216 215 214 Employer's first report of injury, Nov. 14, 1932 8. Date of accident, the 5th day of Sept., 1932, at P. M. o'clock. Injured Person 9. Name of injured person, Wm. DeVellier. 10. Address: Street and No., 96-08 42nd St. City or town, Corona, L. I. 11. Sex, Male. Age.. 12. What was injured person's regular occupation? Mgr. Farragut Theatre. 13. Was he injured in regular occupation? Yes. If not, what was occupation when injured?... 14. Piece or time worker, Time. Wages or averPer week, $32.50. age earnings per day $........ 15. Working days per week, 6. Any other advantage? 16. Length of service..... Cause of Injury 17. Did injured re Yes. Describe fully how injury occurred, Was forced to carry a woman patron part of the way upstairs to the ladies' room. Did not realize injury. Right side hurt and last Wednesday, Nov. 5th, tried to pick up a can of film which he had to drop immediately. Then went to see Dr. who advises operation. 18. Name of machine, tool or appliance in connection with which injury occurred, if any. 19. Part of machine on which injury occurred Nature and Extent of Injury— 20. Nature of injury, Dr's. rep. attached. Notice of controversy, Nov. 29, 1932 217 218 21. Was member or part of member lost? No. 22. Will injury probably result in serious head or facial disfigurement?. 23. Did injury cause loss of time. "yes" when did lost time begin............ If 19........ 24. Has injured person returned to work?. If "yes" on what date........ 19........ 25. Did you provide or authorize medical attention?.... When?...... 26. Physician, Dr. John J. O'Connor, 3743 88th St., Jack. Hgts., N. Y. 27. Hospital (Name). Dated, 11-14-32. Firm name, Century Circuit, Inc. Signed, Wm. Devellier, per J. F. Official title, Mgr. Farr. Theatre. (Address) 222 Notice of controversy, Nov. 29, 1932 220 1. 2. Name of employer, Century Circuit, Inc. Office address: Street and No., 152 W. 42nd St. 3. Name of injured person, Wm. Devellier. Present address: Street and No., 96-08 42nd St. City or town, Corona, L. I. 5. Date of alleged accident, 9-5-32. 6. Nature of alleged accident, Forced to carry woman patron part of way upstairs to ladies' room. Right side hurt. 7. This case will be controverted for the following reasons: (d) If controverted for any other reason, state fully below: Not result of an acc. or not an accident. Not arising out of or in the course of employment.. and reserves the right to controvert for such other reasons as may later appear. 8. Do you believe the controversy can be settled by conference without the necessity for sworn testimony? No. Name of insurance carrier, Aetna Life Insurance Company. Proof of burial and funeral expenses, Jan. 9, 1933 223 PROOF OF BURIAL AND FUNERAL State of New York Department of Labor Office of the Industrial Commissioner Bureau of Workmen's Compensation Syracuse Office: 214 S. Warren Street-Merchants 224 225 Case No...... Ins. Carrier's No.... State of New York, County of Queens, ss. Joseph Urban, Inc., being duly sworn, says, that he is a duly licensed undertaker of City and State of New York at 42-17 69th St., Winfield, that on the 20th day of December, 1932, he prepared the body of William DeVellier for burial; that he placed a coffin, containing the said body in a grave in Flushing cemetery; that he shipped said body via auto to cemetery at Flushing, L. I., that he was directed to conduct such burial by Charlotte Doyle, 96-08 42nd Ave. Corona, L. I., who authorized the following itemized bill: Palms and door spray. Casket Outside box $ 20.00 175.00 75.00 228 227 226 That he was informed said bill would be paid by Charlotte Doyle, 96-08 42nd Ave., Corona, L. I.; that no part of said bill of expenses so authorized for said burial has been paid, except $by Charlotte Doyle, 96-08 42nd Ave. (Signed) Joseph Urban, Inc., Joseph Urban, Pres. Subscribed and sworn to before me this 9th day of Jan., A. D. 1933. John H. Possemiede, Notary Public, Queens County. DEATH CERTIFICATE, DEC. 22, 1932 N. Y., Feb. 17th, 1933. A transcript of a record on file with the Depart ment of Health of the City of New York. |