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, zone, and State)
P. O. Box 127, Garibaldi, Oregon
THE PERSONS NAMED IN ITEMS 6, 8, AND 9, BELOW ALSO WILL 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 Age 36
ADDRESS (Number, street, city, zone, and State)
8623 Piney Branch Rd.
Silver Spring, Md.
7. CHILDREN
FIRST NAME—MIDDLE NAME—LAST NAME
Delbert Carroll NEWHOUSE
Anne Lisbet NEWHOUSE
ADDRESS (Number, street, city, zone, and State)
Same as wife
“ “ “
CHECK ONE
MARRIED SINGLE
x
x
SEX
M F
x x
x
AGE
13
11
(Continue on reverse side)
8. NAME OF FATHER (or male guardian) (First name, middle name, last name)
ADDRESS (Number, street, city, zone, and State)
9. NAME OF MOTHER (or female guardian) (First name, middle name, last name)
Edith May RICHTER Age 55
ADDRESS (Number, street, city, zone, and State)
P. O. Box 127, Garibaldi, Oregon
IN THE EVENT THAT I AM NOT SURVIVED BY A SPOUSE OR ELIGIBLE CHILD, OR OF 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, zone, and State)
P. O. Box 127, 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, zone, and State)
Orting, 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
California, Western States Life Insurance Co.
ADDRESS OF HOME OFFICE
Sacramento, Calif.
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
RECEIVE EACH MONTH
80 % OF MY PAY.
ADDRESS (Number, street, city, zone, and State)
8623 Piney Branch Rd., Silver Spring, Md.
MILITARY ADDRESS
U.S. Naval Air Station
Navy Number 14 (one four)
c/o F.P.O. San Francisco, Calif.
DATE SIGNED
14 DEC 1950
SIGNATURE OF DESIGNATOR
[Signature: D. Clement]
DD FORM 93 REPLACES NME FORM 93. 1 OCT 48: NAVMC 118 (15 PD); NAVPERS 601, PAGES 7 AND 8; AND NCG 2529, WHICH MAY BE USED UNTIL 1 JANUARY 1951. WHEN THEY WILL ALL BECOME OBSOLETE.
16—61480-1