CLAIM FOR DEATH BENEFITS - CARANCI, JOHN C.
Document Type:
Keywords:
Collection:
Document Number (FOIA) /ESDN (CREST):
0001411684
Release Decision:
RIPPUB
Original Classification:
U
Document Page Count:
4
Document Creation Date:
June 22, 2015
Document Release Date:
December 31, 2008
Sequence Number:
Case Number:
F-2007-00327
Publication Date:
August 24, 1970
File:
Attachment | Size |
---|---|
DOC_0001411684.pdf | 391.79 KB |
Body:
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~~:_