RECORD OF EMERGENCY DATA
SEE INSTRUCTIONS ON REVERSE BEFORE MAKING ENTRIES
1. DESIGNATOR'S LAST NAME—FIRST NAME—MIDDLE NAME
2. SERVICE NO.
3. GRADE OR RATE
4. SERVICE
NEWHOUSE, Delbert Clement
177283
CHPHOT
USN
5. MARITAL STATUS
6. FULL NAME OF SPOUSE
7. ADDRESS (Number, street, city, zone, and State)
Married
Norma Isobel NEWHOUSE
3581 S.E. Grant Court, Portland 15, Ore.
8. CHILDREN (List each child of any marriage. If none, so state)
FIRST NAME—MIDDLE NAME—LAST NAME
ADDRESS
MARITAL STATUS
SEX
DATE OF BIRTH
Delbert Carroll NEWHOUSE
3581 S.E. Grant Court, Portland 15, Oregon
Single
M
6/28/38
Anne Lisbet NEWHOUSE
3581 S.E. Grant Court, Portland 15, Oregon
Single
F
3/14/40
9. NAME OF ☒ FATHER OR ☐ MALE GUARDIAN
10. ADDRESS IF LIVING—IF DECEASED SO STATE
Noah Frank NEWHOUSE
Portland, Oregon
11. NAME OF ☒ MOTHER OR ☐ FEMALE GUARDIAN
12. ADDRESS IF LIVING—IF DECEASED SO STATE
Edith May RICHTER
Box 127, Garibaldi, Oregon
IN THE EVENT THAT I AM NOT SURVIVED BY A SPOUSE OR ELIGIBLE CHILD I DESIRE THAT PAYMENT OF 6 MONTHS’ DEATH GRATUITY BE MADE TO THE RELATIVE SHOWN BELOW. (The name of father or mother must be repeated if it is desired that he or she receive payment)
13. FIRST NAME—MIDDLE NAME—LAST NAME
14. RELATIONSHIP
15. ADDRESS
Edith May RICHTER
Mother
Box 127, Garibaldi, Oregon
16. ALTERNATE RELATIVE
17. RELATIONSHIP
18. ADDRESS
Darrel Edwin NEWHOUSE
Brother
Rt 6, Box 756, Tacoma, Washington
19. IN THE EVENT THAT I AM LISTED AS MISSING OR OTHER MILITARY CIRCUMSTANCES PREVENT ME FROM TRANSMITTING FUNDS TO MY DEPENDENTS, IT IS MY DESIRE THAT
FIRST NAME—MIDDLE NAME—LAST NAME
RELATIONSHIP
Norma Isobel NEWHOUSE
Wife
ADDRESS
RECEIVE EACH MONTH
3581 S.E. Grant Court, Portland 15, Oregon
90 PERCENT OF MY PAY
20. I REQUEST THE FOLLOWING COMMERCIAL INSURANCE COMPANIES BE OFFICIALLY NOTIFIED IN CASE OF MY DEATH IN ACTIVE SERVICE
NAME OF COMPANY
ADDRESS OF HOME OFFICE
POLICY NO.
Pilot Life Insurance Company
Greensboro, North Carolina
321583
California Western States
Sacramento, California
399422
National Service Life Insurance
Veterans Administration, Wash., D.C.
V-77-44-32
Government Life Insurance
Veterans Administration, Wash., D.C.
K 948 857
21. DESIGNATION OR CHANGE OF BENEFICIARY—SERVICEMEN’S INDEMNITY (P.L. 23, 82d Cong.)
(Does not operate as a designation or change of beneficiary of any insurance contracts issued by United States Government)
ALL PREVIOUS DESIGNATIONS OF PRINCIPAL AND CONTINGENT BENEFICIARIES, IF ANY, UNDER SERVICEMEN’S INDEMNITY ACT OF 1951, ARE HEREBY CANCELED, AND IT IS DIRECTED THAT SAID INDEMNITY BE PAID TO:
NAME
RELATIONSHIP
SHARE OR AMOUNT TO EACH BENEFICIARY
Norma Isobel NEWHOUSE
Wife
100 per cent
WITNESSED BY (Signature on all copies)
G. L. LUCAS
SIGNATURE OF SERVICEMAN (Sign all copies)
[Signature]
GRADE OR RATE OF WITNESS
Lieutenant-USNR- R
SERVICE NO.
290572
DATE SIGNED
30 March 1955
DD FORM 93 1 FEB 52 Replaces DD Form 93, 1 Jul 50, which may be used.
18-67492-1