WTC Records Folder 0128 Disaster Information General label, 2001

NYC 9/11 Public Portal Document

NYS Crime Victims Board Death Affidavit (Complete and Attach Claim Application Page 1) rage x Claimant Information Claimant Name (Last) (First) (Middle) Social SecunlY Number CVB Claim Number (if known)

Section A - Crime Information Section Address Where Crime Occurred (Sheet or PO Box) ( f No. or Flow) (Cif (Stele) (Zip code) Taste of Crime

Alleged Perpetrator Name (Last) (First) Middle) as Alleged Perpetrator Been Arrested tar this Crime? DYes UNo Has Alleged Perpetrator Been Prosecuted for this Crime? DYee DNo Is Alleged Perpetrator a member of Victim's family and/or did he/s reside in Sam Behold? DYes QNo Is Claim being filed more than one year after the date of the cr e? QYes ONO II yes, describe factors which delayed claim filing

Section B - Life Insurance And Death Benefit Information Section Does Victim have file insurance or other available Death Benefits? (Fret compeis questions is tees senior) pYas p No Name or Life Insurance Canoany Pobcy or ID Number

company Name M Penton Plan Policy a ID Number

Company Name of Olher Imaance Policy a ID Number

Section C - Burial Expense and Insurance Information Section Are there unreimbursed burial expenses as a result of the victim's death? laps complete aypumionv ten adpM fl Yes pNo Funeral Home Name Mn mite TIIepMre Nanpx

Address Lily a Town Slate Zip Code

Is there Insurance or other death benefits that will pay for any of the victim's burial expenses? p1pt compere ax that e1*) pYas pl4o Social Security Death BMenl POICy a ID Hunter

kaedcaie Policy or ID Number

Cornpany Name of tile Insurance Deem Bereal Policy a ID Number

Company Name of Workers Compemason carter Policy or la NlrmMr

company Name of Other Death amerne Policy a ID Hunter

Section D - Dependents of Victim Information Section Are there Children or other individuals who are dependent on the Victim for their support? fares, complete as met apdq EYes No Deperbeni Name (Lull IFiall Date el Bub IMMrDOryYYY( RflagxlshiP m Victim nddrm. Cloy alows Slate Zip Code

DepeMeni Name (Last IFiat Date OI BUN IMMIDDMTYI Retebondtiy b Vain

Address Guy or Town SMIe rap code

Deperrdenl Name ILashl (Post Da4 of arvi (MM/DMYYY) Mahon lm, 0Victor

Adana Cry a Town SMte Zip Cade

Depesdem Nave (Last) (real) Date S BUN dauav WYYY) RetabonN9 to V. Ache» city or Town Shale Zip Cam

Section E- counseling Information Section As a result of the Victim's death. is counseling being provided to the Victim's spouse, parents or children or to the siblings of a Child Victim? DYes QNo counselor Name Mea code Tebdgre Number

Addle,, CM o loan SY» Zp Code

19 there yjsuraneto er counseling cost,? pYes DNo Company Nam Insurance r Poboy a f0 NumM

Section F enaes Inf rmation action Do you ent stisclaim will fxceeot f5, e7 Yea No

CVBMIS-D101 Rev 05115199

NYC-WTC 000137347