CLAIM FOR DEATH BENEFITS - CARANCI, JOHN C.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: CARANCI JOHN
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001411683
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 3
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: August 21, 1970

OFFICE OF FEDERAL EMPLOYEES'
GROUP LIFE INSURANCE
4 East 24th Street
Now York, Now York 10010
PART B.. PERSONAL INFORMATION CON
ERNING THE DECEASED ,
PART A. GENERAL INFORMATION CONCERNING THE DECEASED
1. FULL NAME OF THE DECEASED (Lost) (First) (,Lliddfa) 2, DATE OP 'BIRTH
3. DATE OF DEATH
,
MR. Month Day Year Month Day
n miss CARANCI John C.
Feb. 7, 1922 Jul. 14,1970-,
Central Intelligence Agency,
8WAS DECEASED RETIRED AND RECEIVING AN.
NUWTY UNDER ANY FEDERAL CIVILIAN RETIRE.
MENT SYSTEM, INCLUDING OLD-AGE AND SUR'
VIVORS INSURANCE (SOCIAL SECURITY)?.
DATE OF RETIREMENT..~..".t ,j. -....... ....._..
Washington, D.C.
6. DOMICILE-(Legal Residence at Time of Death-City and Slate)
Providence. Rhode Island
P. (a) WAS-DECEASED ON ACTIVE DUTY IN THE MILITARY FORCES OF THE U,. S. AT TIME OF DEAT
YES tiJ NO
APPROVED FOR
RELEASE DATE:
10-Nov-2008 ,
R DEATi BENEFITS
FEDERAL EMPLOYEES' GROUP LIFE
INSURANCE ACT
2.. YOUR RELATIONSHIP TO
THE DECEASED
1 THE'DECEASED NAMED YOU AS BENEFICIARY ON STANDARD FORM 54 attach a receipted
copy of the Designation of Benefiiary,(Standard Form 54) to this claim, give your, age and reliatioi "' .,
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.
1. HOW MANY-TIMES WAS.
DECEASED MARRIED?
one
2. WAS THE DECEASED SUR-
VIVED SY ANY CHILDREN?
I ,I YES I""I NO
T. YOUR NAME
M R~
3:' GIVE NAME OP EACH SPOUSE (Including all
-W former marriages)
4. HOW WAS MARRIAGE TER-
MINATED? (check one In
each ca")
n DEATH (".~y.DIVORCS
E J DEATH 0 DIVORCE
^ DEATH I""1 DIVORCE
.PART C. INFORMATION CONCERNING THE, CLAIMANT'
FILLING OUT THIS FORM,
READ INSTRUCTIONSrtEoRE;
ORGANIZATION ~t
TIME ODEATH
fRaplmenP,.G~a,r.e-s~
Relationship to,
Deceased
9/21/644
3. YOUR DATE OF BIRTFI
Month Day, ?
None
THROUGH 14 It YOU ARE THE WIDOW OR WIDOWER OF THE DECEASED.
7. WERE YOU LIVINO WITH DECEASED AT TIME OF DEATH?
M YES ^ NO
I PLACE Of MARRIAGE (City and State)
P. IF YOU WERE DIVORCED FROM DECEASED, GIVE DATE AND PLACE OP DIVORCE
MONTH I DAY I YEAR CITY I STAT$
Ibli61
Ib1I31
GRADE OR RANK
MARRIAGE WAS PERFORMED It f l CLERGYMAN OR 1UETICD OF FfAC
OTHER (Specify) . ' a
E. IF NOT LIVING WITH DECEASED AT DEATH, WAS THERE A
pjy
L. ED (^I NO
...I LJ ..i
10. IF SEPARATED BUT NOT DIVORCED, ATTACH A SIGNED ; SlAS
11. HOW MANY TIMES
WERE YOU MARRIED?
12. GIVE NAME OF EACH SPOUSE (include oU
former marriages)
13. HOW WAS MARRIAGE TERMIN4TED?
(Check one in each case)
11 DEATH ^ DIVORCE
DEATH 0 DIVORCE
DEATH f'""1 DIVORCE
 DiI TN PARTS D. AND E. ONLY IF YOU ARE NOT THE DESIGNATED BENEFICIARY OR THE WIDOW OR WIDOWER OF THE DECEASED.
L List bilow the name, ago, rrlattonship, and address oft
(a) Widow at wldowar;
(b) It there Is nu surviving widow or widower, Ilat the child or children of all this docoosoti's ma,tleges (Inrl+ .IVng r+ l+,vt,- l rI+ Id e..IlIeulllma+p
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 are 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.).
RELATIONSHIP TO
DECEASED
Son
Son
FILL IN BLANKS 2. AND 3. ONLY IF ANY OF THE PERSONS LISTED ABOVE ARE UNDER AGE 21,
2. IF A GUARDIAN HAS BEEN APPOINTED BY THE COURT FOR THE ESTATE Of ANY MINOR CHILDREN 3. IF A GUARDIAN HAS NOT BEEN
4 ABOVE, GIVE NAME AND ADDRESS OP GUARDIAN AND ATTACH COPY OP THE APPOINTMENT PAPER ,4PPOINTED, WILL ONE BE APPOINTED?
;i.- ISSUED-BY THE COURT. NATURAL PARENTAGE OR CUSTODY AWARDED AS A, RESULT OP A DIVORCE
DOES NOT CONSTITUTE. GUARDIANSHIP.
El YES El NO
PART E. INFORMATION CONCERNING THE ESTATE OF.THE DECEASED
1.' IF AN EXECUTOR OR ADMINISTRATOR HAS BEEN APPOINTED BY THE COURT TO SETTLE THE ESTATE OF
THE DECEASED, GIVE NAME AND ADDRESS.
NAME
2. IF AN EXECUTOR OR ADMINISTRATOR
HAS NOT BEEN APPOINTED, WILL ONE,
BE APPOINTED?
YES
1..Is'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 retirement is prior to the date injuries
we're sustained which caused the death of the insured.
^ YES
C-j NO
12 NO
I, hereby certify that all statements made in this claim are true to the best of my knowledge, information and belief, and that no evidence
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 subject 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)
u ,st, _~` ' ,_1970
.s guardian for
 tat of QInnnrrtirut
COUNTY OF LITCHFIELD,
DISTRICT OF SALISBURY, S
I, Therese Stanton, Clerk of the Probate Court for the District of Salisbur;
hereby certify that at a Probate Court held at Salisbury, in and for said District, on the 28th da
of October, in the year of our- Lord one thousand nine hundred seventy
was duly appointed Guardian of the Estate of
in said District, a minor, and she
accepted said appointment and gave bon
to the acceptance of the Judge of said Court for the due performance of said trust according to law.
I ALSO CERT[F41, that it appears by the records aril files of said Court, the
said appointment is now in full force.
IN WITNESS WHEREOF, I have hereunto set my hand and the seal of sai
Court, this 28th day of October, in the year of our Lox
one thousand nine hundred seventy.
..........................................................................
'tatr of C1Innni rtirut
COUNTY OF LITCHFIELD,
SS. PROBATE COURT
DISTRICT OF SALISBURY, ti.
Therese Stanton, Clerk
of the Probate Court for the District of Salisbury,
hereby certify that at a Probate Court held at Salisbury, in and for said District, on the 28th
of October, in the year of our Lord one thousand mime hundred seventy
was duly appointed Guardian of the Estate of
in said District, a minor, and she
day
accepted said appointment and gave bond
to the acceptance of the Judge of said Court for the due performance of said trust according to law.
I ALSO CERTIFY, that it appears by the records and files of said Court, that
said appointment is now in full force.
IN WITNESS Wlll,'ItEOF, i have hcrcuni set my hand rand I.he real of said
l.' out., I hi>, 2801 cloy of 0(: It tuber it, the year of r)ur,Lord
one lhousnnrl nine hundred seventy.