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D B Cooper — Part 18
Page 109
109 / 503
Pigase Print
Policy Name of Insured
_ PERSONAL ACCIDENT WiTH Address
2 DOUBLE PROTECTION ON of Insured
: Capital Sum (Scheduled Air) | cy uz as
pi um u lg t tateL ni Code
- $ Principal Sum (Other see) oo Tae y kor TIan
-¢ PREMIUM $—SO.O _|Namevof Beneficiary [
BAGGAGE AND PERSONAL EFFECTS | Address of senatcary
Amount of Insurance
PREMIUM $
D eeiehelney patente eee te
- Effective at:
Hour Z:‘27)__ pn, pae__W/- 2Y -7/ _
- Month Day = Year
BIC
COMBINED PREMIUM $
Personal Signatute
of Insured
f
|
|
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]
Policy
Nusaber
PERSONAL ACCIDENT WITH
DOUBLE PROTECTION ON
SCHEDULED AIRLINES
nsurance?
§ ame ° i ;
LOLLD capita Sum (Scheduled. Ait) Cit f,
SAO ODOC) _ Principal Sum (O ier A ee) YA Palit CD Lo.
PREMIUM $ Name of Beneficiary im -
Address of Beneficia || ; ‘eat Be .-
Effective at:
“Hour 2:30, PK p. m. pate = QW _
, Month Day - Year sates -
Place ——
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+ \ ‘
One eer eA ORR On NR Rane angr ae prgegtprier tet ates
7 aaa mS wadint
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