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DESCRIPTION BAW Boos 2 PAR Shoes Bun shocy F SMe + 25 each 3 sus ey /Prosthe GKGRAY §300-eney . 1 Om OTA Libel 5 undersmers PIS enh S under Panrs % IScack 1D HANOKERCHKIEFS BL gack J Soctés G Nes ‘ 4 Seach LAQES OvErcoaTy CAShmere Swearer Box Choco LATE SAo OLE TOTAL VALUE U.S. $ (local currency) . Do you have private insurance covering this loss? If so, state company and address: $ ressly understood and agreed by me that the furnishing of this form and any assistance furnished me by . employees ot DELTA AIR LINES, inc, are acts.of couite i shall not constitute a waiver of any rights or an admission of liability by or on the part of DELTA AIR LINES, INC, i tevplo've’s Br pagar vi her information and/or documents relating to this statement which are required by DELTA AIR LINES inc? Wi Belurnished by me upon request and shall be considered part of this statement. - AEs heeby warrant the foregoim mplete, true and | hereby make a claim against i . : = OFLTA AIR LINES, ty aS 19 CT The United Stated Post Olt invGStigative jurisdictio + télating to sending false or fraudulent claims through the United States ve mails. Ampcuch+ ceived by DELTA AIR LINES, INC., are reported to thr United States Postal Authorities. Losses of baygage in interstate shipment or of articles trom such baggage come within the purview of federal statutes relating to thefts from Interstate Shipment.ond, therefore, are___. subject to investigation by the Federal Bureau of Investigation. . 5 mon Tie ne rc State of countyat $$$ WAoc Sworn or affirmed the truth of before me this MI 4 day of, \3 wi} Notary Public’ nae tet poet