Document Type: 
Document Number (FOIA) /ESDN (CREST): 
Release Decision: 
Original Classification: 
Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
December 31, 2008
Sequence Number: 
Case Number: 
Publication Date: 
April 22, 1970
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1. YOUR"NAME (Last)(first)' (Mlddto) 2 YOUR RELAT!ONSH.IP T6a 3. YOUR DATE OR BikTH THE DECEASED Month ays ~az.anC .. 2alin ;an FILL IN ELM4 C91"A' TNRi9LIL35I 'T; `?tF YOU l `Tliffi WIDOVIt OR ' iiVIDOWER OP THE DECEASEDf. s k R 4,-DATE OF MARRIAGE S. PLACE OP1MARR IAGE (Clty and State) 6, MARRIAGE WAS PERFORMED Month' Day Year (" I CLERGYMAN 0* JU$ CI( Lj t, f OTHER YSpeclfy) k s ~. " 7. WERE YOU LIVING WITH DECEASED AT TIME OF DEATH? `8. IF NOT LIVING WITH DECEASED AT DEATH, WAS THERE k Itl YES NO 1J YES 1""I NO x a r .. L~ L _1 9. IF YOU WERE DIVORCED FROM DECEASED, GIVE DATE AND PLACE OF DIVORCE . ' 10. IF SEPARATED BUT--NOT DIVORCED, ATTACH A $1001 MONTH DAY YEAR CITY STATE 0M MENT GIVING COMPLETE DETAILS COVERING PERIOD OF5VON_ INCLUDING DATE AND CAUSE OF SEPARATION LEFT THE OTHER. 11. HOW MANY TIMES 12. GIVE NAME OF EACH SPOUSE (Include off 13. HOW WAS MARRIAGE TERMINATED? 14. DATE MARRIAGE WERE Y04 MARRIED? former marriages) (Check am in each case) i MINATED I i DEATH f"1 DIVORCE C f'" 1 DEATH (?I DIVORCE r t g DEATH DIVORCE 2- WAS THE DECEASEDSUR VIYFD;BYANYCHILDREN? YES DNO E DIVORCE DIVORCE , DATE;MARRIAOE TERM1HA`TED "'-" , Fqr~ FED (10 641 ,OFFICE OF FEDERAL EMPLOYEES' GROUP LIFE INSURANCE 4 East 24th Street New York, Now York 10010 1..-PULL NAhtE:OF HP QECEASED MR MRS. MISS Cenral l a;telligerzce Agency 8.'WAS, DECEASED,-RETIRED AND' RECEIVING-AN. NUTTY UNDER ANY `FEDERAL CIVILIAN RETIRE- MENTSYSTEM,. INCLUDING OLD-AGE AND SUR. VIVORS INSURANCE.(SOCIAL SECURITY)?, YES, NO APPROVED FOR RELEASE DATE: 10-Nov-2008- PART A ' c ENERAL. INFORMATION CONCERNING THE DECEASED CLAIM FOR DEATH $ENEFITS FEDERAL EMPLOYEES' GROUP LIFE Jul,-* i4. , 19 6 1 7 .,'DATE OF FINAL' SEPARAT3{ (lf Different Fr Dotvz 27w - ~ YES "~ Nv IF THE DECEASED' NAMED YOU, A$ BENEFTCIAR` C Iii STANDARD FORM .54 attach :ce iecel t+ed, copyof the :C9 signation of" Beneflc9c Ord, Form } fa than ctaam, give your, age and relate ship id the;box "to fhe'a?ig}ht, ans#.'complete Part F., 14 other side, IF A RECEIPTED COPY O. STANDARD FORM' 54 15 NOT ATTACHED, YOU MUST COMPLETE ALL PARTS OF THIS, c AiM PART INFORMATION' CONCERNING THE CLAIMANT O RGANIZA"DTI TIMB OFEAT ARE NOT THE DESIGNATED BENEFICIARY` OR THE Wt' "W OR WIDOWER OF THE DECEA*.:'O. PART ,' INFORMATION CON NEX>~"OF esN OF DECEASED (a) Widow or widower; (b) If there is no surviving widow or widower, fist the child or children of all, the deceased's marriages (including adopted; child or )ilegitiglgttt 1'. List below the name, age, relationship, and address off child, stating which class it is) and the descendants of any deceased child or chiidan; .. .. ,' (c) if there are no children, list the parents; if one or both parents are deceased, so state and give the date of death; (d)" If there are no survivors within the degrees indicated itt (a) through (c), list the, next of kin who may be capable of inheriting from tk t deceased (brothers, sisters, descendants of deceased brothers, sisters, etc.). NAME AGE RELATIONSHIP TO DECEASED. ADDRESS S?n Spr1. Son Sow IN' ONLY IF ANY OF THE PERSONS LISTED ABOVE ARE UNDER AGE 21: , 5r AND 3 LL IN L . FI B ANKS 2. 2 IF A GUARDIAN HAS BEEN APPOINTED BY THE COURT FOR THE ESTATE OF ANY MINOR CHILDREN TMENT PAPER 3. IF A GUARDIAN HAS NOT BEEf+I WILL ONE BE- APPOINTEDF APPOINTED ABOVE, GIVE NAME AND ADDRESS OF GUARDIAN AND ATTACH COPY OF THE APPOIN , ISSUED MY THE COURT. NATURAL PARENTAGE OR CUSTODY AWARDED AS A RESULT. OF A DIVORCE DOES NOt CONSTITUTE. GUARDIANSHIP. YES NO " NAME ADDRESS x3' v. "Ya .tea 1 IF AN EXECUTOR OR ADMINISTRATOR HAS BEEN APPOINTED BY THE COtiRT TOSETTLE THE ESTATE OF Z- If3 AN EXECUTOR OR ADMI.ttNISTR` tr ..,.. ..fir nee~t ?nnr., s14L,1 /IAI '.. PART, E. INFORMATION CONCERNING THE ESTATE OF THE DECEASED PARTI,F. CERTIFICATION BY CLAD 1.',I4 claim being made for death benefits by accidental means (injuries solely sustained through violent, external and accidental means)? If "YES" subTtlit coroner's and police reports, news clippings and-'any other available 'reports concerning the accident. No claim for such benefits can be considered if the date of insured's separtatign or. retirement I4 prior_.; injuries were sustained which caused the death of the 1nt;4ited: I hereby certify that all statements made in this claim are true to the` best of my knowledge, information. and belief, and that- n necessary to a settlement of this claim is suppressed or withheld. WARNING.---Any Intentional false statement im this ,Rleinl or willful misrarraaentrstInn relative therein Is sablecl in f uelshlnei t by n fine of not more then $10,000 nr Imprl-anrnget. of not more than S years, or both. (18 U.S.C. 1001) (NUMBER AND STREET) _ 12 ,Buatvl?t .0970' 5; { (DATE)