Part 18, page 110

Transcript

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Policy Number A 059973 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $60,000 Capital Sum (Scheduled Air) $30,000 Principal Sum (Other Acc.) PREMIUM $5.25

BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none

COMBINED PREMIUM $________ Term of Coverage: _______ Days Countersigned by

--- Please Print --- Name of Insured: [REDACTED b6/b7C] Occupation: [REDACTED b6/b7C] Address of Insured: [REDACTED] City: La Grande State: Ore. ZIP Code: [REDACTED] Name of Beneficiary: [REDACTED] Address of Beneficiary: [guess: Same] [partially illegible handwriting] City: [blank] State: [blank] ZIP Code: [blank]

Effective at: Hour 7:30 p.m. ☒ Date 11-24-71 Place: PDX

Personal Signature of Insured: [REDACTED] AGENT: [blank]

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Policy Number A 059974 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $60,000 Capital Sum (Scheduled Air) $30,000 Principal Sum (Other Acc.) PREMIUM $5.25

BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none

COMBINED PREMIUM $________ Term of Coverage: 3 Days Countersigned by

--- Please Print --- Name of Insured: [REDACTED b6/b7C] Occupation: [REDACTED b6/b7C] Address of Insured: [REDACTED] City: Portland State: Ore. ZIP Code: [REDACTED] Name of Beneficiary: [REDACTED] Address of Beneficiary: [guess: Same] City: [blank] State: [blank] ZIP Code: [blank]

Effective at: Hour 7:40 p.m. ☒ Date 11-24-71 Place: PDX

Personal Signature of Insured: [REDACTED] AGENT: [blank]

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DB Cooper-5443