v2362-681
Finger Prints Taken
Cash advance of $50.00.
Hospitalization of wife.
Quest from Civil Service,
Eespondent's Exhibit No. 6 (Continued)
Name of Relatives
ELIGIBILITY FOR BENEFITS
No Calif. Unemploymt
Unemployment Reason
Waiting Period
Probationary Period
IN CASE OF ACCIDENT NOTIFY
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
Group Insurance ^
'es Policy No. 13523 8-n4-40
Amount ieeftOS
BENEFICIARY Add'l
$1,000
4-30-41 2000 Total
Name Gatha Fislier Relationship Vi
e
Phone
Street No.
1800 t
State Calif.
Name
San Diego, Relationship
Phone
Street No.
City
State
Name
Relationship
Phone
Street No.
City
PHYSICAL CONDITION
State
Eight Eye
Left Eye
Wears Glasses No
Teeth
Right Ear
Left Ear
Heart
Eight Hand
Left Hand
Eight Arm
Left Arm
Eight Limb
Left Limb
Eight Foot
Left Foot
Right Lung
Left Lung
Hernia No
Truss -iVorn No
Hemorrhoids
No
Subject to Fits
No
Vaccinations
Yes
Varicocele
SERIOUS ILLNESS None
OPERATIONS None
COMPENSATION RECORD
Date
Company Cause
Amount
archive.org Volume Name: govuscourtsca9briefs2362
Volume: http://archive.org/stream/govuscourtsca9briefs2362
Document Link: http://archive.org/stream/govuscourtsca9briefs2362#page/n680/mode/1up
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