16.

days.

17.

For what period, from the date of accident is disability likely to exist?

weeks

State in patient's own words, how accident occurred.

I, - -, a Notary Public (or Justice of the Peace) for the State of residing at do hereby certify that on this - day of A. D. 19, personally appeared before me, the above named a physician in regular standing and to me well known, and made oath in due form of law that the foregoing statements, and each and all of them are full and true of his (her) own knowledge, and are made without reservation or concealment.

In witness whereof, I have hereunto set my hand and affixed my notarial seal the day and year last above written

(Seal.)

Notary Public (or Justice of the Peace).

§ 265. Proof of death and certificate authorizing burial

PROOF OF DEATH FROM UNDERTAKER

STATE OF

County of

street No.

(city or town) at day of

says that he is a duly licensed undertaker of -; that as such he was required on the 19, to prepare the dead body of for burial; that he placed said body in a coffin and placed said coffin containing the said body in a (grave,

vault, or express car) in

cemetery (cemetery, crematory, or mauso(relative, friend, etc.) at

leum); that he shipped said body via

to

(address); that he was directed to conduct such burial by

That no part of

said bill of expense so authorized for said burial has been paid, except:

I,, hereby certify that I have read the foregoing affidavit of undertaker; that I authorized the items of expense therein amounting to of deceased workman.

as the

(Signed)

(Person authorizing burial sign here.)

at

We command you, that all and singular, business and excuses being laid aside, you appear and attend before the Industrial Commission of — on the day of - -, 19, at the hour of — o'clock M., then and there to testify in the above entitled matter, now pending before said Industrial Commission of in which is being investigated

and that you bring with you and then and there produce the following described books, papers and records:.

and for a failure to attend you will be deemed guilty of contempt and punished according to law.

Given under the seal of the Industrial Commission of · of, 19—.

Witness:

(Seal.)

day

this

§ 267. Petition for review

PETITION FOR REVIEW OFf Agreement OR DECREE

Applicant(8)

V.

Respondent(s).

Accident Commission that the above named parties on

the above named applicant-, hereby gives notice to said Industrial

day of

19, made an agreement for compensation approved by the Commission (or

that a decree was made by said Commission) that the

name) should pay to

(employé's full name) the sum of

week for and during the term of

weeks.

(employer's full dollars per

That since said decree (or agreement) was made the injury for which the employé was compensated has ended (or increased, or diminished). Said applicant further shows that the accident upon which claim for compensation was based in this matter occurred on the day of at the town (or city) of -, county of sulted in (state full result of injury)..

and State of

——, 19—, and re

The postoffice address of the above named applicant is office address of the respondent(s) is as follows:

and the post

The above named applicant prays for the following relief in that said compensation as originally given may be ended (or increased, or diminished). (Signed)

NOTICE OF HEARING OF PETITION FOR REVIEW OF AGREEMENT OR

day of

To the above named parties and each of them: Notice is hereby given that on the 19, notice and application for petition for review of agreement (or decree) for compensation in the above entitled matter was filed with the Industrial Accident Commission at its office in and that a true copy of said notice and application is hereto attached.

You will further take notice that a hearing in accordance with the provisions of (section and act) will be held on the - day of 19—, commencing at o'clock in the -noon of said day.

at

You are further notified to be present at the time and place fixed for said hearing and be prepared to proceed with the same.

§ 269. Lump sum settlements

AGREEMENT FOR REDEEMING LIABILITY BY PAYMENT OF LUMP SUM

Received of

dollars and

by me, the total sum of

(name of employer or insurer) the lump sum of cents, making in all, with weekly payments already received dollars and cents, a weekly payment having been continued for not less than six months. Said payments are received in redemption of the liability for all weekly payments now or in the future due me under the Workmen's Compensation Act, for all injuries reday of —, 19, while in the em

ceived by me on or about the ploy of

(name of employer and address), subject to the approval of the

Industrial Accident Commission.
Witness my hand this

day of

Witness

(Name)

(City or town)

(Street and number)

19.

(Name of employé)

(City or town)

(Street and number)