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CAUTION: NOT TO tE USED FOR TH1S iS AN iMlORTANT RECORD ANY ALTERATIONS IN SHADED
IDENTIFICATION PURPOSES SARBGUARD iT AREAS RENDER FORM VOID
DD 214 PREVIOUS EDITIONS OF iHK 4945 -FROM ACTIVE DU
ELEASE OR DISCHARGE
1 1UL 79 FORM ARE OBSOLETE.
1. NAME (LsK /isC middlr) 2. DEPARiMENT, COMPONENT AND BRANCH SOCIAI SECURRY NO.
Ji'JJIr-~ ; :cn'iIY i,~~ -
~ 263 l.~l 1908
~a GRADE, RAtE OR RANK fib. PAY GRADE S. DATE OF BIRTH 6. PUCE OF ENTRY INTO ACTIVE DUTY
7. LAST DULY ASSIGNMENT AND AUUOR COMMAND B. STATION WHERE SEPARATED
0. COMMAND TO WHKH TRANSFERRED 10. SGU COVERAGE
`c ~i ri Ya 6 31VQ $t LOU1.s i.C 63132 AMOUNif ~0 000NONE
11. PRWIARY SPECIAl1Y NUMBER, i1TlE ANO YEARS AND 12. RECORD Of SERVKE YEAR p) MON DAY(S)
MONTHS RV S/ECIAl1Y (Additional spteiaty numAtn and tf/a
irwolving periods o/ one or mon yeah) Dal. Ed.r.d AD lhb P.rlod 10 10
_ _ _ b. s.P.rolbn o.a TAb P..ba 19 10~ /ry'~/~\
t N.t Acthr• S.r~k. ihb P.rbd
-
d Tobi Prbr AdFr• S.rvk. ~ Ov
I t iolul Prbr Irotlhr. S.rr,k. ~ ~
i For.ipn S.r~rk. OQ
6• Sw S.nk.
>L ER.clw• DoN .l PoY Grtd• Q (~'-1
~ L R.s.r.• Oblq. T.rm. Oo1. 31 1Q v7
i
( 13. DECORATIONS, MEOAIS. BADGES. CfiAT10N5 ANO CAMPAIGN RIBBONS AWARDED OR AUTHORED (All ptrioda o/uruin)
1
~ -
{ - _ J-_..
5
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11. MILRARY EDUCATION (Count ?Stll, number rvtt4a, and month and ytar tompkted)
1 S. MEMBER CONTRBUTEO TO POST-VIETNAM ERA 16. HIGH SCHOOI GRADUATE OR EOUNAIEN? 17. DAYS ACCRUEO_
IB.VREIAARKS• EDUCATIONAL ASSISTANCE /ROGRAM ? YES ~ NO ~ YES ~ NO LEAVE PAR)
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4s594S
11. MARNG ADDRE~t fl~@ SEPARATION {t~t~~~tt~~ 20. MEMBER REOUESii CONY. BE
~ P. 0. Hoa ]lb~ Ft Pierce FL 33450 BOU~tXrV sENTTO _oel. of vEr
AfFANf ®rES ~ NO
21. SIGNATURE OF MEMBER iEOrG~"~ 22.11PED NAME, GRADE, i1fLE AT OFFICIAL l' l
s / / M1fMOR12EOT051GN y~~y ~ W
3 ~
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