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| Inspection Nr | 307060020 |
| Investigation Nr | 200122620 |
| Line Nr | 1 |
| Age | |
| Sex | |
| Nature of Injury | Concussion |
| Part of Body | Head |
| Source of Injury | Buildings/Structures |
| Event Type | Struck Against |
| Environmental Factor | Work-Surface/Facil-Layout Cond |
| Human Factor | Other |
| Occupation | Miscelaneous food preparation occupations |
| Degree of Injury | Fatality |
| Task Assigned | Task regularly assigned |