RECORD OF EMERGENCY DATA FOR THE ARMED FORCES OF THE UNITED STATES
INFORMATION INCLUDED ON THIS FORM DOES NOT DESIGNATE OR CHANGE BENEFICIARIES OF LIFE INSURANCE POLICIES
*(See instructions on reverse side of form prior to making entries)*
1. DESIGNATOR’S LAST NAME—FIRST NAME—MIDDLE NAME
NEWHOUSE, Delbert Clement
2. SERVICE NO.
177283
3. GRADE, RANK, OR RATE
CHPHOT
4. SERVICE
□ USA
☑ USN
□ USAF
□ USMC
□ USCG
5. FIRST NAME—MIDDLE NAME—LAST NAME OF PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
(Person with permanent address is advisable)
Edith May Richter
RELATIONSHIP (If friend, so state)
Mother
ADDRESS (Number, street, city, and State)
General Delivery, Garibaldi, Oregon
THE PERSONS NAMED IN ITEMS 6, 8, AND 9, BELOW WILL ALSO BE NOTIFIED OF THE EMERGENCY. IF SUCH NOTIFICATION IS NOT DESIRABLE, DUE TO HEALTH OR FOR OTHER PERTINENT REASONS, PLEASE SO STATE UNDER “REMARKS” ON THE REVERSE SIDE.
6. SPOUSE (First name, middle name, last name) (If none, or if deceased or divorced, so state)
Norma Isobel Newhouse
ADDRESS (Number, street, city, and State)
S.E.
3581/Grant Court, Portland, Oregon
7. CHILDREN
FIRST NAME—MIDDLE NAME—LAST NAME
ADDRESS
(Number, street, city, and State)
MARRIED OR SINGLE
SEX
AGE
Delbert Carroll Newhouse
3581 S.E. Grant Court,
Portland, Oregon
Single
M
16
Anne Lisbet Newhouse
Same
Single
F
14
(Continue on reverse side)
8. NAME OF FATHER (or male guardian) (First name, middle name, last name)
Noah Frank Newhouse
ADDRESS (Number, street, city, and State)
General Delivery, Waldport, Oregon
9. NAME OF MOTHER (or female guardian) (First name, middle name, last name)
Edith May Richter
ADDRESS (Number, street, city, and State)
General Delivery, Garibaldi, Oregon
IN THE EVENT THAT I AM NOT SURVIVED BY A SPOUSE OR ELIGIBLE CHILD, OR IF THEIR DECEASE OR DISQUALIFICATION BEFORE PAYMENT OF 6 MONTHS’ GRATUITY IS MADE, I THEN DESIRE THAT PAYMENT BE MADE TO THE DEPENDENT RELATIVE SHOWN BELOW.
(See instruction 4 on reverse side of form)
10. FIRST NAME—MIDDLE NAME—LAST NAME
Edith May Richter
RELATIONSHIP
Mother
ADDRESS (Number, street, city, and State)
General Delivery, Garibaldi, Oregon
IN THE EVENT OF DEATH OR DISQUALIFICATION OF THE ABOVE-NAMED DEPENDENT RELATIVE, I THEN DESIGNATE THE ALTERNATE DEPENDENT RELATIVE SHOWN BELOW. (Other than spouse or child)
11. FIRST NAME—MIDDLE NAME—LAST NAME
Darrel Edwin Newhouse
RELATIONSHIP
Brother
ADDRESS (Number, street, city, and State)
Rt. 6, Box 756, Tacoma, Washington
VOLUNTARY ENTRIES
I REQUEST THAT THE FOLLOWING COMMERCIAL LIFE INSURANCE COMPANIES BE OFFICIALLY NOTIFIED IN CASE OF MY DEATH IN ACTIVE SERVICE. (The “Policy Number” should be entered if possible, since this information will assist in expediting action by the insurance company should a claim become payable.)
12. FULL NAME OF COMPANY
ADDRESS OF HOME OFFICE
POLICY NO.
(Continue on reverse side)
IN THE EVENT THAT I AM LISTED AS MISSING, OR BY OTHER MILITARY CIRCUMSTANCE AM UNABLE TO TRANSMIT FUNDS TO MY DEPENDENTS, IT IS MY DESIRE THAT—
13. FIRST NAME—MIDDLE NAME—LAST NAME
Norma Isobel Newhouse
RELATIONSHIP
Wife
ADDRESS (Number, street, city, and State)
3581 South East Grant Court, Portland, Oregon
RECEIVE EACH MONTH
100 % OF MY PAY
MILITARY ADDRESS
NSC, Oakland, Calif.
DATE SIGNED
5/14/54
SIGNATURE OF DESIGNATOR
[Signature: D. Newhouse]
DD FORM 93 REPLACES DD FORM 93, 1 JAN 50; NME FORM 93 1 OCT 48; NAVMC 118 (15 PD); NAVPERS 601 PAGES 7 AND 8; AND NCG 2529, WHICH ARE OBSOLETE.