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: 
November 1, 1970
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Form FE-6 (10-64) OFFICE OF ?EDERAL EI'APLOYEES' GROUP LIFE INSURAN~E 4 East 24th Street New York, New York 10010 1111161 (b1131 READ INSTRUCTIONS BEFORE FILLING OUT THIS FORM. PART A. GENERAL INFORMATION CONCERNING THE DECEASED 1. FULL NAME OF THE DECEASED (Last) MR. MRS. MISS 4. DEPARTMENT OR AGENCY IN WHICH LAST EMPL INCLUDING BUREAU OR DIVISION 8. WAS DECEASED RETIRED AND RECEIVING AN- NUITY UNDER ANY FEDERAL CIVILIAN RETIRE- MENT SYSTEM, INCLUDING OLD-AGE AND SUR- VIVORS INSURANCE (SOCIAL SECURITY)? ? YES ^ NO GIVE CLAIM NUMBER, T( IF KNOWN .......................................................................... IF RETIRED, SHOW DATE OF RETIREMENT ................... ..................... CLAIM FOR DEATH BENEFITS - FEDERAL EMPLOYEES' GROUP LIFE INSURANCE ACT,, 1) .r (First) (Middle) ()H-4 C. 2. DATE OF BIRTH Month Day Year P B 2 7 1922 5. LOCATION OF LAST EMPLOYMENT (City and State) W SHING-TQ1NT DC 6. DOMICILE-(Legal Residence of Time of Death-City and State) 64 Eddy St Centerd:ale R.I. 9. (a) WAS DECEASED ON ACTIVE DUTY IN THE MILITARY FORCES OF THE U. S. AT TIME OF DEATH? ^ YES ? NO 9. (b) IF "YES," STATE BELOW IF THE DECEASED NAMED YOU AS BENEFICIARY ON STANDARD FORM 54 attach a receipted copy of the Designation of Beneficiary (Standard Form 54) to this claim, give your, age and relation- ship in the box to the right, and complete Part F. on the other side. IF A RECEIPTED COPY OF STANDARD FORM 54 IS NOT ATTACHED, YOU MUST COMPLETE ALL PARTS OF THIS CLAIM FORM. ORGANIZATION AT TIME OF DEATH (Regiment, Co., etc.) Your Age 25 Relationship to Deceased 1. HOW MANY TIMES WAS DECEASED MARRIED? 3. GIVE NAME OF EACH SPOUSE (including all former marriages) 4. HOW WAS MARRIAGE TER- MINATED? (check one in each case) 5. DATE MARRIAGE WAS TERMINATED One ^ DEATH DIVORCE Oct 61 DEATH DIVORCE 2. WAS THE DECEASED SUR- VI VED BY ANY CHILDREN? ^ ^ ? YES 0 NO ^ DEATH ^ DIVORCE AP PROVED FOR RELEASE DATE: 10 -Nov-2008 1. YOUR NAME (Last) (First) (Middle) 2. YOUR RELATIONSHIP TO 3. YOUR DATE OF BIRTH MR . THE DECEASED Month Day Year . CaLranci , John s. Jr. MR Son ,-) T - , W, -I - 21, /AT ; T1945 S FILL IN BLANKS 4 THROUGH 14 IF YOU ARE THE WIDOW OR WIDOWER OF THE DECEASED. 4. DATE OF MARRIAGE . PLACE dF MARRIAGE (City and State)' 6. RRIA E WAS PER ORIJIED BY Month Day Year F-1 CLERGYMAN OR JUSTICE OF PEACE ?!; ~( O3R (Specify) )'. 7. WERE YOU LIVING WITH DECEASED AT TIME OF DEATH? 8. IF NOT LIVING WITH DECEASED AT DEATH, WAS THERE A DIVORCE? ^ YES a NO ^ YES NO 9. IF YOU WERE DIVORCED FROM DECEASED, GIVE DATE AND PLACE OF DIVORCE 10. IF SEPARATED BUT NOT DIVORCED, ATTACH A SIGNED STATE- MONTH DAY YEAR CITY STATE MENT GIVING COMPLETE DETAILS COVERING PERIOD OF SEPARA- TION INCLUDING DATE AND CAUSE OF SEPARATION AND WHO , LEFT THE OTHER. 11. HOW MANY TIMES 12. GIVE- NAME OF EACH SPOUSE (Include all 13. HOW WAS MARRIAGE TERMINATED? 14. DATE MARRIAGE WAS TER- WERE YOU MARRIED? former marriages) (Check one in each case) MINATED ^ DEATH ^ DIVORCE DEATH ^ DIVORCE ^ DEATH ^ DIVORCE 3. DATE OF DEATH Month Day Year JULY 1g 1970 7. DATE OF FINAL SEPARATION (If Different From Date of Death) Month Day Year 1. List below the name, age, relationship, and address ofi (a) Widow or widower; (b) If there is no surviving widow or widower, list the child or children of all the deceased's marriages (including adopted child or illegitimate child, stating which class it is) and the descendants of any deceased child or children; (c) If there are no children, list the parents; if one or both parents ore deceased, so state and give the date of death; (d) If there are no survivors within the degrees indicated in (a) through (c), list the next of kin who may be capable of inheriting from the deceased (brothers, sisters, descendants of deceased brothers, sisters, etc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s claim being made for death benefits by accidental means (injuries solely sustained through violent, external and accidental means)? If "YES" submit 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 separation or retiremept is,. prior do the date injuries were sustained which caused the death of the insured. I hereby certify that all statements made in this claim are true to the best of knowledge. necessary to a settlement of this claim is suppressed or withheld. WARNING.-Any intentional false statement in this claim or willful misrepresentation relative thereto is subjeci to punishment by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001) 1 Nov 1970 (NAME OF CLAIMANT-TYPE OR PRINT)