AGENCY CERTIFICATION OF INSURANCE STATUS
Federal Employees' Group Life Insurance Act of 1954

NAME OF EMPLOYEE: Burke, William P., Jr.
DATE OF BIRTH: October 22, 1900

CHECK THE REASON FOR TERMINATING INSURANCE:
- [ ] SEPARATED
- [ ] TRANSFERRED
- [ ] RETIRED
- [ ] NOT ELIGIBLE
- [ ] OTHER (Specify):

CHECK APPROPRIATE BOX CONCERNING 31-DAY EXTENSION OF INSURANCE:
- [ ] SUBJECT TO 31-DAY EXTENSION OF INSURANCE
- [ ] NOT SUBJECT TO 31-DAY EXTENSION OF INSURANCE

DATE OF EVENT CHECKED IN ITEM 3: October 27, 1962
ANNUAL COMPENSATION (See Conversion Table): $7,925.00 PER ANNUM

I CERTIFY THAT THE ABOVE INFORMATION HAS BEEN CAREFULLY VERIFIED AND IS CORRECT. THE EMPLOYEE NAMED WAS COVERED BY FEDERAL EMPLOYEES' GROUP LIFE INSURANCE ON THE DATE SHOWN IN ITEM 3.

SIGNATURE: D. DeFelice
TITLE: Insurance Officer - Alternate
AGENCY: Central Intelligence Agency
ADDRESS: 2430 E St., N.W., Washington 25, D.C.

DATE: 17 DEC 1965

SEE OTHER SIDE FOR INSTRUCTIONS TO EMPLOYING AGENCY

PART 3 - FILE COPY