24 SETTLEMENT FOR ACCIDENTS TO AMERICAN SEAMEN

REPORT OF PERSONAL INJURY
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Name ccoeeeeervsconsunsonseammesoas.
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Age cceacermeiceen COLO eee. SeX eee... Married or single...
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2. (a) In whose employment when injured __oooeoomereeeee. ein AAR
(4) How long employed oes. (0) Wages per foe een
3. (0) Date man signed 00 ...coeecreucecrererconarnsneeeae (0) Where ........
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¢. (@) Date when man was paid off eeeerememeeeeeemeeemermermeeens (8) VVREE® amram
(60) Before WHOM eeeeereoeeeeeeaececcccimaeeeccanscamncceaeee (3) Amount of wages paid cceeeceeerooocare-5.
 Date crew paid off for voyage, if known ......... ... eens rmesmsmmsnssessentsemressabemmmesenboeamem—————ead
8. Injury received: (@) Date ccooeeeereeee (0) Hour coe ee oo (6) Place eee
(d) To whom first reported ...oeeeeeeeee- emremennrmennmmssnmncsncnns (€) WBE qrermceeeecnees
7.. Describe fully what was being done, how the accident happened, and nature of Injuries wueeeeeeeeeeeeenennns

8. What machinery or gear was in use
Was it in good ordar? W, nmmnsemonsenanmssss

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9. Was steamer loading or discharging? eee
From or to dock 2 lighter? ene rors rr
10. Name of person in charge of work at time of accident .ooooooooo nooo