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(e) The uracstt enil ka crd s, énl ea  oer is até ce icatadéççesl

( Parbtdd.

(e) Uai laies, sts, temtilren uné t. yat dá rraad iboa etr Lt wo rs ipale t rl raprott, sad aho were viciy or pastily depeadat ees tha deèsd engdeyee

( Go ndpeaets y er pertatiy  pendei epea Ced d umpirre

Uedr the lar, Che tem "eatl" inelekes sepetibien, adopted rhétrer, Ladl po dhamoau cléldren, lant daea not isseds ztied chitea. Tte tenaa "hotker" aad "sister" ischrla t’ephedhers end tapitees, hl laodets nart hal tia, and others end sistur by aloption, bet o pot iatlude nzrried lbest rs or siters. Ad od the atove terans anel the tera "graadua" jntude only persors who at to tie of the dtà of the decca glenptoyte are unde 1s yezrs ef age or pver ul at sze d laeryatie of seiste. The tu "pareat" inciedestep-paratsand paaadsby adoplion. The tea "vidoa" inchoies ly the deeodeat's vte Evig with or dgea lent fer suprert upon liu et te tine nf lis death. The tera "vidomer" itclades ly the decehut's budcaad depeadeat for support upas ler at the time of lier denth. Tho terus "adapted" and "adoption" usad ia thi la inede oaly legal adoptina prior to f tiae of tte izjury.

The cisim shou'd be sigzd by the persoa matiaz the cisin or bis éaly euthorized teprezestative. Ttere should be givea : trracs and addrests of all persoat who may be estitled to coapezsstios on attvent of death, togeter with the atltrer of : peraon akisg tochi, which hol be swo to by the peson estited to concssatiun, or by tas Jrerson aatorizd to n is belef.

Oa(hs of eliaaatresiding in fcreiga countrie shouid be raede befores United States consular oTicer or sceretary of lsation If beiore s loeal ceiel, a certifcate of sueh Csited States cvzsular ctcial or zecrttary of legatioa showiag tts zuthority of luecl ocial to aurizister caths sbould be anacted.

A certißed copy ef tze drath certiscate stould secompaoy this dlzim. If, for asy reason, it cannot be secured, give full anntiaa at the boitora ef this sbcet.

I the relatiooskip to tbs decgdest ef any persoa catitled to clim corepeosstion is tbat ol adoptioo, a certised copy of the er of adoplion should acccopany this clain.

Itenized bilt- in dupicate coveriag the msdieal and burisl expenses should be subuitted with the claieı.

Full nainc of deccased cruployce.
Ago...43 3. S. 4. OccupationSupco.Tioch
Was deccased ablo to speak English? Yes 6. Il not, whet lnguage?
Timo of injury: (c) (b) 23 (c) 1053. (a) 2:30 m
Pleco whero injury occurred (D:) (, ,  ) (Flxo er en
Nature end extent of icjury dooth

Rate of pay of deceased employce at timo of iajury which resulted in death, s.020,Q0- per .enzv. and subsisteeco velued at S.... per.

Did dacessed leava any other relatives entitied to comppusation?I so, give nates, eddresies, ages, end relationskáp below. irsee

nntdr emtrirr that each ard every statenent set forth abovo istee to the best of my knowledge ref. 1 .7

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ixkzny czktirr tlat the zuswers to the above questioss cre (rue to {be best oí y knouledge and belief.

i imp-niant that above certifcate be furuisbed, but if for any eaust it capuot bo secured, give full explssaticn balow wit seth otter proef ol desth as uay be obtzinzble.

CERTIFICATE OF OFFICIAL SUPERIOR

th a Ter No. C,  uzt ka t Bea, s r sus be d scps tit raa t eNsioa] iennor centrr thst the persoa on zcecount of whose death the forrgoiug thaina is made was coploscd by the Caited chca injured and efcal report ef death was msde ou 28 Noror 1955 (du)

R.. CIAES CERTIFICATE

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i. Full naao of injured employee :, 19
;. Tiro of injury . . . (D=jo(vut) (,. .?. 4) (Datc.) in

(Deyovul) (1our, c. m,  2.n.) m:

3. Did emplepee return to the same work and at saine rate of pey: cfter termination of disstillty f not, stato cheracter of work performed upea teturu to I so, when?. duty and rate paid employco for such work

... days. ). Actual time disabled (Gncluding Sundays and holidays) ... ). Actus e a --ntloon dissbled . davs.

1. Number of days for which employee would have receivéd pay had he not been disabled  days. tirvatiod ?. If employee wes recciving subsisteree as part of his wages, was such subsistecce furnished duriug entire perioa of disability If pot, give dates on which subsistenco wes not furnishéd

3. Has employee been paid for any portion of nbove absence en aecount ol (a) Anmual leavet (Gittcad (clee.) (b) Sick leave?. (Uite eret ccirs.) (c) Any otber reason..

[The fellswine inforpation is to be furniched only in eare ef death rezultine from an injury unstsined while in tice cerfortance of aty. I dah tss imuaelatciy, or if po kepor of lnjury has previsrsiy been sabaitted, auch report, en Fortn C. A. , shucld = forvatded herewith.]

. Time of death3 eve -1953 dtr) (074)

. Timo employee's pay stopped rzie 1953 L:so.am. () (je)

), Immediato cause of deathioereahock-en hszorige-oouleanz-rea fcl.ro.icath.leen.cr.hotsl.

Widow of deceosed einployeo.lico.Olon. R.EDore yan (Gimsru rame.)

. Children of deccased esployce under 1s years of age, or those over 1s wbo are incapable oí solí-suppor: Nome. 95 Erlo Wiclo Csen Lco Ticls Caca 7 5 Wls Wels Cren

3. Names, relationship. and addresses of nll other persons known to be dependent, in any degree, upoa deçedent at tive of death:

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295

1. Dep'met z.
3. Place of emé caeci
4. tuiez c

11 Occupation an2 divisioa a. Va empkyee doirg his rezula (Ch, t,;Lr) sork? YOS - Il aot, what woik?

1s. Dates of other injurics\_19 Hovenber 1953 is Aat2 of ini cavain daath on 23 cy.

16. Rate of pa on date of inju,, p  and ne valued a and quare valeed at  pr

17. Emplayee begins work zt 7:45 2.0. m. 18. Regclar ds work ends \_. 4:30 0.=. . (hou or .) (Host,e. n.o1 y.Li)

.. · 2C, Will employve rerrive pay fer any portion af atove sbsence an accreia éf (a) Anaual leave Ho (b) Sick leave (Giv ct is) Ho (Cire ceott ésts (e) Any other reason 1o

27. Deseribe in full hoy injury occured Ju fell Aro. tc lcorof hotol

28. State part of body injured znd natare and extent of injury Iultinbofractures henorrhaa res l4dne in docti

be ijur] + 29, Did injety cause loss of any member or pat of meaber?elE so, dessribe exectly

30. Was émployee injured ehite in pertorance of éaty?\_ If noia éouèt, cive dstalled statezent \_ Doath resultod fren ciretestances arisins ad o his official dutios

31. Was injury coused by: (c) Willid miscondurt of the enptovee? () Intentiozarlayee to brin abaet iajury er dea of hiaseif or antrr? (a) Empte's mtosen men foe t emelrion

s2. Was wrilten notice of injary given witaia ss hours?Ihot, did immediete superior hav artea! knowledge ef injary!

exãia 2 àrera 23. Names and addresses of witneases to injury \_. 653 1855 7Hans

S4. Was ijery cavd dy a thinl party cther thaa a Covenueat eanr ezaey? ? 1f rə, ha: eapyte ben jucractet ia petndute pader Phe Pereus ruatéz eopoyte ben jutructat la petedute uader Phe erea's tudaté?

5

Theijeed rzplojce

FLd eobcet

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I, Alice S:tth Elcla 01aon , behng duly sworn, on oath say that I ain resi
RED.55 city of county of
State of Harzland : that on the \_20th day ofNoyember 195
Husband (Paltinuia) Frank\_?udalch\_Olso.... (iane of decelent) had personal domicile in and wei a resida
.e city of 1 , county of Frsdarick and State of l
on said day diedl intestate; that burial expenses amounting to Sirehinzced asl. and fifty cents doli:
93.50 ) were ineurred, es per original itemized bills herewith; that the amount of \_lone. dollars (\$. ) has been paid on such burial expenses from funds belonging to
hat there is a balance of Six-hundrad and Det conts dolars(8693.50
nias unpaid. (:) (ere the sSant must state specißc fecls es iadicaled by instruetions on back of this form)

(Wll or ! no) be made to the Veteraus' Administration for lurial expenses; that at fhe timo of case conpensation. 35.... (Wa : was cct) . due said decedent from the Bureaa of Employees' Compensation, and re has been no adniinistration, and if any amounts payable under the Euzployees' Coinpensation Aet be paia, ristration will be requtired.

as to by said before mé, and subaerioad in m this day, at my aäce ia saiä eity. And I certify thet said afant is psrsonaily wel Lown to

NoTis -Rd earrfa"y ietrcticaen th huek befure evécatiaz tis cidavi