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HomeMy WebLinkAbout1875 i yG 2'70053 TM~ s~~ aECOao ~ 1~: 1 Ul4T NAYEfti15T NAYEJ~OIE qAME 2. SERVICE lAJ40BER 1 SOCML SEGIlpITV MJNOER H T.. . ,rl . ^~i . ~ / n. r Q V~~.?J ,:..~tl ~~1.'...L':~ s..liv~ I',F / ~C ~ ? oEawra~+r. to~r~a+o+r wrv ew~e+t?~ ow cu~ss s. ai+woe. a?~ ow awt~c a vw~~ a p,~Te owr wwtm ve~u+ oF ~ _~_~s-_:;;.: ~t,_;r~ C.' ~:~:~:._l3 ~rJ~ -1; ""..c 1C _.ov ~ 7. V S. C(TIZEN l PIACE Of 9NTM IL1r r/!~~ ~?~Ifl 9 OATE OAY MOMTN VEAR l. 1 ~ ~ 1 ~YES QMO 1t,.~J~~:ti.v'.~'..~~ :~.1.c~..~L_c3 ~tTM ~ ~ t~~. -yCi ~ Oa SELECTNE SERVICE MJYBER ? SEIECTNE SERV~CE IOCAI B~MD lIUMBER. CR~I. COIJNTY. STATE A!~ ZIP COOE t- OATE 1lQ1CiED ~~F owr ro~vrr rE~?rt - ~ ~ n ~n ~ - - ` ~ i. i,V _L:~ i_- 7...: :~CT'v il`"'..CE'.~ 'i.GT~l'1~''.. ii-r~C ~ ~'~"2' -u lla 7~1PE OF TRANSFER OR O~SCMARC+E • STATION OR NSTALLATION AT W WCN EFFECTEO ~ ..i1d~1~c::e.~., .:e:__<~:~y < ' ~ = e. REASON AND AUT?aOq~TY a DAV MONTM YEAR t~ a - - - - : . _ - ni ..i_ _'_~I: _~1:iJL:___.t on~ 17 ;G ~O 2 U?ST CUTV ILSS~GNrMENT w?aD Mn~OR COMwAt~D l3a G'ARACTER OF SERVICE L T/P£ OF CERTFCATE 65UE0 :,p ; ~ j;~- . ~ ~1. ...~-_.:._'L ..i... ~i_i.v.l:_:+ ~J .`OT' : .:jj ~ ~ ~ - . K 1< pSTtt~CT. AREA CW~Mw?'~D OR CORPS TO W?iCN iiESERV~ST TRANSFERFtEO . 1S. REE?A15TYEHT COOE , ~ . TERIM OF r. pATE OF ENTRY 6 TERYWAL DI.TE Oi RESERYE' 17 CURRENT ACTNE SEqVICE OTHER THAN BY tNOl1CTIpP1 UYIi65 Oea.~Gl?TqW a SOURCE OF EHiR1I- R~ACE DA~/ MONTH YEAR OAY ~lp~TM YEM ~ ENI~STED 15nt L~e~, . ~ Er~l6TE0 ~Ro Selonl ~ REEIVl15TEO ~ _ ~OTNER :.t1 g PR~QR REGUTAR EMi15TMENT 19 GRAOE. RATE OR RANK AT TIME OF 20. PIACE OF ENTRY WTO CVRRENT AGTIVE SERVIGE IQp ~w/9ab1 ~ ENTRII ?RO CtJRRENT AGTNE SvC ~ ~ _r1 i- ~ vCY~Fti.1.. -3~.~ (3:: ~ ' ZOI~1Q ' ~ ~ ~ ~ ~ ~ 21 ?qME OF RECpiD AT ZM~E OF ENTRY MO ACTNE SERV~CE y~ STATEMENT OF SEIZVICE YEAft~ Y00lT?15 DAVS ~ ~ SID. OOt~i Srtr ~t ZLl C~fri t ~ j ~-.J ~ ~O l,. _;a J ~Z' li (1) NET SERV~CE TFYS PEitqO ~ y - • . , - . CREOfTABLE ri. ~ .'~Cii v a_..:'CG ~ a L i.... ~ 1~. ~ -_~i J_ J.~ OR BASIC PAV l~ OTMER SEFtVICE ti~/ tJIJ f . .-a ~ PIlRFO5E5 ~'J ~ z~ s~cu~TV ++~~w a T.r~ ? R£LATED GVl1A:~ OCCUPATION ANO ~a, ron~c w. u~ ~r. r... u~ Q 1 1 v ; 0 ~ 00.T. NU4BER g ~ - ~ ~ . T~,~,~ c ~ 1 ~ ~ e ~ ~ ~ _ ~ -y _ r~ p ' ~ ' y. - ~.i~• c FORE~GN ANDrOR SFJISERVICE lJ_...yl,.~ l' i .-V .ia„'.:"v "J~ ~ . i~z"i..C.l._.~"_ ..2' ~4 W ~ V N OEGORAI~ONS, MEDALS. BADGES. COYtiENOAT~ONS. CRATIONS AND CAYWAK'aN R~H60N5 AWAROED OR J1lliF~OfbZEO } C ~ ~ p _ . Y ~ ~ '*+i i~ _ ~ ~c~~ -~i ZIER~(Ci=~^~T ~ ~ 2S EpUCATqN ANO 7ftMtiiG CO~'IFTED ' ~ 1~ 1 !f '73 ~,C ..~E vl v"_" ~ ~ ~ a. ' ~ ~ 2`10053 ~ J_,.._..~~I' ~ ~ 16a Np~iPAV PER100S TIME LOST 1l~ee~iy R DAYS ACCRUEO IEAVE PIUD 7a INSURANCE N fORCE 1- AMOIJMT OF ALlOT1iEM t ~p NT ~ Tw IirH W3tl ~ 17901~ ~ ~o ? rEg ~ NO . , .:a w = V ..lr _ ~ vw qJJ1r MwrBER 79- SERV~CEYEt+S GwoUP lFE NSURwMCE COVERAGE i5 t r >p C- ' - ~ t10.000 Qf6.000 ? NCM~E ~ ~ pEMI1R~C5 ~~~''y`. ~ .i..a,l . 1 a~ _ ~ ~ Y s~ ~4 . ~.l - t. . - . ~ y r ~ :y; 31. PERMANENT ADOR£SS fOR MAR~ PVRPO''.aES AFTEA TF/WSFER OR 015C?IAFiGE 3t. S1GriATINtE OF PEft50!'i BEWC. TRANSFERREO OR D~SClMA(:E ZO 1-4n~S RID. ~p. Co~O. !nt ~.f llI C~il / ~ .,-21 ~~t,~~~. ~ ~~~,ti ~ , ~ ~ Y 7~IpEp NAIyE. GRApE AI~Q TITIE OF AUiHOH1LNG OfF1GER 3~. SIGf~I~TVRE OF ER "s,'~'~ t ~r i~ ~ ! " ~ ~..:1,. I+ F~ P17E V1QU5 ELXTIONS OF T?t5 fORM it Gvo 1~s-ast-112 ARMED iORCES OF THE STATES ~ OD ~ ~ ~E OBSaETE EFFECTIVE 1 JAN 67 ~~j ~ TR~~~ ~ ~ ~ x ' J , ~ $Utl~ 1 - ' = ~ ~ ._.v , _ w_