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.... -= ...................... __ """' ..... _.;, 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 D GUARD (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) D IN PAY DNONPAY O ' TEMPORARY DISABILITY STATUS STATUS' AETIRED LIST I AND TITLE OF VA OFFICIAl. 1 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- 26 7. 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 RETIRED- STATUS UNKNOWN J::] AVAILABI.E REQUESTED O'TEMS 8 69. AMD 1:1 TI"IROUGH 15 . IW:I RECORDS FORWARDED CORRECT r"r.I.TI!MS B B 9. AND 12 THROUGH III CORRECT, BKCBPT: 15 HOi 1 l"el. Healt.h not on f ile. If dates ",,1110 nlac'O's of trc -'? -tYnent are ir rnished 3n effort 'he ]":1r.'. 08 to 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 -I Y \ '0 ' TIT,!!; . .. ... .. J:-"::' f,-' SEIaY1C,EI Q , - _ . '..)" -,{::/./, IN 0 ,.T ",.i: ru: . ,,<. MATION , . .. . ·· . ... PHYSICAL X'RAYS . _ " , I I ' \ ... .. ".! ./ ,. DENTAL RECORDS DATE ' .. SIGNATURE AND t l'rt;E - ,: ,.. .. MEDICAL ' '-"IC' , .. '., .'. ,.. RECORDS AT SEPARATION - OTHER RECORDS \fA FORM OCT 1969 . .. . SUPERSEDES VA FORM07-3101. OCT 1968. WHICH WILL NOT BE USED. ' .. . -' .'. . 1
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Page 1: V~RIFII!D - WordPress.com

~~~~~~ .... -= ...................... __ """' ..... _.;, 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.

' .. . -' .'. ~;:~ . ' .

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