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Siamdord bo obs 4br yor, + oom, CLA FOR UNCAIB COMPENSATION Or BECEASED CIViLTAN EMPLOYEE : (KO DESIGNATED BENEFICIARY OR SURVIVING SPOUSE) 7 we a a E ° cae 41 rad! Woes a dayetecenea) Laceodie make: claim a6 xecutor fax amnunte dun fram tha Bs , oe é Phy Lit hbdbatad egw, grea wbey Pagers Madi adh Cha? | - ine i te "hi ' ee eee eee ee | GlLAVUMAILoO MUL abaees REL “so elatiouship : United States or the Distriet of Columbia in the case of . John Edgar Hoover oe cease staseecpesentestesce (Nam: of dercdent) whodiedon the 799 day of May ,1972.. pac MEM Sa to At the titne of death the deccdent was a legal resident of The District of Columbia ..............,.Stetecf ee . , and was employed by the United States or the District of Columbia as follows: Fedsral Tureau of Investigation -— Do partaie nt and bureau, “agency, © or r eatublishment} ee eee ee eee 3. The deceased is survived by the following: Widow or widower (if noe, 80 state): Naine Childven (Show ench Heine child of the darease Tf mane co atatel- Meek OE Qa eda Phd) Raa ak Li Ul Catia, an UHI, OF BLaLt sy. Name of Child Age Street Address, City, State, and ZIP Code none 7 week bene eee teen e cece eee tree ece Gewsceepeevsr snes 0 gecenesaewee ve ceeee seeeecececeecuseeeeeesceeecescecaeuueeee ecucceccuccermecnenssececee ensanecmmaneeness 7 Grandchildren (List only the children of deceased children. If none, so state): Name, Age, Strect Address, City, State, aud ZIP Code Name of Deceased Parent none wetetaneecees . So cececaeseeteceseeensteccsceeeceaceegseeeneeaeeesctetues 0 weapereeseeesenesscappp aeeseseneneseeecacrneatersea “he CM paraysaph 3 is executed the or on b& ‘halt of 4 children o or . prandchildren ¢ of the de ceased, divreyard paragraphe 4, 6, 6, and 7} 4. If no widow or widower, child ar grandchild survives, enter below the name and address of each surviving parent, and state whether natural, step, foster or adoptive parents, (If none, so state.) Name ef Parent Strect Address, City, Statc, and ZIP Code Woathar none se Guiti . oo. . . co peapeeseea cece ade epee en mene sep ence een eee eee b es Ce enka ee meee Father. FOMe cecceegctscueucuevitees cates cceetteee conse tice apueusesiersnsnaesiesensniscieenes ccntene caesceeseceeneeecstesuess aay ie yes i 1 “UES you are the surviving ‘parent (81 ‘of th. dereneed, dintevard paragraphs §, 6 and 7) sy LOTT DATOS HRT RRO LT ROR TL ee capa Met omen ET et GMI nt gm Nee AA TE SRO ORES RIRUTIBE BO RE me NAR aR TE FE atari ge ae ' y ty