RECORD OF EMERGENCY DATA
SEE INSTRUCTIONS ON REVERSE BEFORE MAKING ENTRIES
C-1
1. DESIGNATOR'S LAST NAME—FIRST NAME—MIDDLE NAME
2. PRESENT SERVICE NO.
3. RANK/RATE
4. SERVICE
5. DATE OF BIRTH
NEWHOUSE, Delbert Clement
177283
CWO4
USN
6-5-13
6. HOME ADDRESS AT TIME OF LAST ENTRY INTO SERVICE (City, county, and State)
7. FORMER SERVICE NO.
Garibaldi, Tillamook, Oregon
393 07 21
DESIGNATIONS
FIRST NAME—MIDDLE NAME—LAST NAME
ADDRESS
RELATIONSHIP
8. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Norma Isobel NEWHOUSE
3581 SE Grant Court
Portland, Oregon
Wife
9. BENEFICIARY FOR GRATUITY PAY IN EVENT THERE IS NO SURVIVING SPOUSE OR ELIGIBLE CHILD
PRINCIPAL
Edith May RICHTER
PO Box 127
Garibaldi, Oregon
Mother
CONTINGENT
Darrel Edwin NEWHOUSE
Rt. 6, Box 756
Tacoma, Washington
Brother
10. BENEFICIARY FOR SERVICEMEN'S INDEMNITY (PL 23, 82d Congress) (All prior designations are canceled. Designation for indemnity does not affect insurance (NSLI or USGLI) beneficiary designation)
PRINCIPAL(S)
SHARE $
Not Applicable. NSLI
SHARE $
CONTINGENT(S)
SHARE $
SHARE $
11. BENEFICIARY OR BENEFICIARIES FOR UNPAID PAY AND ALLOWANCES (PL 147, 84th Congress)
SHARE 100 %
Norma Isobel NEWHOUSE
3581 SE Grant Court
Portland, Oregon
SHARE %
Wife
12. PERSON TO RECEIVE ALLOTMENT OF PAY IF MISSING OR UNABLE TO TRANSMIT FUNDS
PERCENT OF PAY EACH MO. 80%
Norma Isobel NEWHOUSE
3581 SE Grant Court
Portland, Oregon
Wife
13. PERSON TO RECEIVE PERSONAL EFFECTS FOR SAFEKEEPING
Commanding Officer
14. COMMERCIAL INSURANCE COMPANIES TO BE NOTIFIED IN CASE OF DEATH IN ACTIVE SERVICE
FULL NAME AND ADDRESS OF COMPANY
ADDRESS OF OFFICE RECEIVING PAYMENT OR HOME OFFICE
POLICY NO.
California Western State Life Insurance Company
Sacramento, California
399422
FIRST NAME—MIDDLE NAME—LAST NAME (If deceased, so state)
ADDRESS
15. FATHER
Noah Franklin NEWHOUSE
Unknown
16. MOTHER
Edith May RICHTER
PO Box 127, Garibaldi, Oregon
17. WIFE OR HUSBAND (If none, so state)
Norma Isobel NEWHOUSE
3581 SE Grant Court, Portland 15, Oregon
18. NAME OF CHILDREN (If none, so state. If step or adopted, so state)
ADDRESS
MARRIED
SEX
DATE OF BIRTH
YES
NO
Delbert Carroll NEWHOUSE
3581 SE Grant Court, Portland, Oregon
X
M
6-28-38
Anne Lisbet NEWHOUSE
3581 SE Grant Court, Portland, Oregon
X
F
3-14-40
19. ORGANIZATION AND ADDRESS OF DESIGNATOR
20. DATE SIGNED
Utility Squadron FIVE, NAVY #3835, c/o FPO, San Francisco, California
2-9-56
21. SIGNATURE OF WITNESS
22. SIGNATURE OF DESIGNATOR
A. C. WALKER, LT, USNR-R
DELBERT CLEMENT NEWHOUSE
DD FORM 93-1 1 OCT 55
For Navy, Marine Corps, and Coast Guard use: Will be used in lieu of DD Form 93.