Part 41, page 71

Transcript

The scan is the source; the transcript is machine-generated from it.

STATEMENT OF PERSONAL HISTORY

INSTRUCTIONS: Read the certification at the end of this questionnaire before entering the required data. Print or type all answers. All questions and statements must be completed. If the answer is "None," so state. Do not misstate or omit material fact since the statements made herein are subject to verification. If more space is needed, use the Remarks section, item 20, and attach additional sheets if necessary. The information entered hereon is for official use only and will be maintained in confidence.

1. (Print) FIRST NAME—MIDDLE NAME—MAIDEN NAME (If any)—LAST NAME [X] MR. Harold Allen Countryman

2. STATUS X CIVILIAN | MILITARY ON ACTIVE DUTY

3. ALIAS(ES), NICKNAME(S), OR CHANGES IN NAME (Other than by marriage) None

4. PERMANENT MAILING ADDRESS 6814 - 30th NE, Seattle, Wash. 98115

5. DATE OF BIRTH (Day, month, year) 5 Dec 33 PLACE OF BIRTH: Yakima, Yakima, Washington PLACE CERTIFICATE RECORDED: Seattle, Washington, 27Dec33

RACE: Cau HEIGHT: 5'10" WEIGHT: 155lbs COLOR OF EYES: Blue COLOR OF HAIR: Blonde SCARS, PHYSICAL DEFECTS, DISTINGUISHING MARKS: ½" Scar right knee cap

6. DO YOU HAVE A HISTORY OF MENTAL OR NERVOUS DISORDERS? YES [X] NO ARE YOU NOW OR HAVE YOU EVER BEEN ADDICTED TO THE USE OF HABIT FORMING DRUGS SUCH AS NARCOTICS OR BARBITURATES? YES [X] NO ARE YOU NOW OR HAVE YOU EVER BE[EN]... USE[R] [IN] EXCESS OF ALCOHOLIC BEVERAGES? YES [X] NO CAUTION: SPECIAL HANDLING REQUIRED

7. U.S. CITIZEN: [X] YES NATIVE: X YES IF NATURALIZED, CERTIFICATE NO.: N/A IF DERIVED, PARENTS' CERTIFICATE NO(S): This material copied from records of National Personnel Records Center, St. Louis, Missouri, for reference only. Do not reproduce or disseminate in its original form outside

ALIEN: N/A REGISTRATION NO: N/A NATIVE COUNTRY: N/A

8. MILITARY SERVICE ARE YOU PRESENTLY ON ACTIVE DUTY IN THE U.S. ARMED FORCES DRAWING FULL PAY? YES [X] NO

GRADE AND SERVICE NO.: 1st Lt - 05 703 722 SERVICE AND COMPONENT: Army-USAR / MPC-USAR ORGANIZATION AND STATION: H/HCo, 2nd Bn, 104th Regt (AIT), Renton, Wash.

HAVE YOU PREVIOUSLY SERVED TOURS OF EXTENDED ACTIVE DUTY: [X] YES COUNTRY: USA SERVICE: Army COMPONENT: MPC FROM (Date): Mar 53 TO (Date): Mar 56 TYPE DISCHARGES OR SEPARATIONS—GRADE AND SERVICE NO.: Hon Cpl E-4 RA 19 469 110

9. EDUCATION Sep40 - Jun46: Garfield Grade School Yakima, Wash - x - 6th Grade Sep46 - May48: Skykomish Jr High Skykomish, Wash - x - 8th Grade Sep48 - May52: Skykomish High School Skykomish, Wash - x - 12th Grade Oct52 - Feb53: University of Washington, Seattle, Wash - x - 2 yrs ACD GED Test US Army

10. FAMILY FATHER: Roswell I. Countryman, 20 Feb 1889, Foley, Minn, 1721 Conger, Olympia, Wash, X MOTHER (Maiden name): Ethel M. Tallman, 15 Jul 1891, Cambridge, Minn, 1721 Conger, Olympia, Wash, X SPOUSE (Maiden name): Floreta F. Warrington, 21 Feb, 1932, Tulsa, Oklahoma, 6814 - 30th NE, Seattle, Wash, X OTHER (Specify) Father-in-Law: Jacob Warrington, 2 Nov 1899, Oklahoma, 4424 Dayton, Sacramento, Calif, X, b6 Per NPRC (Mother-In-Law): Rosalee O'Neal, 11 Oct 1901, Arkansas, 4424 Dayton, Sacramento, Calif, X

DB Cooper 12001