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NOTE—.This farm ;hould be filed with the Retirement Board by the member or in his behalf- WITHIN NINETY DL1S <br /> -� from the date of accident or hazard undergone <br /> U. '� d B^ky (��1' �1II11t1IIIIriIUPF[11h D� �R,tiBZ;IhII13I.an8 <br /> �aa <br /> COUNTY OF BARNSTABLE RETIREMENT SYSTEM <br /> BARNSTABLE, MASS. I <br /> NOTICE OF INJURY <br /> TO THE BOARD OF RETIREMENT <br /> Gentlemen:- <br /> 6 This is to notify you that.............J.t�(A+!;N..lA.r....f.LN.+!.1LV..V.J,lA.1,l.t1-J.M.........................received injuries incurred through <br /> 7_ (Full name of employee) <br /> accident in the line of duty or due to a hazard which occurred in like line of duty Awhile employed in the service at <br /> the ....Tnwn....of.. mMash Pie.............._...........................- on ------..�.i.................._r2...7.............$1..........and whose home address is <br /> .(QaxNae of Dept. or Institution) (North) (Day) (Yeae <br /> ............1A...at.4xkd.._Lane....................................._.................. ........... •MaghT . .e............................02649............ <br /> (Street sad Number) (City or Town) (Zip) <br /> (Write the word) If named <br /> III SINGLE <br /> I• Single la. Husband of .......................(Gi.....aiden....................................................... <br /> MARRIED "b (litre maiden acme of ji�(1e io}�`1 <br /> 2. Date of Birth ..............March..........1..............19.300.._........ 2.a Date of entry in service.....1.21..A7/...L�......................... <br /> (Month) (Day) (Year) <br /> 3. The cause of injury was......Tripped---an...aarpe.t.An...the....affi.ae_..wi.th..xight....fta.t....amd............... <br /> ury <br /> landed wrong and hard on left heel. DS` be ......` `°j <br /> ............................................_............................_........................._._..............................................................................................................I................... <br /> (If statement requires more space use other aide of this blank and write m this apa,,SEE OTHER SID£) <br /> ...................................._.....................................................................................................................................................................................I.............. <br /> (Important: Sign your name after what you write on other aide) <br /> ............................................_......................................................................................................................................................................................... <br /> 4. The nature of injury is as follows Same as above. <br /> .... ............................ <br /> .—Same —_..... <br /> ................... <br /> .................. <br /> ......... <br /> . ....... <br /> ........................... ........... <br /> Describe injury with such eaactness u possible <br /> 0..................................Ili <br /> _......._................................................................................................................................. . ... .. .............................................. .. <br /> IMPORTANT—Nos. 5, 6 and 7 must not be left blank. Some at.tc.t most be roade.—Example—Not taken to a hospital­—No witness,eta <br /> SII, 5. NAME AND ADDRESS OF DOCTOR WHO ATTENDED EMPLOYEE ...PGb@Yt*...JG_...Rl en,...M.D............. <br /> (Full e) <br /> Address ......Falmau.th..Hos..pi.tal..Yaerg_emy....Room........................................-•---......................................................... <br /> (Street and number) (City) (state) (zip) <br /> G. NAME AND ADDRESS OF HOSPITAL ...FalMOI th-HGspi.tal........................................................................................... <br /> (Full esese) <br /> Address ...T.er....Heun-Drime....._......................._...................................._........F-allaouth._...---.......MA..................02540 <br /> (Street and number) (City) (State) (zip) <br /> 7. NAME AND ADDRESS OF WITNESS (If possible give two names of eye witnesses) <br /> 1. Name .......................................................—............Address No. ................................................................................Street <br /> Cityor town .............................................................................State ..................................................................................(zip)..... <br /> 2. Name .............................................._._..._...............................Address No. .........._..................................................................Street <br /> Cityor town ..............._...........................................................State ..............._...............................................................(zip)................ <br /> IMPORTANT—Nos. 5, 6 and 7 must pot be left blank. Some atatcmeat meat be made.—Example—Not taken to a hospital--3j"wit'—,,ettc <br /> Signature <br /> . .:... ..�m�����Lf/T:�L.�.S::KfTrS.,,......... <br /> . '���— — _ t emp�or ocher irrformane> <br /> - ...................................................................................................................... <br /> (if other informant. relationship or title of superior officer) <br /> IMPORTANT <br /> The law requires that injuries incurred In line of duty AFTER JULY 1, 1938, ahsll be reported to the RETIREMENT <br /> OARD WITHIN NINETY DAYS to give unlimited time coverage for (1) retirement based upon accidental injuries or (2) <br /> accidental death benefit. - <br /> IF the NOTICE OF INJURY is not so Sled WITHIN NINETY DAYS an APPLICATION for (1) accidental disability <br />' retirement, or (2) for a death benefit based upon accidental injuries incurred MORE THAN TWO YEARS PRIOR to the <br /> date of application, IS VOID. <br /> Foran 17 unto+ o,rms sueot. Co.. Svc . posTon. .•sss. <br />