! .ppllcu", b.dgloulld ~ob "qul~em"nh. 9, DRIVE o H", poo,ly d.riud go.l, ud .ppun to .ct withouf PU'PO!" 1 D. OVERALL o 0" r;nl!!!!..~~.!.~!i, f. c fo_,:". o F.i, ,el.llon,l,ip befw..n .ppllunt'. b.dg,ound .nd Job ,equirem.nh. o Appu,. to 'el go. I. too low .nd to put 'o,tl, little 'l'ort t. .ehiev. th.II, ~~_~!t.nr!~"~. o Av"'.g, .mount 01 m..ninglul b.dground .nd e.!e..,ie_~cI. o App..,. to h.v, ''''''g' go.I,; puh lorth ."er.9' 'i~ort to ,..eh Ihl.e. o t AYlr~_9" . o Quid to und.nfand: perclivl' "ery well. o rB" F.lrlV w,lIlnformedi knows mo,. th"n .VI"ge . lIunt. o Badground "Iry good; eonlid."br, '.peri,ncI. o Appu,. to .tri.. herd; hu hlCJh dOli" 10 .chi,'t~.: o ~ Elception"lIv k..1'I end .I.,t. o o Hes Ilc,lIlnl 'nowl.dgl oftn. (I.ld. EtCIII,n' beckCJ,ound ud ..p"I.n(l. rV ~ ~:I;;':t:I~:~~:~~,~~tj:l. '0 echil"l th.... o O,fl"lt~r,. '~"'f'1 aY"'1~' Ouht.ndl"q, ~ (PLEASE SEE REVERSE SIDE) ----, " .,-, ",-, ~"~'_""'''A'''/~_';~''' -~"_'< .'. . -""'I _,:,.-."- ..~~: "l~''" .\ ~ , ' _ ',1 - -~'",,'.~. . ['. l:-..)'- ) '/1'1 (7:0/ ' . j/fI>fy ,'!;M;' If ~ J" 9s1J/, flI.~'-8::t t',gtlc.~ _7?/?~4 r:: Ts 1')1 -4 N (ENe;, --!:: ;J:tfr t;Jij;;" 1/0/Jl1 (Pasi tian Applied for) ;fjJ /}tf'I/' / I PRE-ENl'WnlENT APPLICATION Cutl?~' ~ ~~<</ /P0? IEeJ-f) 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 basad upon a bona fide occupational qualification. (State Law: Chapter 49.60 RCH and HAC 162) U1PORTANT: Complete all section. Please usp. ink. Print name only. 41~ :z-.~ 1. Name: .:5J1cF~,,s'-t:> '-LEE (las t) / E/) LJ -4K 1> (first) (middle) 2. Address: Rr (, (street) 13 <'SJL LL2. 4. <:;.F ('.';( V U.21 (c i ty) I.A/ 4-, (state) :J8..sR<. (zip) 3. Social Securi ty No: S7 ';> - 60 - B, S- .3 /,. Date of Birth: I 94U6,5:2.. (age will not be used to discriminate) 5. 7. Gi?..3- 5';?;:J?-...~.~~_=~,sS_ Home/Message phone: (;8:3 - 72. 54 (U^'LlC.rE-'\') 6. Businass phone: Education - Total year.s of pre-university schooling: CIrcle year completed: 2 3 4 5 6 B 10 11 @ Have your passed the General Education Development (GED) Test in lieu of lIigh School Gradu;..l t:l on? Yes_No Year ~l..Q.a.C9 attended Years :;; ~oK A.N,::; P:B-'-L~ c.O.!12.r.ll- CL.ARk CO ('1l7yyJnl CJ)( L B. 9. -1>ti".1Y.J 'v ,$ c..J L A- ,... (j L. <--S:"- ('... 6' From To Der~ee c..,,) L L /:!J. I? ,0 --- ~ /97''- - ~ ;')79 10. RgFERENCES: (plense cia not list relatives) NAME ArlIlRESS OFI'ICE/lIo~m PIIONE 4:,- ;1.-8 <t9/ P"Jf!,r; AN?,c:.L.e3._ ,,. , , 1. 'i(c~iI't::! '" .,.. ,4, 2. JII (;.1< OLS dY/ (,.P'A,,-J-I. ~LrI'~J<:/.. A.SS""C IN ,( I I 3. L.()"f<. 4.. 4.I<C'N^/Er'-J 5, ;'~G'"NNl~"J./ T~~~~__ I( (.J, -5(,U~/:5.LygL--!-1 A, CL.A f!.1< " " If ----- " f'orm 100,' 0.1' .C, C., Rev Il('e 1 !)74 ......-...."""... - ~ --" ., .. "" ,.n . V " . .' r , _ . \... ,,' ~" ..._.~ '" ... 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