Part 45, page 28

Transcript

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

RECORD OF EMERGENCY DATA FOR THE ARMED FORCES OF THE UNITED STATES

1. DESIGNATOR'S LAST NAME—FIRST NAME—MIDDLE NAME LIST, John Emil

2. SERVICE NO. O978253

3. GRADE, RANK OR RATE 2nd Lt

4. ORGANIZATION 9206 TSU-TC Ft. Mason, Calif.

5. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY (First name—Middle name—Last name) Mrs. Alma M. List ADDRESS (Number, Street, City and State) [redacted]

RELATIONSHIP (If friend, so state) Mother

[Middle name—Last name] Miss Augusta List ADDRESS (Number, Street, City and State) [redacted] b6 per NPRC b7C

RELATIONSHIP (If friend, so state) Aunt

7. CUSTODIAN TO WHOM PERSONAL EFFECTS ARE TO BE SHIPPED (First name—Middle initial—Last name) Mrs. Alma M. List ADDRESS (Number, Street, City and State) [redacted]

RELATIONSHIP Mother

8. AS A GUIDE IN ADMINISTERING LEGISLATION GOVERNING THE WELL-BEING AND PROTECTION OF MY DEPENDENTS IN THE EVENT THAT I AM UNABLE TO MAKE PROVISION THEREFOR, IT IS MY DESIRE THAT

FIRST NAME—MIDDLE INITIAL—LAST NAME Mrs. Alma M. List ADDRESS (Number, Street, City and State) [redacted]

RELATIONSHIP Mother

A. 100 PERCENT OF MY PAY RECEIVE EACH MONTH OR B. _______ DOLLARS

PERSON TO RECEIVE SIX MONTHS GRATUITY PAY

9. SPOUSE (Given name—Middle initial—Last name) (If none, or if deceased or divorced, so state) NONE

ADDRESS (Number, Street, City and State) b6 per NPRC b7C

10. CHILDREN FIRST NAME—MIDDLE NAME—LAST NAME [blank]

ADDRESS (Number, Street, City and State) [blank]

DATE OF BIRTH [blank]

ACTUAL RELATIONSHIP [blank]

11. IN THE EVENT THAT I AM NOT SURVIVED BY A SPOUSE OR ELIGIBLE CHILD, OR ON THEIR DECEASE OR DISQUALIFICATION BEFORE PAYMENT IS MADE, I THEN DESIGNATE PAYMENT BE MADE TO THE DEPENDENT RELATIVE (other than spouse or child) SHOWN (one only). (If designation of a dependent relative is declined, state in your own handwriting: "I decline to designate any person to receive this pay.")

FIRST NAME—MIDDLE NAME—LAST NAME [handwritten] I decline to designate any person to receive this ADDRESS (Number, Street, City and State) [handwritten] Pay

RELATIONSHIP [blank]

12. IN THE EVENT OF DEATH OR DISQUALIFICATION OF THE LAST NAMED DEPENDENT RELATIVE, I THEN DESIGNATE AN ALTERNATE DEPENDENT RELATIVE (other than spouse or child). FIRST NAME—MIDDLE NAME—LAST NAME [handwritten] I decline to designate any person as [illegible] ADDRESS (Number, Street, City and State) [handwritten] this pay

13. I UNDERSTAND THAT THIS FORM DOES NOT DESIGNATE OR CHANGE LIFE [obscured by stamp] POLICY [obscured] THAT ANY SUCH DESIGNATION OR CHANGE CAN ONLY BE EFFECTED BY SEPARATE [obscured]

SIGNATURE OF DESIGNATOR [handwritten] John Emil List

SUBSCRIBED AND SWORN TO BEFORE ME THIS 30th DAY OF November 1950

SIGNATURE OF OFFICER ADMINISTERING OATH (First name—Middle initial—Last name) [signature]

NAME OF OFFICER ADMINISTERING OATH (Print or type) Elwood G. Penner

GRADE OR RANK 1st Lt TC

SERVICE NO. 01 951 186

ORGANIZATION 9206 TSU, TC, SFPE Ft Mason, Calif.

NME FORM NO. 93 REPLACES WD AGO FORM 41, 1 NOV 45, WHICH IS OBSOLETE.

DB Cooper-4651

U.S. GOVERNMENT PRINTING OFFICE: 1948—O—808820

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CAUTION: SPECIAL [illegible] from records [guess: of] Louis, Missouri [guess: a copy] [illegible] Personnel Records [illegible] reference [guess: to] its original to be [guess: disseminated] [illegible] the Bureau

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