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HomeMy WebLinkAbout1340 ~ C.IUiION NOi i0 BE USED fOR THIS 1S AN IMPORTANT RECORD ANY ALTERATIONS IN SHADED !DEN IlFKATION PURPOSES ~ SAFEGUARD IT ~ AREAS RENDER FORM VOID DO FORM PREVIOUSEDITICNSOF 1HIS CERTIFICATE OF RELEASE OR DISCHARGE 1 JUl 79 FORM ARE OBSOLETE. FROM ACTIVE DUTY I NAME ((,off, j,,,~ rniddlq ~ 2. DEPARTMENT. COMPONENT AttD BRANCH 1. SOCIAL SE=tCURITY NO. ~ 1~ .1 d GRADE. RAZE OR RAW( Ib. PAY GRADE S. DATE.OF BIRTH 6. PLACE OF ENTRY INTO ACTNE DUTY - ~ ~~R ' ' 1A 51 DUTY ASSIGNMENi AND MAIOA COMMAND B. STATION WHERE SEPARATED ~•=s /Z~LR Pi11LR ~VlQltr~ia ~ t~« ~i~ii, 'vw COMMAND TO WHICH TRANSFERRED 10. SGU COvERAGE u AMOUNT f_~000 ~ NONE iv~!Maer SDECI.utr vUMBER. `t1IE aNOrEAttSAND 12. RECOROOF SERVKE YEAR (s) MON (s) DAY (s1 MONIH~IN SVF{IA!Iv ~Addl:unui syeeiaRy numbers oAd t@lts inc+at~eng l.arn..i.• •.j .:ne .~r morn vmre) d DoN ErJ•r•d AD TAis ?•ri•d a +_4 b. S•poroli•n Dob iAls P•riod T~iQ, ~1r7~J~lii ~i3iiMi, ~ ~ ~ G N•t Activ S•r.ic• iAis P•riod • d. idol Drior Acti.• S•r•k• G iota) Prior Irwtfkv• S•nk• L for•gn S•nk• g. 5•o S•rvk• b. EN•ai.• Oo4 a Foy Grod• L R•strv Oblq. Tptn. Dm• ? DEC:JV.;!!JNS. MEDAlS. 3A AGES. CliailONS AND CAMPAIGN RRiBONS AWARDED OR AUIHORQEO (All potiods ujae?vite) ltisksNR>R (Eifle llt-liAl) i : MiutAar EDUta!tON /Cuursr Tole. number weeks. and month and year completed) Materiel Svppl~ ~islist, 12 Neeks l9TS) ! i M[+•idEk CO`~IPtBUIED TO DOSi-VIEiNAM ERA 16. HIGH SCHOOL GRADUATE OR EOUNAIENT 17. DAYS ACCRUED E ~ vETEkAwS' fL`UCaT1;iNAl ASSISTANCE cRUGRAM LEAVE ?AO ~ ~ YES ©NO ~ YES ~ NO I ~ t4. REMARKS 1 ~ ~ zaRUre (trriita~l,e ti[ all p~ am0~t 1~4! e~_alll~) - 4 DreT+s= 4b-iC~9~iGi~ 199 OCt 12 PiI 28 iT. UCI pp~~~1Y~YiLA. R POITRAS a clRaxT couRT x 19. MAIIRVG ADDRESS AFTER SEDARAiiON STS CO?Y 6 RE r u~ ~ Tsi~ SENT TO ~_OMI. OF VET AFfAMS ®YES ~NO ~ 21. SIGNAT1IRE OF MEMBER BERVG SEPARI~iED 22. TYP N AND AZURE OF . ~ AUfT O S 1 _ SPECIAL ADDRIONAL INFORNIATiON (Por ust by a+wAon6rd ~aaid onbr) 23 TYPE Of SEPARATION 21. CW?RACTER OF SET[ViCE (lwt~dea •rp~?oder) • Q 25 SEPARA110N AUTHORRY 2A. SBARATION CODE . ~ CODE 2>. NARRAT E ASON FOR SEPARA110N ' ~ 20 GATES OF TIME IOSi DURWG THIS PERIOD i R0. A~ABER REOIIESiS COM 1 NITIAtS i ' - siN oloz-IF-000-z1~o Q _-..r'~s~~t MEMBER -1