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SCORE-Bench

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01 17 1940
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3. What history of injury or employment related disease was given to you?
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N/A
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4. If treated for disease, give diagnosis.
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N/A
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5. If death was not instantaneous, describe the treatment you provided
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Blunt force trauma
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6. Show dates on which treatment was given.
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7. What was the direct cause of death?
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Horseriding accident
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8. What were the contributory causes of death, if any?
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N/A
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9. In your opinion, was the death of the employee due to the injury or employment related disease as reported in item 3 above?
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[x]
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Yes [] No
Give the medical reasons for your opinion, unless causal relationship is obvious.
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10. Was a biopsy or an autopsy performed? []Yes
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[x]
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No
Arrange for a copy of the report to be submitted.
11. Name, specialty, and address of physician (Please type - include ZIP Code)
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Ashley Wilks
Coroner
Atlanta GA 30303
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I certify that the statements in response to the questions asked above are true, complete, and correct to the best of my knowledge. Further, I understand that any false or misleading statements or any misrepresentation or concealment of material fact which is knowingly made may subject me to criminal prosecution.
12. Signature
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Ashley Wilks
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13. Date signed (Mo., day, year)
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01 / 10 / 2002
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Form CA-5 PAGE 2 (Rev. 10-2020)
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Worker’s Claim for Benefits Under the Energy
Employees Occupational Illness Compensation
Program Act
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U.S. Department of Labor
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Office of Workers’ Compensation Programs
Division of Energy Employees Occupational
Illness Compensation
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• DEPARTMENT OF LABOR • UNITED STATES OF AMERICA
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Note: Please read the instructions on page 2 before filling out this form. Provide all information requested, and sign and date the bottom of page 1. Do not write in the shaded areas.
OMB Control No: 1240-0002
Expiration Date: 05/31/2028
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864 29 75
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Employee Information (Please Print Clearly)
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1. Name (Last, First, Middle Initial)
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WELLS, HELENA G