~~~~~~ .... -= ...................... __ """' ..... _.;, Approved Exception 10 SF 180 VETERAN.S ADMINISTRATION. " . TYPE of CLAIM
USAJ-I.C 11
REQUEST FOR INFORMATION 2. SEPARA"rION FORMS ON .FILI! 9. DATA REQUESTED
O'YES E1 NO _~ SERVICI! 0 MEDICAL 0 DENTAL O OTHER
4. BRANCH OF SERVICE
r¥. 0 OAIR 0 MARINI! o COAST CJARMY NAVY FORCE CORPS GUARD
SA. NAME AND ADDRESS OF VA REQUESTING OFFICI!
FROM VAC SAN JUaN FE - 455
6. LAST NAMI! - PIRST NAME - MIDDLI! INITIAL (Undo, whJch ........ d)
10. DATE OF BIRTH
13. DATE ENTERED
ACTIVE DUTY
A. 7-16-68 s. C.
B.
c.
17. ALLEGED DISEASE OR INJURY
II. PLACE OF BIRTH
Unk. 14. DATE SEPARATED FROM ACTIVE DUTY
7-15-70
18. DATES OF TREATMENT
JIJ(C
22A. SUBSEQUe:NT ,I:Se:RVE OR RETIRED STATUS .
' ONONE DREsERve: DBLIGATlON .(Compr ..... lt .. m 228)
22B. OBLIGATION TERMINAL DATE UC. RETIRED STATUS
NATIONAL ...., GUARD LJ(Anny)
NATIONAL
DGUARD (AIr)
SB. ORIGINATING UNIT
ADJ. DIV. (21)
III'.. ALL SERVICE NOS. ,..........
50 189 919
15. CHARACTER OF SEPARATION OR DISCHARGE
Unk.
19. PLACES OF TREATMENT
ORETIRED (Complele/lom 22C)
DIN PAY DNONPAY O 'TEMPORARY DISABILITY STATUS STATUS' AETIRED LIST
I ~G'f?'E AND TITLE OF VA OFFICIAl.
1 .~~AL E. A. FOX, ADJ. OFF. ENDORSEMENT VERIFICATION BY SERVICE DEPA!V'IAENT (Check applledl. 1>0>« ... »
O.RIG. }WP.
....,OTHER U (Spsc/ly)
6 . CLAIM NO.
C- 267. INSURANCE
9B. 601::IAL SECURITY NO.
12. DATE OF DEATH
16. LAST GRADE • .RATE;; OR RANK. AND ORGANIZATION
Unk o
20. ORGANIZATION AT TIME DISEASE OR INJURY
WAS INCURRED
O RETIREDSTATUS UNKNOWN
J::] AVAILABI.E REQUESTED O'TEMS 8 69. AMD 1:1 TI"IROUGH 15 .IW:I RECORDS FORWARDED V~RIFII!D CORRECT
r"r.I.TI!MS B B 9. AND 12 THROUGH III ~ERIFIED CORRECT, BKCBPT:
15 ~ HOi1 l"el.
Healt.h r~cord not on file. If dates ",,1110 nlac'O's of trc -'? -tYnent are i r rnished 3 n effort ~qill 'he ]":1r.'.08 to c~,taip rl"co" '(~S of aJlec:,pc! t·reabn::m+ .•
-
NO. 0 F ENCLOSURES ORIG. COpy t-_N_O_._E_N_C_I._S._f_C_OR_l'_) -t_O_R_IG_'J-C_O_P-IY " ~i:' :-(·'~-.~.:r- \ '0 ' SlGI+A~~' ~O TIT,!!;. ~~':;;&t\:' .. ~; ... .. J:-"::'f,-' SEIaY1C,EI Q , - _ . '..)" .'S.:\~ .~ -,{::/./,
~HE;.:;A;.;;L=-T:..:H.:....:..;cRE::.CO=R.::D:..:S'--+""':""-+_-II..:C.::L:..:IN:..:IC.::A",L::....:..;R.::ECO=R.;.:D:..:S'--f--+--I IN F~lu_ 0 ,.T oJ. ~. ",.i: ru: ~/!'...... . ,,<. ~';.;.-r MATION , . 11"r~-5."~ ... ··,· ....
PHYSICAL X'RAYS . _ " , ,~ . I I ' \ ..... ".! ./ ~~A:~~~;~O;i ,. DENTAL RECORDS DATE ' .. SIGNATURE AND t l'rt;E - "#&~- ,: ,.. ..
1~.!.-:::.1.-'.=c:.::;=---t--+--"U·::=":":::;"-"'==""---f--+--I MEDICAL ' '-"IC', .. '., .'.
~~~~II~~';.IONS ,.. I~M::.E::;D:..:I.::C:..:A:::.L..:..R,-=E,-=C.::O:..:RD:::S=--+_-+_-! RECORDS ~ AT SEPARATION - OTHER RECORDS
\fA FORM OCT 1969
. .. . SUPERSEDES VA FORM07-3101. OCT 1968. WHICH WILL NOT BE USED.
' .. . -' .'. ~;:~ . ' .
1