Ca5 Claim For Compensation By Widow Widower And Or Children Page 2

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Attending Physician's Report
2. Date of death (Mo., day, year)
1. Name of deceased employee (Last, first, middle)
4. If treated for disease, give diagnosis.
3. What history of injury or employment related disease was given to you?
5. If death was not instantaneous, describe the treatment you provided.
6. Show dates on which treatment
was given.
7. What was the direct cause of death?
8. What were the contributory causes of death, if any?
9.
In your opinion, was the death of the employee due to the injury as reported in item 3 above?
Yes
No
Give the medical reasons for your opinion, unless causal relationship is obvious.
10. Was a biopsy or an autopsy performed?
Yes
If yes, give name and address of physician
No
and arrange for a copy of the report to be
submitted.
11. Name and address (Please type - include ZIP Code)
13. Date signed (Mo., day, year)
12. Signature
Previous edition usable

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