CLAIM FOR DEATH BENEFITS - CARANCI, JOHN C.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: CARANCI JOHN
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001411682
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: November 1, 1970

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.).
NAME
AGE
RELATIONSHIP TO
DECEASED
ADDRESS
1'
C:
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
ABOVE, GIVE NAME AND ADDRESS OF GUARDIAN AND ATTACH COPY OF THE APPOINTMENT PAPER
ISSUED BY THE COURT. NATURAL PARENTAGE OR CUSTODY AWARDED AS A RESULT OF A DIVORCE
DOES NOT CONSTITUTE. GUARDIANSHIP.
3. IF A GUARDIAN HAS NOT BEEN
APPOINTED, WILL ONE BE APPOINTED?
NAME
ADDRESS
YES NO
^
1. IF AN EXECUTOR OR ADMINISTRATOR HAS BEEN A
THE DECEASED, GIVE NAME AND ADDRESS.
HAS NOT BEEN APPOINTED, WILL ONE
BE APPOINTED?
YES ^ NO
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 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)