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AITLICATIOH! FO: NEATH RERTTIS CIVH. SIRVICE R OREMEMI! SYSTEM Mio!i Ar't. ti .ue il posi. Inthts ndm as.id dlay: i. Ted carefully th "Tnomation lor the Aoplican on twe. st.s of d.. sl.et; 2. Con !te ajrliratim in futl 3. ll answcr to any qnestion is "tu" c1 "none" so state; 4. Type or 1 1 5. A. PLSOHAL TIORAAHOHI CONCTRNNG TTE TECIASED (t.(t) (Maale) DAE EIRTH 3.DATECATH MA (Du+i (Yrr) Hoover, John Hogar 1/1/1895 5/2/1972 DOrit., t in Givi tnNi Of ECr srousi rinimh ail jumt . HoW WAS MAERIAGE TER 3.DATE MARRIAGE WAS ef in MATEDC one iN TERMINATED enhcac) Washington, D.C. HAA DIVORCE 5.HOWPAY HSWAS D(IASLD DEATH M..h.I.I.7 DIVORC none DEAT DIVORC DEFAUMNT OR AGT IN Y/CH IAS MPIOYID, NCIUNC EUXEAU 2.LOCTCOFASEPOYAT 3.DATE O FINAI SEPARATION OP VSIJN (City and State) (Month) {Duy) (Year) Fedcral Buronu of Investigation. Washington, D.C. 5/2/72 WAS LCASD RHIANDA[ 5IF AGIVE CL NUMER, 6. D DECEAS!D HAVE A SCCIAL 7.IF ANSWER TO ITEM 6 IS YES' CEIVINA, CIVH St KtKl AINJITY? I FNOWN SECURITY iILIMBER? GIVE DECEASED'S SOCIAL SECU RITY ACCOUNT NUMEER G no CSA E] rES no 577-60-1114 IF DCE.SEDHAD REIIRED ACTIVE DUIY, WHIC TEIAINATED UNDTR HOHRAE!E CONDIONS. I ANT OF THE FOLLOWING SERVICES, COMPLETE THE SCHEDULE BELV. TO THE BIST CF YOUIR ACILIY I AVAILAEEATTACHA COPY OF THL DISCHARGFCERTIFICATE (o) AFAY, NAVi.MAFIF CCRP, AIR HCHCEOR COAST GUARD OF THE UNHTED STATES,OR L) R.CUR CCRFS O RESERVt COKiS CF THI FUTIIC H[AITH SRVIE AFi{k RUNL 30. 196OOR AS CVIIC.D OFFICFR CF 1H COAST ANi>GEODEIC SURVtY AFTEP JUNE 30I9OR Id) AS A CCAMISSC'IiI OIHICLK INTH EVIKONALNTA SCIENCt SERVICES ADMINISTRATICH DA.TE CF ENIR/.HICE DATE OF SEPARATION LASI GRADE ORGANIZATION AT DISCHAR SEV SERIAL NO. ON ACIIVE DUTY FROM ACIIVL DUIY OR RANK (Dir..Krgieut,C... ch.) C. INIORMATION CONCTRNING TIE APPLICANT YOUFNAE (last) (Iint) (Midlh ) 2.YOUPREIATIOISHIP j.YOUR DATE Of TO TH DECEASFD M57/2271986) HRT Tolson, Clyde A. Executor 4.ARIYUACHUITEDSTTSANERICA S. w answer io nea 4ts "Nc," OF what cOuriry are yoU a Ctizen? (Pbox Cn []s1[X] Fill in iter's G thruagh I6 if yui are the y ihow or w idougr of the deceused.. 6.LA CI MF 7.PACEMAKIE MARRIAGE WAS PERF OR,AtD 6Y 9.WERE YOU LIMIiG WITH DECEASED (Momb)(3.o) (Yer) Stte ) SLERGYMAN OR JUSTICE OI AT TME OF DEATH? ]OTEk (Spify) ] ye$ no 10.WEF YEVE 2VE NArnSPm frr 13.HOWWAS AATRIACE A 14.DATE MARRIAGE 15. DO YOU HAVE A DIVOKCED FROM murrirges) MIATED? (Chct onr in WAS TERMINATED SOCIAL SECURITY cahcn) ACCOUNT NUMBER? DE CEaSED? rIs]NO DEAT DIVOkCE EMISiS YES," ] DEATH DIVORCE NUI GIVE TOUR NUMBER WIRE YOU MASRIED? IVORCE Hews I7. 13, and s9. a! ddy outy if yon are th. s inloue? ( busband) of tbe deceased.. 17.AP[ YCINCAPFI OF SFF 18 DID YOU RiCEIF MORE THAN 3Iu # ONY 'SaA.. JNY # ONY 4I SWJ HIOa Ot StaANSNY JnOA # 61 SUPFCAT BECAUSI CDIS H HALF YOUR SUPPOKT FROM DECEASED DHED WIL STHL EAFLOYED AFTER AT LEAST I NONTHSCIVIUAN Aelthy? THE DiCtaSED? SKVICE, AIIACH A SEPARATE SHEET GIVING FULL PARYICULARS ABOUI YOURE [] res [7 no yeS [ no DIS ASLITT AH THE EXTE! OF SUIPDRT FROM THE DECEASD AND A SUMMARY OF YOUR INCOME TROML ALL SOUSCES D. INFORMATION CONCH I:IINIG THE ESTATF OF THE DECEASED 2IF AN EXECUTOR OR ADWNISIA DECESD, gio +As ATs or H! ExI cinor C: Ab+naisT,Aie?. TOE HAS NOT BEN APPOINTLO. HANE Abunss c/o Rjggs National Bank WULL ONE E APPOINTED? Personal Trust Diyision, P.o. 1 Box 1149 res ] no Chyds A. Tojson Hashington, (CONTINUF ON OTHER SIDE) STANDARD FORM 2800 Rcempe.1969