Employee's claim for compensation, Dec. 4, 1932 3. Nature of business, Theatres. Place and Time 1. Location of place where accident occurred, Farragut Theatre, Brooklyn, N. Y. 2. Name of foreman.. 3. Date of accident, The 5th day of Sept., 1932, at 10:10 o'clock P. M. The Accident 1. How did the accident happen? While assisting woman patron to rest-room. Nature and Extent of Injury 1. State fully nature of injury, Received rupture right side. From lifting patron who fainted. 2. On what date did you stop work because of injury?........ 19........ 3. Have you returned to work?. "Yes" on what date.......... 19........ 4. Does injury keep you from work?. If 5. Have you done any work during period of disability? Yes. 6. Have you received any wages since your acci dent? Yes. If so, from and to what date? Full salary to present date. 7. Has injury resulted in amputation?.. If so, describe same.. 199 200 201 204 Claim for death benefits, Jan. 9, 1933 202 Notice 1. Have you given your employer notice of in --------------、 19........ jury? Yes. When?.. 3. Was it given orally or in writing? Writing. I hereby present my claim to the Industrial Commissioner for compensation for disability resulting from an accident arising out of and in the course of my employment and not occasioned by my willful intention or solely through intoxication, and in support of it I make the foregoing statement of facts. Signed by William Devellier. Mail address, 96-08 42nd Ave., Corona, N. Y. CLAIM FOR DEATH BENEFITS, JAN. 9, 1933 Form C-63 State of New York Department of Labor Office of the Industrial Commissioner 214 South Warren Street, Syracuse, N. Y. Case No. 3225468 Ins. Carrier's No., Aetna. Claim for death benefits, Jan. 9, 1933 205 206 I hereby make claim for compensation under Section 16 of Chapter 67 of the Consolidated Laws and in support of my claim make answer to the following questions, unless otherwise stated, relating to the time of the death of deceased: 1. My claim arises out of the death of William Devellier at Manhattan Gen. Hosp. 2. Who died on 20th day of December, 1932, as a result of injury sustained on 5th day of Sept., 1932, in the employ of Schwartz Bros. Century Circuit of 152 W. 42nd St. 3. What was your relationship to deceased? Mother. 4. I was born on the 23rd day of April, 1889. 5. Were you wholly or partially dependent upon the deceased for your support? Partially. 6. If partially dependent, to what degree? $30.00 a week. 7. What other sources of income do you have? Husband, about $25.00 a week. 8. I own property as follows: Real estate, assessed value ($.. income of $.. is an indebtedness of $. .), from which I receive an ..annually and on which there ...notes, stocks, bonds or mortgages; money in bank ($.. ..) from which I receive $.. ..........annually. sources of income, if any. 207 State other 9. Is deceased survived by any other dependents? No. If so, name them and state relationship of each to deceased: 210 209 208 10. Name and address of last physician or hos pital, Manhattan General Hospital. 11. Name of undertaker, Urban. Address, 69th St., Woodside. 12. Amount of undertaker's bills, $ Amount paid, if any, $.------ 13. By whom paid.. Dated this 9th day of Jan., 1933. Charlotte Doyle. Address, 96-08 42nd Ave., Corona, L. I. AFFIDAVIT State of New York, County of Queens, ss. On this 9th day of January, A. D. 1933, personally appeared before me the above named Charlotte Doyle and made oath that the answers by her above named and subscribed are true. John H. Possimiede, Notary Public. 42-23 69th St., Winfield, L. I. Employer's first report of injury, Nov. 14, 1932 211 EMPLOYER'S FIRST REPORT OF INJURY, Aetna Form 6180-B State of New York Department of Labor Office of the Industrial Commissioner Bureau of Workmen's Compensation 212 213 Claim Department Aetna Life Insurance Company 100 William Street, New York, N. Y. Case No......... Ins. Carrier's No...... Employer 1. Employer, Century Circuit, Inc. 2. Office address: Street and No., 152 W. 42nd St. City or town, N. Y. C. 3. Nature of business, Oper. of Motion Picture. 4. Name of insurance carrier (not broker), Aetna Life Insurance Co., Hartford, Conn. 5. Have you notified your insurance carrier? Yes. Place and Time 6. Location of place where accident occurred, Farragut Theatre. 7. Name of foreman, Mr. DeVellier, Mgr. |