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. day of Witness (Name) (City or town) (Street and number) 19. (Name of employé) (City or town) (Street and number) |