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gee 2 df pone of the cheve 2 ives and an exeeutor or aduninisira log been appuinted, the following pAb bk howld be couiptety’ ify . mo . Ui ftiacs bo aduly appotated es bow. of the estate of the deceased, as evidenced by (Taccuts og oF r ediwinieteator) ceruiceste of appointinest herewith, adniinistration having been taken out in the interest of di waiste ition of the estate, (Name, wah Neag As, and relationship of i in alereated "Telative : or rereditor) wud sich appointinent ts still in full force and effect, Note. [Ef making claim as the executor or administrator of the estate of the deccused, no witnesses are required, but a court gertificate evidencing yuur appointment must be submitted, (Ff you are the cxecutor or administrator of the estate of the deccased, hi corard paragraphs 6 ard 7.) 6. If none of the above survives and no executor or administrator has been appointed, the following iafurmation should be furnished: Brothers and sisters (if none, so state): Name Age Street Address, City, State, and ZIP Code Nephews and nieces (List only the children of deceased brothers and sisters. If none, so state): Name, Age, Street Address, City, State, and ZIP Code Name of Deceased Parent 7. Have the funeral expenses been paid? YES. (If paid, receipted bill of the undertaker must be attached {Yes or No} claimant's personal funds for excess. hereto.) Whose money was used to pay the funcral expenses? estate tunds_ to extent of $1,000. / FINES, PENALTIES, and FORFEITURES are imposed bz Jaw for the mnaking of false oz fraad- ulent claims azainst the Cnited Siates or the making of (alse sistemenits in connection therewith seossssesseseseneeens ceessecsseveeseesenusaspiavessestanasec Ltt Oe de per eeeenncneveenene (Signature ot ‘elmimant) (Dated Cl de A. Sjangts ture of claimant} (Date) sevneeeeesssesuseessssevipiesessgeeseisssessestevisestinauseiessmnane § c/o Riges National Bank (Strect address} Personal Trust Dittistiere) P.O, Box 1149, Washington, D.C. 20013 __ : ° (City, State, “‘andZIPcode) SSS (City, State, and ZIP code) | We certify that we are well acquainted with the above __Glyde Ae Tolson.. wu... and that the signature(s) of the “oe was (were) affixed in our presence.ames of claimante) Lo etind. AP 2 CMAP A co LB lesa (ena 2... Klip ceseceeeceteee Slonature A. othe, (Signature of with (Sign: ature of witness) C4 HAT). Ble ag ried. een KBR. Counratinne Ces. LO — (Street address) Wrap Vl feoorh ls GLA, P24)... OC, fons ®..... (City. ote nnd ZIP ofodey $18 Staiy and ZIP code) AU Ge anemedt chooks in the pores ion Of the claiment, drawn to the order af the decedcnt in payment ef ee compensation,” sheuld accomps' - thay ecleoa AU Government checks drawn te the order of the decedent for ether purposes (such as veterans’ benefits, secisl security benefits, er Feder tan refsuds) ghoall be returned to the eceney from which received, - bi S GOVZENDTHT PRINTING OFFICE. 144 -O-218-304 G44 LPP te BUM op epg cory pabebonent ootmrss gay {Street aldeces)