Document Type: 
Document Number (FOIA) /ESDN (CREST): 
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Original Classification: 
Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
December 31, 2008
Sequence Number: 
Case Number: 
Publication Date: 
August 24, 1970
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APPROVED FOR RELEASE DATE: corm FE-6 (10.64) OFFICE OF FE GROUP LI Now York, DERAI EMPLOYEES' FE INSURANCE 24th Street Now York 1C010 CLAIM FOR DEA Ei4EF TS FE3 ERAL VMPI,O`: EES, GROUP LI INSUANCE ACT 1. FULL NAME OF THE DECEASED (Last) MR. MRS. CARAi:''CI, John C. MISS 4. DEPARTMENT OR AGENCY IN WHICH LAST EMPLOYED, INCLUDING BUREAU OR DIVISION Central Intelligence Agency 0. WAS DECEASED RETIRED AND RECEIVING AN- NUiTY UNDER ANY FEDERAL CIVILIAN RETIRE. MENT SYSTEM, INCLUDING OLD-AGE AND SUR- ViVORS INSURANCE (SOCIAL SECURITY)? li YES ^ NO GIVE CLAIM NUMBER, If KNOWN .................... 2, DATE OF BIRTH Month Day Year Feb. 7, 1922 5. LOCATION OF LAST EMPLOYMENT (CUY and State) (bl(61 (b1(31 READ INSTRUCTIONS BEFORE. FILLING OUT THIS FORM. 3. DATE OF DEATH Month Day Yec Jul. 1, ,a?:. 7. DATE OF FINAL SEPARATION (If Different From Date of Dea9 t West In On J) . C . , Month Day "Yen , 11 9, (a) WAS DECEASED ON ACTIVE DUTY IN THE MILITARY FORCES OF THE U, S. AT TIME. OF DEATH? E YES (~ HO 9. (b) IF "YES," STATE BELOW BRANCH Of SERVICE 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. cage and relation- ship in the box ito the right, and complete''Part F. on the. other side. IF A RECEIPTFD COPY OF STANDARD FOW 54 IS HOT ATTACKED, YOU MUST. COMPLETE ALL PARTS OF THIS CLAIM FORM. PART B. PERSONAL INFORMATION- CONCERNING, THE DECEASED ORGANIZATION AT TIME OF DEATH (Regiment, Co., etc.)` Relationship to, ,Deceased son' 1. HOW MANY TIMES WAS 3o GIVE NAME OF EACH SPOUSE (including all 4. HOW WAS MARRIAGE TER- 5. DATE MARRIAGE WAS DECEASED MARRIED? former marriages) MINATED? (chock,;one in . TERMINATED?-: '.. If, each case) f t DEATH DIVORCE Sept, s , ORCE DI 2. WAS THE DECEASED SUR- DEATH V D VIVEDSYANYCHILDREN? 1`7~-7 YES NO D DEATH !"] DIVORCE 1. YOUR NAME (Last) (First) (Middle) 2. YOUR RELATIONSHIP TO 3. YOUR DATE OF BIRTH THE DECEASED Month Day ' Yaar MR. FILL IN BLANXS 4 THROUGH 14 IF YOU ARE THE WIDOW OR WIDOWER OF THE D E 4. DATE OF MARRIAGE S. PLACE OF MARRIAGE (City and Stafe) b'. MARRIAGE WAS PERFORMED BY. . Month Day Year (") CLERGYMAN OR JUSTICE OF PEAC L__I OTHER (SpecIfy), 7. WERE YOU LIVING WITH DECEASED AT TIME OF DEATH? 3. IF NOT LIVING WITH DECEASED AT DEATH, WAS THERE A DIVO RCE YES 1""1 NO YES f "1 NO 9. IF YOU WERE DIVORCED FROM DECEASED, GIVE DATE AND PLACE OF DIVORCE 10. IF SEPARATED BUT NOT DIVORCED, ATTACH A SIGNED 'STAT! MONTH DAY YEAR CITY STATE MENT GIVING COMPLETE DETAILS COVERING PERIOD OF SEPAL TiON, INCLUDING DATE AND' CAUSE OF SEPARATION AND; WH LEFT THE OTHER. 11. HOW MANY TIMES 12. GIVE" NAME OF EACH SPOUSE (Include all 13. HOW WAS MARRIAGE TERMINAITED? 14. DATE MARRIAGE WAS 1114 WERE YOU MARRIED? former marriages) (Check one in each case). MINATED {??1 DEATH ("1 DIVORCE f"1 DIATH DIVORCE 1 ""1 DEATH f 1 DIVORCB FILL .4 PARTS 0. AND F. a 1LV 10 VMIJ AD4' KIe%T ^!e In, _KlATPrs nenecefa+.xnu a.e rur e. ..._ PART D. INFORMATION CONCERNING NEXT OF KiN OF LrGCEASED Li 4 below the name, age, relationship, and address oft (c) 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; (tj' 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.). NAME AGE RELATIONST11P TO DECEASED ADDRESS FILL IN BLANKS 2. AND 3. ONLY IF ANY OF THE PERSONS LISTED ABOvE ARE UNDER AGE 21. t, - 2.`;IF A GUARDIAN HAS BEEN APPOINTED BY THE COURT FOR TH= ESTATE OF ANY MINOR CHILDREN -ABOVE, GIVE NAME AND ADDRESS OF GUARDIAN AND ATTACH COPY OF THE APPOINTME T A 3. IF A GUARDIAN HAS NOT BEEN A N P PER ISSUED BY THE COURT. NATURAL PARENTAGE OR CUSTODY AWARDED AS. A RESULT OF A DIVORCE DOES NOT PPOINTED, WILL ONE BE APPOINTED? CONSTITUTE. GUARDIANSHIP;. JAMS, ADDRESS ^YES ^ NO PART E. INFORMATION CONCERNING THE ESTATE OF THE DECEASED 1.31' AN EXECUTOR OR ADMINISTRATOR HAS BEEN APPOINTED BY THE COURT TO SETTLE THE ESTATE OF sYHN DECEASED, GIVE NAME AND ADDRESS 2. IF AN EXECUTOR OR ADMINISTRATOR , HAS NOT BEEN APPOINTED, WILL ONE TAMP. ADDRESS BE APPOINTED? 1YES ( NO PART F. CERTIFICATION' BY-CLAIMANT 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 , ^ YES fl NO 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 retiietnent is prior- to the date injuries " wee sustained which caused the death of the insured. I hereby certify that all statements made in this claim are true to the best of my knowledge, information that no evidence ' ttecesiary to. a settlement of this claim is suppressed or withh WARNING.-Any Intentional false statement in? this claim or willful misrepresentation relative fhereto is subject to punishment by a fine of not --- (NAME Of -TYPE OR PRINT) more than $10,000 or imprisonment of not more ,than 5. years, or both. (18 U.S.C. 1001) STANDARD FORM 56 JANUARY 1970 AGENCY- CERTIFICATION Of INtSURANGE STATJ~~:_