28 SETTLEMENT FOR ACCIDENTS TO AMERICAN SEAMEN

REPORT OF ILLNESS

Be Be eee assert aas an nea nse m enn nee ane
Managing AZOnb. ..uuenneecoanecmmencnee ene naere seca mnmen.
Date of Sailing «oon
Vovage NG. eooeeeoeene.

{ NOE eee ivearranesecanamnemeeenonee ATES NO. oir
| Adress meee
Occupation eee eeeeceeiereeerers ececee. Citizen or alien... ooo
re JAZ creer COIOF eames SOE oer. Married or BIOGN nnn sin iinmsibmmmmmranns
B Name of nearest relative... . . JERI 13152171. SU
LAB00 csmssmmmermesssesinsen. AE
2. (@) In whose employment when taken ill ooo ooo
(5) How long employed. wuewuevsmemeesvecececener (¢) Wages per fren) AAR belie
3. (2) Date man signed OD..eeeeooeeeee oo cenimncncnncns (8) Where ooo.
(¢) Before Whom. oc.oeeeeeeeeccaeaneereaennns Cie A bres Ema m———
(d) Physical condition on examination, if any, prior te signing articles A RE

4. (a) Date when man was paid offewee oer (8) WRI eso
(¢) Beforewhom ieee. (d) Amount of WAZES PAI ceeeeeeaneacameee
5. Date crew paid off for voyage, if KNOWI. ooo commie eee eee
5. Tlness contracted: (@) Date mmneeereeeceee (BY HOUT roooeeee (6) PIRES emma
(d) To whom first reported oo oooeereeeee a cecarsecoavereeoeeene (6) When... ammo mman
{f) What was done for sick person hy party lo whom first, reported? Sm ———————————

7. Physical signs and symptoms omen.

RB, Diagnosis «oem