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D B Cooper — Part 18
Page 117
117 / 503
PERSONAL ACCIDENT WITH: Se
DOUBLE PROTECTION ON #3'S5*
SCHEDULED AIRLINES™* =**'
Anipunt o of Insuranée?
cee! (Scheduled hig CY PAVE An Ad Site’ Ove 2 - Codd
Principal Sam
PREMIUM scene Nane of Benefii gf
| -COMBINED PREMIUM 8 ep
Term of Coverage: —~.
Hour OO ff im) date LL = ee~Z)
Month Day~- Year
Personal Signature
of Insured
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- PERSONAL ACCIDENT WITH -
DOUBLE PROTECTION ON
SCHEDULED AIRLINES
_ O mount of Insurance: .
© Capital Sum (Scheduled Air) { cit faWa
REMIUM $. Good 2S | Name of Beneficiary
BAGGAGE AND PERSONAL EFFECTS | Address of Beneficiary - aD (IMA <2
gLhOne— amount of Insurance.
PREMIUM sf/LOne. a
Effective at: -
O am. -
Hor DUS p.m . pate__LL—-D4--~T7/
. Month Day = Year
COMBINED PREMIUM $
Term of Coverage:
rsonal Signature » ,
Insured
AGENT COPY
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“DB G¢ooper-5450
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