RECORD OF EMERGENCY DATA
SEE INSTRUCTIONS ON REVERSE BEFORE MAKING ENTRIES
1. DESIGNATOR'S LAST NAME—FIRST NAME—MIDDLE NAME
NEWHOUSE Delbert Clement
2. PRESENT SERVICE NO.
177283
3. RANK/RATE
GHPHOT(W4)
4. DATE OF BIRTH
6/5/13
5. RELIGION
Prot.
6. HOME ADDRESS AT TIME OF ENTRY INTO SERVICE
P.O. Box 127 Mrs. VencI Richter
Garibaldi, Oregon
7. PRIOR MIL. SERVICE
☑ Yes ☐ No
(DATE LAST ENTRY)
8. FORMER SERVICE NO.
393 07 21
9. SOCIAL SECURITY NO.
540-46-3224
FIRST NAME—MIDDLE NAME—LAST NAME (If deceased, so state)
ADDRESS
10. WIFE OR HUSBAND (If none, so state)
Norma Isobel NEWHOUSE
208 Bryant Road, NP, Pensacola, Florida
11. NAME OF CHILDREN (If none, so state. If step or adopted, so state)
Delbert Carroll NEWHOUSE
Anne Lisbet NEWHOUSE
ADDRESS
Same as Block #10
MARRIED
YES ☐ NO ☑
SEX
M x
F x
DATE OF BIRTH
6/28/38
3/14/40
12. FATHER
Noah Frank NEWHOUSE
ADDRESS
? Tacoma, Washington
13. MOTHER
Edith May (Newhouse) RICHTER
ADDRESS
P.O. BOX 127, Garibaldi, Oregon
14. ADULT NEXT OF KIN NOT NAMED IN ANY OTHER ITEM
Darrel Edwin NEWHOUSE
ADDRESS
304 Labor Temple, Tacoma 3, Washington
14a. ALL PERSONS RECEIVING MORE THAN 50 PERCENT OF THEIR SUPPORT FROM ME (OTHER THAN WIFE OR CHILDREN UNDER 21)
Florence Estelle STROM
ADDRESS
Portland, Oregon
4619 N. Michigan Avenue/
RELATIONSHIP
Mother in Law
DATE OF BIRTH
5/4/81
15. PERSON(S) NAMED ABOVE WHO ARE NOT TO BE NOTIFIED DUE TO ILL HEALTH
None
ADDRESS
DESIGNATIONS
16. BENEFICIARY FOR GRATUITY PAY IN EVENT THERE IS NO SURVIVING SPOUSE OR ELIGIBLE CHILD(REN). NAME PARENTS OR BROTHERS OR SISTERS ONLY (P. L. 881 84th Congress).
FIRST NAME—MIDDLE NAME—LAST NAME
ADDRESS
RELATIONSHIP
Edith May RICHTER
P.O. Box 127
Garibaldi, Oregon
Mother
Darrel Edwin NEWHOUSE
304 Labor Temple
Tacoma, Washington
Brother
Noah Frank NEWHOUSE
Tacoma, Washington
Father
17. BENEFICIARY OR BENEFICIARIES FOR UNPAID PAY AND ALLOWANCES (P. L. 147, 84th Congress). PERCENT OF SHARES MUST TOTAL 100 PERCENT.
100 %
Norma Isobel NEWHOUSE
Same as Block #10
Wife
%
18. PERSON TO RECEIVE ALLOTMENT OF PAY IF MISSING OR UNABLE TO TRANSMIT FUNDS.
PERCENT OF PAY EACH MO.
100
Norma Isobel NEWHOUSE
Same as Block #10
Wife
19. INSURANCE POLICIES IN FORCE INCLUDING USGLI AND NSLI (Agencies 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.
National Service Life Insurance
Government Life Insurance
Veterans' Administration,
Munitions Building, Washington 25, D.C.
V774432
K948857
20. SERVICE ORGANIZATION AND ADDRESS OF DESIGNATOR
Naval Air Technical Training Unit, NAS, Pensacola, Florida
DATE SIGNED
19 Aug 1957
21. SIGNATURE OF WITNESS
Mrs. Mabel M. Kirkland
22. SIGNATURE OF DESIGNATOR
Delbert Newhouse
DD FORM 93-1 1 Dec 56 Previous Editions are obsolete. For Navy, Marine Corps, and Coast Guard use: Will be used in lieu of DD Form 93.