[Enlisted Personnel Discharge and Release from Active Duty (Other than at Separation Centers)]
[From the U.S. Government Publishing Office, www.gpo.gov]
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Document Reserve
NON-CTRCITLATnw
IjVI E®
W A R
DEPARTMENT TECHNICAL MANUAL
ENLISTED PERSONNEL
DISCHARGE AND
RELEASE FROM
ACTIVE DUTY
( OTHER THAN AT SEPARATION CENTERS )
WAR
DEPARTMENT
JANUARY 1945
Niou LIBRARY
Ch I \fi/l,3S': /it-X35 ’ ................nr rn mit»
LilijriBArW | TM 12-235
TECHNICAL MANUAL
ENLISTED PERSONNEL DISCHARGE AND RELEASE FROM ACTIVE DUTY (OTHER THAN AT SEPARATION CENTERS)
Change|
No. 1 J
TM 12-235, 1 January 1945, is changed as follows:
Contents page, delete “Counselor’s Interview Memorandum, WD AGO Form'100-1—Illustration 16.”
Page 7, under column headed OTHER AGENCIES, delete remark which reads:
“If transferred to or remaining assigned to ERC or RAR to: Commanding General or Service Command of place of residence of man.
If discharged on CDD to: Veterans Administration Facility or Area Office.
If discharged to accept a commission to: AGO.
All other men released from active duty to: State Director of Selective Service having jurisdiction over man.”
and substitute the following therefor:
“If transferred to or remaining assigned to ERC or RAR to: Commanding General of Army Area of place of residence of man.
If discharged to: AGO.”
Page 7, delete NOTE referring to WD AGO Form 100-1.
Page 16, delete “Counselor’s Interview Memorandum, WD AGO Form 100-1” from title; delete illustration of Form 100-1; delete last sentence of Note.
[AG 300.7 (17 Mar. 46)]
By order of the Secretary of War:
WAR DEPARTMENT Washington 25, D. C., 14 June 1946
Page 22, delete Note 2.
Pages 26 and 27, under column FIRST DAY opposite INTERVIEWERS, delete “100-1.” Under column THIRD DAY, opposite PERSONNEL SECTION, delete “Form 100-1.”
Pages 32 and 33, delete all references and remarks to WD AGO Form 20.
Pages j6 and j.7, delete all references and remarks to WD AGO Form 20.
Page 58, notes 1 and 2 are amended to read:
1. Prepared in triplicate by Registrar from information on Service Record, hospital records or data secured by interview with patient.
2. Copies 1 and 2 are forwarded to Veterans Administration, Copy 3 is retained as a suspense copy.
Page 65, under column headed WD AGO Form 20, delete reference opposite “VA Area Office or Facility” and “State Director of Selective Service.”
Note (★) is amended to read: “If transferred to or remaining assigned to ERC or RAR to Commanding General of Army Area of place or residence of man: if discharged to: AGO.”
Official :
EDWARD F. WITSELL
Major General
The Adjutant General
DWIGHT D. EISENHOWER
Chiej oj Staff
Distribution:
AAF (10); AGF (10); Def Comd (10); SvC (10); FC (2); Class III Instls (2); GH (15); RH (15);
SH (10); CH (15). No OVERSEA DISTRIBUTION.
For explanation of distribution formula, see FM 21-6.
AGO3903A—.Tune 696322°—46
U. S. GOVERNMENT PRINTING OFFICE: 1946
NTSU LIBRARY
NTSU LIBRARY
WAR DEPARTMENT TECHNICAL MANUAL
T M 12-235
ENLISTED PERSONNEL
DISCHARGE AND
RELEASE FROM
ACTIVE DUTY
i
( OTHER THAN AT SEPARATION CENTERS )
WAR DEPARTMENT
JANUARY 1 Q 4 5
United States Government Printing Office Washington : 1945
TM 12-235
1 JAN 45
WAR DEPARTMENT Washington 25, D. C., 1 January 1945
TM 12-235, Enlisted Personnel Discharge and Release from Active Duty, Other than at Separation Centers, is published for the information, guidance and compliance of all concerned.
[AG 300.7 (12 Dec. 44)]
By order of the Secretary of War:
Official:
J. A. ULIO
Major General
The Adjutant General
G. C. MARSHALL
Chief of Staff
Distribution :
AAF (io); AGF (io); ASF (io); Def Com (io); SvC (io): MDW (io); PC&S (2);
GH (15); RH (15); SH (10); Conv Hosp (15).
Overseas distribution will not be made.
For explanation of symbols, see FM 21-6.
1 JAN 45
TM 12-235
FOREWORD
1. For a long time there has been a lack of uniform procedure in discharging or releasing personnel from active duty. Too many times the importance of making the transition from military life to civilian life as smooth a procedure as possible has been overlooked. The change is a hard one — equally as difficult as the initial experience when men and women are first inducted or enlisted in the service.
2. In recognition of this problem, an attempt has been made to cut out the "red tape" in discharge procedures and substitute a working system which may be adopted throughout the Army. The aim is to foster a method which will cover the requirements of permanent recording of service and at the same time aid service men and women in the difficulties of readjustment to the responsibilities of civilian life.
3. The basic purpose of this manual is:
a. To simplify the primary procedures in discharge or separation from active serv;ce.
b. To clarify the procedure for discharge on certificate of disability under AR 615-361, and to develop a standard method of effecting such discharge after maximum military hospitalization has been obtained.
c. To clarify the various procedures for transmittal of necessary records to the Veterans Administration in order to effect prompt adjudication of claims, and to expedite the transfer and subsequent discharge of patients sent to Veterans Administration Facilities.
d. To reduce to a minimum the time and effort required to process men who are being separated from active service, in order to make available hospital beds and other facilities, after necessary care.
iii
1 JAN 45
TM 12-235
4. Changes to this manual will be supplied on a page basis, and will be published as required. As change pages are received they will be inserted in their proper place, and the replaced pages destroyed.
5. Each page of the manual bears a date in its upper inside corner. This date is the date of the publication. Pages which represent changes will carry the date and number of the change.
6. Pages are numbered consecutively throughout the book. If new pages are added within the book the added pages will carry alphabetical suffixes — A, B, C, and so on. For example, if a new page is added between 35 and 36, the page will be numbered 35-A. A second additional page in the same place would be numbered 35-B, and so on.
7. The procedures set forth herein have been developed and tested extensively in the field. In many cases they represent major changes in existing methods. The procedures and forms in this manual will be placed in effect immediately at all installations effecting discharge or release from active service. No deviation in forms, procedures, or requirements is authorized without prior approval of the War Department unless specifically noted otherwise in this manual.
8. The procedure charts in this manual illustrate graphically the flow of each document and the action taken on each copy throughout the process. The rectangular blocks represent the forms and the number of copies prepared. The shaded portion inside the lower right hand corner of a block indicates that the document was originated by the organization unit shown in the column heading above, example: | J. The numbers appearing in the blocks reflecting the copy numbers do not necessarily appear on the forms, but are intended to be used as a guide in following the flow of a document.
9. Forms not bearing a WD AGO or VA number may be reproduced locally.
10. Recommendations for change or improvement in forms or procedures should be transmitted through channels to the Control Division, Army Service Forces, The Pentagon, Washington 25, D. C.
IV
1 JAN 45
TM 12-235
CONTENTS
FOREWORD ........................................................................ id-iv
CHAPTER 1-BASIC DISCHARGE AND RELEASE FROM ACTIVE DUTY................................................................................. 1
Discharge and Release from Active Duty — Reference Chart................... 2—3
Basic Discharge and Separation Procedure — Chart........................... 4—9
Information for Soldiers Going Back to Civilian Life — WD Pamphlet 21-4-Illustration .......................................................... 10
Allotment Discontinuance, WD AGO Form 30-S — Illustration................... 11
Honorable Discharge Certificate and Report of Separation, WD AGO Form 53-55 — Illustration .................................................. 12
Discharge from the Army of the United States and Report of Separation, WD AGO Form 53-56 — Illustration............................................ 12
Dishonorable Discharge from the Army of the United States and Report of Separation, WD AGO Form 53-57 — Illustration. ........................... 12
Certificate of Service and Report of Separation, WD AGO Form 53-280 — Illustration.............................................................. 12
Report of Separation, WD AGO Form 53 series — Illustration.................. 13
Final Payment Roll, WD Form 371 — Illustration........................... 14—15
Army Separation Qualification Record Work Sheet — Illustration.......... 16
Counselor's Interview Memorandum, WG AGO Form 100-1 — Illustration 16
Army Separation Qualification Record, WD AGO Form 100 — Illustration 17 Report of Physical Examination of Enlisted Personnel — WD AGO Form
38 — Illustration ....................................................... 18
Previous Employer Card, WD AGO Form 519 — Illustration...................... 19
Identification Dischargee Certificate — Illustration........................ 19
Notation of Discontinuance of Allotments in Service Record — Illustration 20
Extract from Service Record, WD AGO Form 25 — illustration.................. 20
Final Indorsement in Service Record — Disposition of Final Indorsement Copy of WD AGO Form 53 Series — Illustration................................ 21
Individual Report of Enlisted Reservists, WD AGO Form 167 — Illustration 22
ERC Identification Card, WD AGO Form 166 — Illustration..................... 22
Lapel Button and Records to be given to Dischargee on Separation or Release — Illustration ..................................................... 23
CHAPTER 2-DISCHARGE BECAUSE OF DISABILITY....................................... 25
Time Schedule for Processing Medical Discharges — Time Schedule......... 26—27
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TM 12-235
1 JAN 45
Discharge Because of Disability — Chart.................................... 28-33
Transfer to a Detachment of Patients or Station Complement — Chart. . 34-35
Patients Property Slip, WD AGO Form 8-111 — Illustration...................... 36
Diagnosis Slip, WD AGO Form 8-176 — Illustration.............................. 36
Morning Report, WD AGO Form 1 — Illustration.................................. 37
CDD Transfer Order — Illustration............................................. 38
Request for Photostat — Illustration.......................................... 39
Work File Copy for CDD Case — Illustration.................................... 39
Request for Clinical Records — Illustration................................... 40
List of Approved Cases — Illustration ........................................ 40
CDD Work Sheet — Illustration . .............................................. 4]
Certificate of Disability for Discharge, WD AGO Form 40 — Illustration 42
Register Card, WD AGO Form 8-24 — Illustration................................ 43
CHAPTER 3—TRANSMITTAL OF RECORDS TO VETERANS ADMINISTRATION - TRANSFER OF PATIENT TO A VETERANS ADMINISTRATION FACILITY................................................. 45
Receipt and Transmittal of Records to a Veterans Administration Area Office or Facility — Chart................................................ 46-47
Transfer of a Patient to a Veterans Administrative Facility — Chart. . . . 48—53
Letter to Relatives in Case of Mentally Incompetent Soldiers — Illustration 54
Affidavit for Assumption of Responsibility — Illustration..................... 55
Application for Pension or Compensation for Disability, VA Form 526 — Illustration.............................................................. 56-57
Statement That Soldier Does Not Wish to File Claim — Illustration......... 57
Request for Designation of Veterans Administration Facility — Illustration 58
Notification of Designation of Facility — VA Form 2834 — Illustration... 59
Application for Hospital Treatment or Domiciliary Care, VA Form P-10 — Illustration.............................................................. 60-61
Telegraphic Notifications Regarding Transfer of Patient to Veterans Facility — Illustration ................................................... 62
Transmittal of Case Records to Veterans Administration Area Office or Facility — Illustration...................................................... 63
Receipt for Person and Property — Illustration................................ 64
FINAL DISPOSITION OF RECORDS - Chart.................................................. 65
TM 12-235
1 JAN 45
CHAPTER 1
BASIC DISCHARGE AND RELEASE FROM ACTIVE DUTY PROCEDURE .
1. Definitions:
a. The terms “enlisted man,” “patient,” or “dischargee” as used in this manual include all enlisted military personnel, male and female, who are to be separated from the military service, including reversion to National Guard and release to reserve components.
b. “Personnel Section” as used herein is an all inclusive term for the unit personnel section, station complement, military personnel branch, or detachment of patients, whichever is applicable.
c. Wherever mail is designated as the mode of transmission, the use of air mail is hereby authorized if such action will result in expedition of necessary papers and speed the discharge procedure.
d. All local forms designated to be filed or retained as suspense copies will be kept only until the purpose of the original has been attained. These copies will then be destroyed. War Department forms indicated for filing will be retained only so long as necessary for completion of the case and any necessary questionable items which may arise in the future. War Department Forms will be disposed of periodically as announced in directives.
2. Simplification:
a. The basic discharge and separation procedures and forms as set forth in this manual have been simplified.
b. All unnecessary signatures have been eliminated.
c. Copies have been reduced to a minimum, providing only those which are mandatory for completion of the separation procedures and matters arising therefrom.
d. Coincident with the reduction in the number of signatures and copies there has been a substantial reduction and elimination of unnecessary operations.
e. Forms have been revised to standard typewriter spacing to facilitate rapid preparation ; other forms have been discontinued, and many forms have been combined to expedite their preparation.
f. Elimination of duplication of effort and information has been the primary objective.
g. The procedures as set forth in this chapter should require a maximum of 48 hours to effect discharge once separation has been approved and ordered. To maintain this schedule will require — speed, accuracy, and a high degree of coordination between interested authorities, agencies, offices and personnel.
TM 12-235
1 JAN 45
REFERENCE CHART-DISCHARGE
AUTHORITY FOR DISCHARGE OR RELEASE FROM ACTIVE SERVICE REASON FOR DISCHARGE OR RELEASE FROM ACTIVE DUTY FORM OF DISCHARGE OR RELEASE FROM ACTIVE SERVICE
AR 615-360 EXPIRATION OF SERVICE WHITE OR BLUE (Dependent upon character of service rendered).
AR 615-361 DISABILITY WHITE OR BLUE (Dependent upon character of service rendered).
PREGNANCY WHITE
AR 615-362 PURCHASE (SUSPENDED FOR THE DURATION)
MINORITY WHITE OR BLUE (Character of service rendered governs form of discharge regardless of element of misrepresentation as to age or consent of parent or guardian).
DEPENDENCY WHITE
AR 615-363 RELEASE TO RESERVE COMPONENTS CERTIFICATE OF SERVICE
DISCHARGE FROM RESERVE COMPONENTS WHITE OR BLUE (Dependent upon character of service rendered)
AR 615-364 DISHONORABLE YELLOW
AR 615-365 CONVENIENCE OF THE GOVERNMENT WHITE (Dependent upon character of service renderea except as noted in par. 3(d), AR 615-365 or approved proceedings of a board of officers under par. 4b(2), AR 615-360).
AR 615-366 MISCONDUCT a. FRAUDULENT ENTRY INTO SERVICE BLUE (Except as noted in par. 3b(l), AR 615-366).
b. AWOL AND DESERTION BLUE
c. CONVICTION BY CIVIL COURT BLUE
AR 615-367 WRIT OF HABEAS CORPUS WHITE OR BLUE (Dependent upon character of service rendered).
AR 615-368 UNDESIRABLE HABITS OR TRAITS OF CHARACTER BLUE
AR 615-369 INAPTNESS, LACK OF REQUIRED DEGREE OF ADAPTABILITY OR ENURESIS WHITE
NOTE: AR 615-360 is the basic discharge regulation and gives the procedure
2
1 JAN 45
TM 12-235
AND RELEASE FROM ACTIVE DUTY
BASIS FOR ELIGIBILITY FOR DISCHARGE OR RELEASE FROM ACTIVE SERVICE BY WHOM DISCHARGE ORDERED A
Completion of service
Recommendation of board of Medical Officers / COMMANDING OFFICERS - SPECIFIED IN PARAGRAPH 6, AR 615-360
Certification of pregnancy by Medical Officer
Compliance with Section II, AR 615-362
Compliance with Section III, AR 615-362
Classes of personnel specified by the War Department and those persons specified in par. 2, AR 615-363
Order of the President or Secretary of War and those persons specified in par. 11, AR 615-363 By order of the President, Secretary of War or those Commanding Officers specified in par. 5, AR 615-363
Sentence of General Court Martial or Military Commission Approved sentence of General Court-Martial or Military Commission
Classes of personnel to be discharged under this regulation to be specified by order of the Secretary of War. Commanding officers specified in par. 6, AR 615-360
Compliance with section 1, AR 615-366 Commanding Officers specified in par. 6, AR 615-360
Compliance with Section II, AR 615-366 Commanding General of Service Command or Officer exercising special or general Courts-Martial jurisdiction
Compliance with Section III, AR 615-366 Commanding Officers specified in par. 6, AR 615-360
Order of U.S. Court, Judge or Justice thereof Order of U.S. Court or Judge or Justice thereof
Approved proceedings of a board of officers Officers having General Courts-Martial jurisdiction
Approved proceedings of a board of officers Commanding officers specified in par. 6, AR 615-360
and authority for effecting all other discharges in the 615-360 series.
3
TM 12-235
1 JAN 45
BASIC DISCHARGE AND
nnriiMFNT PERSONNEL
u u u u in l n 1 DISCHARGE TYPIST ALLOTMENT TYPIST
SECTION 1—PREPARATION OF DISCHARGE CERTIFICATE, REPORT OF SEPARATION AND FINAL PAYMENT ROLL.
INFORMATION FOR SOLDIERS GOING BACK TO CIVILIAN LIFE WD PAMPHLET 21-4
RECORDS JACKET, SERVICE RECORD AND ALLIED PAPERS
RECORDS JACKET SERVICE RECORDS AND ALLIED PAPERS
RECORDS JACKET SERVICE RECORDS AND ALLIED PAPERS
- Uses to prepare WD AGO 53 series.
- Uses to prepare WD AGO 30-S.
DISCHARGE CERTIFICATE AND REPORT OF SEPARATION
WD AGO 53 SERIES
REPORT OF SEPARATION NATIONAL GUARD ONLY WD AGO FORM 53-2
1 WD AGO 53-55
2 WO AGO 53-55 |
WD AGO 53-55
WO AGO 53-55
M 3 \ 4
' 5 WD AGO 53-55
w [6 WO AGO 53 55
[7 WD AGO 53 55
8 WD AGO 53 55
DISCHARGE CERTIFICATE I S REPORT OF SEPARATIO
ALLOTMENT DISCONTINUANCE WD AGO FORM 30-S
FINAL PAYMENT ROLL WD 371
-Completes Discharge Certificate and Report of Separation in one operation by interview with dischargee and reference to Service Record, WD AGO 24, Soldiers Qualification Card, WD AGO 20 and Immunization Register, WD AGO 8-117.
- Prepares WD AGO 53-55 for men being discharged under honorable conditions.
- Prepares WD AGO 53-56 for men being discharged without honor, but not under dishonorable conditions.
— Prepares WD AGO 53-57 for men being discharged under dishonorable conditions.
- Prepares WD AGO 53-280 for men being released from active duty to a reserve component. (See page 8.)
— Prepares WD AGO 53-2 in addition to WD AGO 53-55, WD AGO 53-56, WD AGO 53-57 or WD AGO 53-280 (whichever is applicable) in case of all National Guardsmen being discharged or released from active service.
- Has soldier sign copies 1,2 and 4.
- Has soldier thumbprint copies 1 and 2.
— See Section VI, Cir. 389 WD 1944, as amended by Section II, Cir. 435 WD 1944, as amended for direction as to preparation and proper entries on above forms.
— Prepares Allotment Discontinuance Document by reference to Service Record or Pay Card.
— Inserts permanent address for mailing purposes as shown on WD AGO Form 53 series.
- Prepares discontinuance form for all men being discharged whether or not they have allotments.
4
1 JAN 45
TM 12-235
SEPARATION PROCEDURE
SECTION
PAYROLL TYPIST
PERSONNEL OFFICER
DISTRIBUTION CLERK
SOLDIER (DISCHARGEE)
WD PAMPHLET 21-4 GOING BACK TO CIVILIAN LIFE
WO PAMPHLET-?I 4 GOING DACITTO CIVILIAN LIFE
- Gives booklet to soldier.
-See Note.
— Soldier keeps book for his information.
RECORDS JACKET SERVICE RECORDS AND ALLIED PAPERS
- Personnel Officer checks all records for accuracy and completeness.
- Receives Service Record and allied papers from man's former organization.
— Uses to prepare WD 371.
RECORDS JACKET SERVICE RECORDS AND ALLIED PAPERS
3
5 WD AGO 53-55
6 WO AGO 53-55
WD AGO 5355
WD AGO 53 55
WO AGO 53 55
7 WD AGO 53 55
2 WD AGO 53 55
X 8 WD AGO 5355 DISCHARGE CERTIFICATE S > REPORT OF SEPARATION
— Personnel Officer signs copies 1 and 2 and the National Guard copy when prepared.
NOTE
WD Pamphlet No. 21-4, Information for Soldiers Going Back to Civilian Life, will be distributed to all men being discharged under honorable conditions. Those men being discharged with a blue discharge certificate (WD AGO Form 53-56) will be given a copy of WD Pamphlet No. 21-24, Explanation of the Provisions of the Gl Bill of Rights, Public Law 346 — 78th Congress in lieu of WD Pamphlet No. 21-4.
- Personnel Officer signs copies 1 and 2.
-Prepares by reference to Service Record or pay card.
-See TM 14-502 (Change 3) for proper entries to be made on pay roll.
RECORDS JACKET SERVICE RECORDS AND ALLIED PAPERS
— Collects all records and effects proper distribution.
5
1 JAN 45
TM 12-235
DOCUMENT
BASIC DISCHARGE AND
Personnel Section
- Signs Discharge certificate and forwards to Disbursing Officer or Class B Agent Officer through Personnel Section.
WD IGO 20 SOLDIERS QOIUFICITION GIRD
WD 371 FINIL PAYMENT ROLL
1 WD IGO 53-55 DISCHARGE CERTIFICATE
I REPORT OF SEPIRITION
8 WO IGO 53-55 DISCHIRGE CERTIFICATE t S REPORT OF SEPIRITION
RECORDS JACKET SERVICE RECORD IND ALLIED PIPERS
1 WO 371
2
WO IGO 53 55
WO 371
Processes
WD 371
FINAL PAYMENT ROLL
PERSONNEL SECTION OFFICER DESIGNATED TH ClPkl niCPUADPC DISBURSING OFFICER
DISTRIBUTION CLERK IU oluN UlolnAKut CERTIFICATES OR CLASS B AGENT
SECTION 2—DISPOSITION OF PERSONNEL RECORDS
RECORDS JACKET, SERVICE RECORD AND ALLIED PAPERS
DISCHARGE CERTIFICATE AND REPORT OF SEPARATION
WD AGO 53 SERIES
REPORT OF SEPARATION NATIONAL GUARD
ONLY WD AGO 53-2
ALLOTMENT DISCONTINUANCE WD AGO 30-S
FINAL PAYMENT ROLL WD 371
SEPARATION QUALIFICATION RECORD WD AGO
PREVIOUS CARD
WD AGO
100
EMPLOYER
519
SOLDIERS QUALIFICATION CARD WD AGO 20
IDENTIFICATION DISCHARGEE CERTIFICATE
LAPEL BUTTON
- Distributes records.
WO AGO 5355
1 WO IGO 53 55
2 WO IGO 53 55
4 WO IGO 53 55
5 WO IGO 53 55
I 6 WD IGO 53 55
, [7 WD IGO 53 55
— Sends copy 1 to person designated to sign face of discharge certificates.
— Distributes as shown on form.
WD IGO 53 2 REPORT OF SEPIRITION (NIT. GU1RD)
— Sends to Adjutant General of state from which National Guardsman was inducted or called to active duty.
1 WD 1G0 30 S [2 WD IGO 30 S
WO AGO 30 S
WO IGO 30
I WO IGO 30 S
7
6 WO IGO 30 $ HLOTMENT DISCONTINUANCE
- Distributes as shown on form.
- Sends to D.O. or Class B Agent.
- Computes final pay on copies 1 and 2.
-Pays man being discharged or turns money over to Class A Agent for that purpose.
-Makes necessary entries on WD AGO 53-55.
- Gives Discharge Certificate to Dischargee.
- Witnessing Officer signs certificate No. 2 on copy 1 and certificate No. 3 on copy 2.
- Processes according to current directives.
-Sends to Separation Classification
EIPEE DOTTON
— Gives lapel button to dischargee.
6
1 JAN 45
TM 12-235
SEPARATION PROCEDURE (CONTD)
SEPARATION CLASSIFICATION INTERVIEWER OTHER AGENCIES THE ADJUTANT GENERAL SOLDIER (DISCHARGEE)
Mails
Personnel Officer signs
624890 0 - 45 -3
Forwards to Registrar for transmission to Veterans Administration
- Prepares identification Dischargee certificate.
To Adjutant General of state from which National Guardsman was inducted or called to active duty.
Copies distributed as follows:
2, 3. Government Insurance Allotment Div.
4, 5. Office of Dependency Benefits
Copies distributed as follows:
2. Final Indorsement copy — To AGO
3. Service Command copy
4. Veterans Administration HQ copy
5. Veterans Administration Regional
L Office
* 6. Board of Registration copy
7. Reemployment Committeman copy
8. Veterans Employment Representative copy (See AR 615-360, 615-361, and Cir. 389 WD 1944 as amended for proper addresses)
WD AGO 20
4 SOLDIER'S QUALIFICATION CARD
- Uses in interview of dischargee.
WD AGO 100
WD AGO 100 SEPARATION QUALIFICATION RECORD
-Completes WD AGO Form 100. See Note.
- Gives copy 1 to dischargee.
WD AGO 519 PREVIOUS EMPLOYER CARD
- Prepares and mails Form 519 to previous employer, if any.
IDENTIFICATION DISCHARGEE CERTIFICATE
If transferred to or remaining assigned to ERC or RAR to: Commanding General or Service Command of place of residence of man.
If discharged on CDD to: Veterans Administration Facility or Area Office.
If discharged to accept a commission to: AGO.
All other men released from active duty to: State Director of Selective Service having jurisdiction over man.
NOTE
If counselling is desired prepares WD AGO Form 100-1 in addition to WD AGO Form 100 and gives to Dischargee.
- Keeps.
- Keeps
WO AGO 100 SEPARATION QUALIFICATION RECORD
RECORDS HCRET SERVICE RECORD AND ALLIED PAPERS
- Checks and transmits to Demobilized Records Branch
IDENTIFICATION DISCHARGEE CERTIFICATE
- Uses to purchase special fare coach ticket.
— Keeps.
LAPEL BUTTON
7
TM 12-235 1 JAN 45
BASIC DISCHARGE AND
SECTION 3—TRANSFER TO ENLISTED RESERVE CORPS OR REVERSION TO NATIONAL
1 WD AGO 53-210 nil 1 WD AGO 53 280 b
CERTIFICATE OF R w. k r certificatf ■
SERVICE AND REPORT pr \ I "I" of servce ■—
OF SEPARATION °53 2111 JUi^— a
WD AGO 53-280 >1 4 I _Receives with p P
5 WO AGO 53 280 RoU 7
I, |~6 WD AGP 53-2.0 | -Inserts amounf Qf
7 wo AGO 53 210 In— final pay.
N 8 wo AGO I MMWRH ■—
(See sections t report of sepiritim^B^™"®
REPORT OF WD AGQ s3 2 k
SEPARATION — report of separation
NATIONAL GUARD (hat. guard)
WD AGO 53-2 - Completes from Service Record, Soldiers Qualification Card and Immunization Register. - Takes thumbprint on copies 1 and 2. - Has soldier sign copies 1, 2, and 4.
— See Circ. 389 WD 1944 as amended for proper entries and disposition.
- Prepares WD AGO 53-2 if soldier to be released is a National Guardsman, in addition to WD AGO 53-280.
-Has officer designated to sign discharge certificates sign copy 1.
IDENTIFICATION CARD k £
ENLISTED RESERVE identification card J
CQRpS RESERVE CORPS^O^^^^^^" ■""■■■■■■
WD AGO 166
-Prepares form, thumbprints soldier and then gives to individual.
- Prepared only for enlisted reservists.
1olZsTSnGR WDPAMPHEET2I4 |
SOLDIERS GOING GOING BACK
BACK TO CIVILIAN LIFE
WD PAMPHLET 21-4 WhMMMbI
- Gives to soldier.
- See Note 1, Section 1, Page
LAPEL BUTTON lapel button
REPORT OF CHANGE - Gives to soldier. j_________ __________k J_______________________
OF ADDRESS — N REPORT OF CHANGE I ’
ENLISTED RESERVE of address
CORPS WD AGO 167 — Notes information. , .
y
SECTION 4—DISCHARGE FROM THE ENLISTED RESERVE CORPS. ________________
(By Commanding Generals of Service Commands at the request of 1nr-*0.A60”,55., \
Commanding Generals of Major Commands.) U I 3 wo AGP 53 55 "bZBZZMJ
q 4 WD AGO 53-55
DISCHARGE \ 5 wo ago 53-55
CERTIFICATE AND \ 6 wo ago 5^?'A
REPORT OF r=-- "k
SEPARATION - ■■■■------
WD AGO 53 SERIES 'w 8 wo ago 53 55
IISCRARCE CERTIFICATE > S I REPORT OF SEPARATI.N^fl
- Prepares WD AGO 53-55, 53-56 or 53-57 (Whichever is applicable).
8
■h
1 JAN 45 TM 12-235
SEPARATION PROCEDURE (CONTD)
Checks
Ft-----------------k and
Personnel I wo ago 53 280 ■ rz------------------k files
Section kA 'J'I'J'J*” I L 2 wo AGO 53 280 I
n OF SERVICE ■ -A REPORT
T SEPARATION ■ f
Wf - Keeps 3 wo ago 53-200 |
- Receives copy stapled [4 WO ago 53 280 |
to final indorsement n WD ago 53 280 h
page in Service Record. r~,----.------------“k
r L 6 wo AGO 53 280
MRMaMMIOORIMM 7 W0 AGO 53-280 |
8 WD AGO 53-280 I CEATIFICATE OF SERVICE I
W A REPORT OF SEPARATION ■
k wo ago 53-2 hFi*®
A REPORT OF SEPARATION I^A _. ., , ,.
y (HAT guard) - Distributes copies as follows:
3. Service Command copy
4. Veterans Administration HQ copy
-Notes information. 5. Veterans Administration Regional Office
copy
6. Board of Registration copy
7. Reemployment Committeeman copy
8. Veterans Employment Representative copy (See AR 615-360, 615-361 and Cir. 389
WD 1944 as amended for proper addresses)
• ----------------------b
^F I WD AGO 166 I
IDENTIFICATION CARO r ENl. RESERVE CORPS
— Keeps \
. WD PAMPHLET 21-4 ■
GOING BACK
F TO CIVILIAN LIFE
- Keeps for his information.
- Keeps
W0 AGO 161 I
REPORT OF CHANGE J
OF ADDRESS c , .
Forwards to
Demobilized
-Submits to Commanding Records Branch,
General of Service Com- High Point, N. C.
mand annually or on change
of address. wo ago 53-55 ■ |
-------------------K k REPORT
— k WD AGO 53-55 | 7 Of SEPARATION ■ ■■
CERTIFICATE ■
- Checks information and fo wn ten k
-Keeps combines with records [7~ wo ago 53-55 |
previously received -------——-----------"k
upon release to inac- W° *60 53 55 1
tive status. >w 6 wo ago 53-55 | * 9
■■■MRH^ % 7 W0 AGO 53 55 |
L 8 WD AGO 53-55 |
IISCNARCE CERTIFICATE I
> t REPORT OF SEPARATION ■
-See distribution above.
9
TM 12-235
1 JAN 45
INFORMATION FOR SOLDIERS GOING BACK TO CIVILIAN LIFE WD PAMPHLET 21-4
REFERENCE: CIRCULAR 445. WD 1944
CIRCULAR 461, WD1944
^rin n,f°^Af ^eC /
w, ngo^co ter^h an,p°'H /
WWg^*^ ) hat Ton rationSanl harg' HosP'tal /
/ /Z V°U 4'e/> 31'S°°'’ai Fo %V,'CC R'bbo P"Se /
( . ^ZoA ^*^ I
/ Co "'"*«<. '~^o " /
L___ « /
" ,?* \ _Ja)— \ i.h \a 9,5*1 vi J" —-—
,____-A \ \ U-'-." \ ,0 _'.'^ \ Xrt San vr
f A \ \ \ \ \ Dec Uy 1-— ? .1 Bar*- J fllETMTlI iH FTTW
\ r"\ V-A \H i.9°_Y^^\ WWWiWl
\ \ t\ \___1 \“ \\ v\ -.0.0° “’ \ \ _\ 1
\ \j\ uTZa VYn \ c \ i” \ — \ 1
t—"A pu rTJ \ \n \\ \’- JiV— \ . - \ i
\ r"\ \ \ \ V-A \® \ 1 14 \ 1
\ \ r\ \ \ \ \\ \ '- \ \Z\ \ Ua££^JiV----^^ ulHGiot( «5- °‘ ’ ___
_-A Va H \*U Wa ;„“ -~"_______ \\
CoH n n w W \
\ \ V\V*\ \ 3 \ *i\ \" \ \ t^.A \ «••*’
\ V V\ y \
\ \\ \ .^1-1 _________________________
\ \ .««■’• _______—■—
\ ywT *‘ _________
NOTES: 1. All copies of form are prepared in one operation.
2. WD AGO Form 30-S is prepared and distributed for every enlisted person discharged or released from active duty even though there are no allotments recorded in the Service Record.
ii
TM 12-235
1 JAN 45
DISCHARGE CERTIFICATE
REFERENCES:345-470 345-500 CIR. 38 9,
WD, 1944, AS AMENDED.
honorable JDisfctjarse
SMei ei A eer/ej/y Ma/
LLOYD M. CARPENTER
32033197, Technical Sergeant, 317th Infantry Regiment
Arms at H|» flntteb states
ei A'ere/y 9&eun‘eM/y fam Me m/i/iry
teeweee efa Me Mne'/ee/ Qtya/ee efa Si/meeeexe.
SM/> eee/efaea/e ei aee'areM/ a> a M/emenea/efa Z/Venei/ ane/ . fiAAAe/ ,/A.Aa fao~e 1 DtcnffiKR 1M2 21 NOVBffid 1944 / £)itrr_ ^*^***^_
\ q\ Ur’ \ •/ FORT DU, fcw JKRSEY J“ /
\ t t \ A
\ U>Ar \ 21 NOVDIBSR 1944 U
\ \ T°Al, K
\ \ 0 ‘^r/r /
\ \ ?Q>Ar^ /
\ \ ,,. a,,™ < a,Th*t J >
\ \_______________________________________________________________________________________ '....................................../
\ **'*'’~z ,Aet/^Xt,^z>„,0 /
\ V^flBSQSE^k / /
\ ”4 \ / °'a /
\ w /
12
1 JAN 45
TM 12-235
AND REPORT OF SEPARATION WD AGO FORM 53-55
Forms’^ and 's'aid P®fSon given an Honorable Discharge. Thu fora supersedes all previous I
phghtd under the "Army Requla^ons edition! of WD AGO Foma S3 and 55 I
applicable to those lorms and distn- 1 1 TO TYPIST: KEEP PUNCTUATION MARKS \^J which will not be used alter receipt I k Vi14 KblL'J
ro a oi ■>»
ENLISTED RECORD AND REPORT OF SEPARATION
HONORABLE DISCHARGE
I. LAST MASS - F1RBT BAMS . BIDDLE I SIT I AL 1. ASST BE REAL SO. 3. SSAM I 4. AM OR S1RVICE I B. COM FORI NT __
Carpenter Lloyd M 32 0 33 1 97 T/Sgt | Inf | AUS
«. ORGANIZATION 7. DATS OF BKFARATION B. PLACE OP SEPARATION
Co A 317th. Infantry Regiment 24 Nov 44 Tilton GH Fort Dix NJ I
•. permanent Aooeua for baiurr purpobu io. oats or bimtn ii. flack of birth
411 Highland Ave. San Francisco Calif. 28 Aug 1915 Los Angeles Calif. [““1
IS. ADOREBB FSOB WHICH IMPLOTMENT WILL BE BOUGHT IS. COLOR KYM114. COLOR BAIS IS. HEIGHT I IS. WEIGHT |I7. HO. DEPEHD.
See 9 Blue | Brown 6 ft | 170 t>v | 1 p—->
IS. HACK I IS. MARITAL STATUS I KO. B.S. CITIZEN KI. CIVILIAN OCCUPATION ABO NO.
|-» !«■ Blectrical Engineer 218______________________________________
MILITARY HISTORY
“^1'""dATE or INDUCTION IS. DATE OP INUSTBKIIT| 14. DATE 0* ENTRY INTO ACTIVE MRVKE IS. FLACK OP ENTRY INTO SERVICE
30 Nov 40 I 30 Nov 40 San Francisco Calif. ' I
mECTIVRto. I»4 S«W»T«S«> 17. LOCALS.S. BOABB WO. I IS. COUNTY AND STATR IS. HOME ADDRESS AT TIBI OS ENTRY INTO SERVICE
“data* ^1 x* |110 90_______I San Mateo, Calif._____________________411 Highland Ave. San Francisco Calif.
so. hilitanv occupational specialty and no. I si. MILITARY Qualification abo oat( (i.e., infantry. aviation and mar ksmanship badges, etc.)
Radio Repairman 174[Expert Infantryman's Badge 30 Sept 44
Normandy Campaign, 6 June 1944 to 24 July 1944
31. DECORATIONS AND CITATIONS
American Defense Service Medal Good Conduct Medal
European African Middle Eastern Theater Medal Purple Heart
34. WOUNDS RECEIVED IN ACTION
15 Oct 44 European Theater Bullet wound, right leg
SMALLPOX | TYPHOID I TETAHUS OTHER (specify) DATE OP DEPARTURE DESTINATION DATE OF ARRIVAL
1 Dec 42 1 Dec 42 7 June 42 None 2 Feb 44 European
97. TOTAL LENGTH OF SERVICE SS. HISHEST SHADE HELD TheatCF 6 Feb 44
^T.NENTAL SERVICE, I foreign iesvick_Z 18 Oct 44 USA 20 OCt 44
TEARS IhONTHSIDAYS TEARS NORTHS DAYS
3 I 3 I 8 | 0 I 8 | 17 T/Sgt
United States Navy 3 years.
40. REASON AND AUTHORITY FOR SEPARATION
Certificate of Disability for Discharge AR 615-361 and 1st Ind Headquarters*
41. SERVICE SCHOOLS ATTENDED I 42._EDUCATION (Years) _
Signal Corps School, fort Monmouth,NJ
PAYDATA
I^3*^Sc»V?Tr^O^Ar^Pu7pO*«»r4«^^HUmillH4 OUT FAY I4S.B0LDIIR DIFOIlTlI 48. TRAVEL PAY I 4Z^-(0TAL ANOUNT. AAHF>^O|SBUItS|NC,€FFrCER/ Z z- X I
..mYlTl1" l°*2*5 TOO. l;w,r Hone
INSURANCE NOTICE
n.rJnwllIT ii'pKHMll M II- NOT PAIIl WHEN DUl! OK *ITH1N THIKTV-ONK DAYS TH IK It IT KM. l-iSUIMMk HILL l.ll’M.. IHM. . HI < K.-. OU M. s k. > ' OHUk.Hs l-.MAUl.l
IMPORTANT TO THE THIABUXEa OP THE U. B- AND FOHWAHD TO COLLECTIONS BUBDIViaiON. VETERANS ADMINISTRATION, WASHINGTON 88. D. C._
44. KIND OP INSURANCE I 4S. NOW PAID | BO. D.W of Allot- I SI. Oete o« Nexi Premium OU. sa, PREMIUM Out 33. INTENTION OF VETERAN TO
N., Hcrv. I U.S. Ootl I AiloUeot c. (One month alter 50) each month . commonly I....,.il7n=—
| x I | I x | V-A- | 30 Nov 44 I 30 Dec 44 | ,7.90 | x |, I
5* a 88 (This space tor completion of above items or entry ot ether items specified in V.' D. Directives)
? Time lost under AW 107: 1 day
j Lapel Button issued
j * Tilton General Hospital Fort Dix New Jersey dated 22 November 1944
’ Z/^"7 1 a J ° °- 1st Lt- MAC
CAJ ----Asst. UPO Tilton GH
1 November 1944 WD^AGO Forms 53 and 55 for> enlisted persons ®
will not be used after receipt of thU revision.
r2. FINAL INDORSEMENT COPY (Affixed to final indorsement page of Service Record)
3. SERVICE COMMAND COPY
4. VETERANS ADMINISTRATION HEADQUARTERS COPY
5. VETERANS ADMINISTRATION REGIONAL OFFICE COPY (To: Regional Office responsible lor address shown in Item 9)
6. BOARD OF REGISTRATION COPY [To: State Director ot Selectiv^^^* Service lor State «hown in Item 28 when available, otherwise hem 29)
7 RE™PL°^MENT COMMITTEEMAN COPY (To: State Selective Service for State Bhowa in Item 12)
8. VETERANS EMPLOYMENT JippRESENTATTVE COPY
Veterans Employment Re^edentatfve of the Wat Manpower SkraX™ fn h^>h]2S),a1* Dfa**w 04 Service for the
NOTES: 1. The WD AGO Forms 53-55, 55-56, 55-57, and 55-280 combine the Discharge Certificate and Report of Separation allowing preparation of both in one operation.
2. When this new form is not available, WD AGO 53, 1 September 1944 and WD AGO Forms 55, 56, 57, or 280 respectively may continue to be used.
3. Report of Separation is completed from Service Record, Soldiers Qualification Card, Immunization Register and information ascertained by interview with the dischargee.
4. WD AGO 53-2 will be completed in addition to the above for men who are to revert to National Guard status or former National Guardsmen who are discharged.
5. See Cir. 435, War Dept. 1944 for coding medical data on final indorsement copy.
13
TM 12-235 ] JAN 45
FINAL PAYMENT ROLL WD FORM 371
iEFERENCES: AR 345-475 I
TM 14-502 FINAL PAYMENT ROLL ---------------
of
DETACHMENT OF PATIENTS , '
TILTON GENERAL HOSPITAL __________________________________________________________
(OrtaolutioD) (Regiment)
FORT DIX, NEW JERSEY ________________________________________________________________________
(Station) (Principal arms) 1
Discharged on November 24, io 44 Paid November 24 1944 (Foru»atPaying om«)
APPROPRIATIONS: I
__________________________ _______________________?____________ Fort Dix, NJ November 24,1944
(Symbol) (Allotment) _(Station) (Date)
I certify that this roll is made out as required by --------------------------------------------------- Army Regulations and that entries pertaining to each name are correct; that where rental and/or subsistence .-------------------------------------------------- - - allowance is due, the soldier was not furnished rations
in kind nor received the equivalent thereof in money: ________________________________________________________________________________ that where quarters allowance is credited for the enlisted man, his dependents, or both, public quarters were not _______________________________________________________________ available or assigned to such persons nor did they receive ’______________________________________________________________» monetaiy allowance in lieu thereof; and that payment
Total amount disbursed st V1.? ,enl^sted men named on the within pay roll is not
d ~ * --- prohibited by any provisions of law limiting the avail-
AIIOTMFNT QIIMMARY. ability of the appropriation(s) involved. Except os
ALLOTMENT SUMMARY. otherwise stated in remarks, each enlisted man is entitled
to travel pay to the place indicated after his name and cu“ “N------------------------------------------*------------ was last paid to ind.ida as per remarks ,p ,
Class “E"____________________________________________________by-----------------——__________________, F. D- U. 8. A.
Certificate on £0 /Q das, --------------------------------------------------------reverse
CUa8 ..F„ part hereof 1st Lt. MAC_______________
ASSt. Unit Personnel Officer.
ClaSS ih*T-4. J Ah, ,1.11-a-. ..
Class 1
Dati or Nam“’ Oiud<» axd Comtonxkt ALLOTMENTS
rp Enu.mtmxnt No. (Date and place of acceptance for enlistment, or place of _____________________ ___________
J (Induction « notice tor active duty, by reservist; indue- Saaui. No. Month
... or all to 8“v’ hon; reporting for duty as NaUonal Guardsman under and year c£“ c£“ c^“ cu“ yV^Y
COT.I FC active duty) K< SavffaJowamJa?* President, to which entitled to deducted N E D F
.___ Honorably discharged by reason of: CDD AR 615-361 (See Remarks)_____________________________________________ *
(Bute reason and order, if any) No time lost under A. W. 107 except as indicated.
----1.OTHER COMPONENTS______________________________________________________________________________
---- 2 TECHNICAL SERGEANT
GoVCn Nov 30/40
Q p ] 3. i Carpenter, Lloyd M. 32033197 Nov 7.90 10.00 22.00 100.00
TRUST 1st Ind HQ Tilton GH Ft
M ____________________Dix IIJ dtd 22 Nov/44. Trfd
as T Srt fr 1245th SCSU Ft Dix NJ to In. ‘ unas.gd.
Forf. b 6- Atchd .iet <,f Pnts 1257 SCSU Tilton GH 1 i Nov/44.______________________________________
g rj . L/P 31 Oct 44 by GL Rogers, Capt FD. N ilmt $7.90
6- discon ;d Nntd Nov_____________________________________________________
---- 30/44. F (led $22.00 discontd Nov 30/44 Due US
7- gPLD 3 LJJL___T/P San Francisco, Calif, : K>P $300.0 ),______________________________________________
------I 411 Highland Ave., San Francisco, Calif
Army Ex ______________________________________________________________________________________________
Individui g
Paid by < TECHNICIAN FIFTH GRADE
------ io.________________________________________
T< Dec 30/40 Oct 6.50
w^d.fc 11,3 Cover, Charles W. 19019713 Nov 6.50 100.00
lst Ind HQ Tilton GH Ft
_______________Dix MJ dtd Nov 21/44. Trfd_______________________________________________________________WhM as T/5 fr L245th SCSU Ft. Dix NJ to DEML Unasgd.
' I?- Atchd let if Pnts 1257 SCSI! Tilton GH O r-.t 25/44.________________________________________________ 1
T/P Fort Missoula, Montana. N Almt $6.50 discontd \
14. Hoy 30 (44>._MOP $300.00, Box 62, Uniontiwn, P»._____________________________________,_______________
15.
PRIVATE
16. ____________ ' '____________________________________________________
Jan 19/40
YL__________3____Mottolo, Michael J._______________6977905____________________________________________10Q.QQ
1st Ind HQ Tilton GH Ft
_______________Dix NJ dtd Nov 22/44, L/P________________________________________________________________
Aug 31 '44 jy GL Rogers, Capt FD. Trfd is Pvt fr
19. Det Me it 1261st SCSU SI Area Sta Ilo sp SI NY_______________________________________________________
to MD Jnasjd. Atchd Det of Pnts 1257 SCSU Tilton
20. GH Ocj...19/ 14j_T/P Schenectady. New Yort. MOP______________________________________________________
$300.01, 9 39 Main Ave., Schenectady, Nev York.
I-------———............... _ L--
14
1 JAN 45 TM 12-235
FINAL PAYMENT ROLL WD FORM 371
(PAGES 3 AND 4)
FOR USE OF FINANCE DEPARTMENT ONLY__________
We hereby acknowledge receipt TN CASH of amount* ia
CREDITS COLLECTIONS column "Balance Paid" set opposite our reepeetive name*, and in
case of payment of Quarter* ollowanoa* we certify that we (our -------------- -------- 1 I ■■ I dependent*) actually occupied quarter* at the addreeae* ihown ■ m__.T during the period for which allowed, and that during the current I
Allow- i * WArtie Total Balance period for which allowance* are claimed we have made oontribu- ■
Danosits anrws for „ _ _ , COLLECTIONS PAID Uon* for the .upport of our dependent* liated,Lar~>n at a rate I
Travel Govt. Sol. Dvs Lpproxim.uJy equal to the rate of contribution* for the support of ■
Net ray and BUD. or Pay Laundry Home the same dependent* a* *hown in affidavit* and/or certificates here- I
Interest Furlough r | with or heretofore submitted and that there ha* not been a^matenal I
||--rated therein. |,
I certify that rations in kind or any monetary allowances in lieu thereof were not furnished to any enlisted person on the within roll during the period for which the furlough ration allowance is claimed, and that in all cases the enlisted person returned to his assigned station from furlough on the date designated and that in any case where there was an over staying of furlough the delay in reporting for duty has been excused by the officer competent to approve the furlough.
CHANGE LIST Computed by
----------$20.00 $......... Checked by„
Cbeckwriter
__—_______________________________________________
ft u. ». SOVUNHENT MiBTtMa orneg I 1U4 ifr—37Ml-lb
w
I certify that each enlisted man shown hereon to be entitled to a musteringout payment was a member of the armed forces and was engaged in active service in the present war; that he was discharged or relieved from active service under honorable conditions after 7 December 1941; that he has not heretofore been paid a mustering-out payment under the Mustering-Out Payment Act of 1944; that each enlisted man shown hereon to be entitled to a mustering-out payment in excess of $100 performed active service for at least sixty days; that each enlisted man shown hereon to be entitled to a mustering-out payment in the sum of $300 served outside the continental limits of the United States or in Alaska; and that no enlisted man hereon falls within any of the classes of persons to whom payment is prohibited by section 1(b) of said Act*
» . _ ______________________________________________________________________________________________________________________
624890 0 - 45 - 4 J5
™ 12235 1 JAN 45
ARMY SEPARATION QUALIFICATION RECORD, WD AGO FORM 100;
WORK SHEET; COUNSELOR’S INTERVIEW MEMORANDUM, __________________________________________WD AGO FORM 100-1
WORK SHEET - SEPARATION QUALIFICATION RECORD WD AGO FORM 100
»-UST HINE - FIRST H»MF - MIDDLE INITIAL IB-AWHY SERIAL HO. (C-GRAOE |O-SHM OH SEHV. I E-COHP.
CARPENTER, LLOYO M._______________________________________32 033 197 t/sgT. "7^. A U.S.
' OHTE OF £ » 0 S‘)EJ’J H-L*. HCCHUEO_1-5/0 FH, SEE. CEHTEH TO HOKE___________________ J-HILEHSE HOME JUTHOBIZED TO
A/ZllZ MOUTHS OATS ORDER HO. I PAH. HO. I DATE OF ORDER lOATE REE' 0 FR. AO ,C'” ’ ST‘,£>
30 NOV. 1944 SAN FRANCISCO, CALIF
________________DAYS______________ 7 ^-SEPARATION FORM AUTHORIZED REMARKS_-------------------------------------------------------------
IND AGO S3-55 NONE
L-PERMAHENT ADDRESS FOR MAILING PURPOSES ('trfpf and number - city or county - utate) ————————————————
411 highland avenue, san franc/sco, cal if.
CIVILIAN EDUCATION_________________________________________________________________________________
HIGHEST GRIDE COMPLETED LAS^TfAR RfCEIVED°EGREE ' MAJ0R C0U’SE 0F STU0Y M4ME AND *OO«ESS OF LAST SCHOOL ATTENDED
/S ''939 BE- '^G/NEER/NG nyu.school of engineering
~None M €°",sl 944
SUHMARY OF MILITARY OCCUPATIOB ABD C It5I 0IIt «««"■ OY.TL '".M
RADIO REPAIRMAN AGCT (. I A") I DEC. 40 iyy L-HI Trrr
IN STALLED TESTED M A 12 JUNE *F2 13 I X
AND RECEIVING INS------------------------------------------------------------------------------------------
IN CO NN ECT/ON WIT----------------------------------------------------------------------------------------
MUN I CATIONS. USE-----------------------------------------------------------------------------------------
DEVICES- ISOLA TES__________________________________________________________________________________________
TH EM. '------------ ------------
SUMMARY OF MILITARY OCCUPATION AND C
ENTRIES UNDER ITEMS 2. 3 AND « ARE JUDGMENTS OF THE COUNSELOR 12) suggested acoitio«al sch56l!TWaYmiWC “ —------
COURSE N COMMERCIAL RADIO ENGINEERING
TaTF OF SEPARATION ■’]
24 NOV, 1944
HD AGO fUt-M 100-wS 4 •>: ‘~ze- 'j) SUGGESTED flUO OF WORK “ ' ' “ —-------
Ni^I^H RADIO BROADCASTING ENGINEERING
io .EM...S man plans to seek employment in radio 0R'oaoca5Ting based" oncivilian experience as electrical engineer ano service experience IN RADIO REPAIR and CONSTRUCTION EZ^i^ (2
L_......................................................
UmHm’ 1 TF“TAT'*< THIS IS NOT AN OFFICIAL WAR OfPAPIKTNT RFCORD R4 - 99 5T9-19 5M
I nc I ti i
NOTE: WD AGO Form 100, Work Sheet is completed in interview with dischargee and reference to Soldiers Qualification Card, for use in preparing typewritten copy of WD AGO Form 100. WD AGO 100-1 is prepared by the Separation Classification Officer for each man who indicates a desire for vocational counseling. 16
1 JAN 45
TM 12-235
ARMY SEPARATION QUALIFICATION RECORD WD AGO FORM 100
ARMY
SEPARATION QUALIFICATION RECORD
LAST name F i FST mAmE - miDHLE Ini I iAl " lARMY SERIAL HUMBER ] GRADE | DATE OF ENTRY I N TO I SEX I D ATE OF BIRTH
ACTIVE SERVICE
Carpenter Lloyd M___________________________ 32 033 197 |T/Sgj 30 Nov 40 M |28 Aug 1915
PERMANENT ADDRESS FOR MAILING PURPOSES (Street and Number - City - County - State) “]
411 Highland Ave. San Francisco, San Mateo, California____________________________________________________
______________________________________________CIVILIAN EDUCATION____________________________________________ HIGHEST GRADE COMPLETED IlAST YEAR IHIGHEST DEGREE ImAJOR COURSE OF STUDY JNAME AND ADDRESS OF LAST SCHOOL ATTENDED OF ATTEK- RECEIVED DANCE
15 1939 B.E.__________Engineering___________________N.Y.U. School of Engineering
_________________________________________________OTHER TRAINING OR SCHOOLING_ ,____________________ .._j _______________________________________________________________________________________________________COURSE_NO .HRS._C€ U= -E_ NO. HRS. _COURSE_ NO.HRS. COURSE_ NO.HRS.
None
______________________________________________SERVICE EDUCATION_____________________________________________
SERVICE SCHOOL COURSE BeIbJS)*AT 1HG ARMY SPECI*LIZEO TRAINING PROGRAM
“ . . .. . “ ~ . 7T INSTITUTION CURRICULUM ANT T£fiM NO. OF |_ Q RADU AT J
Ft Monmouth NJ______Radio___________________ 4 Ex where enrolled (cqufse of gaining pursued)_weeks yes no
.......................................................................None_________________________________—
_________________________________________________________________1__________________________________L_J—J ■■hih1
CIVILIAN OCCUPATIONS
Electrical Engineer I stconoAKr occupy■ ox
job summary speciaiized work in designing. J0B SUHM,R’ electrical equipment such as dynamos, switches, cables, switchboards, radio equipment and communication systems.
KO.OFlLAST DATE Of EMPLOY-IHAME AKO ADDRESS OF EMPLOYER HO.OFl LAST DATE OF EMPLOY-IKAME AKO ADDRESS OF EMPLOYER
YEARS MEH I YEARS HEKT
New York telephone Co.
1 15 Nov 40 New York, N.Y.
MILITARY SPECIALTIES
ASSIGNMENTS I
YEARS MQt.THS GRAPE PRINCIPAL DUTY I ARMY COill soj YEARS MQN1HS GRAPE PRINCIPAL DUTY [ARMY CODE ~MQ
______3 Pvt Basic training________________521___________________________________________________________
3 8_____ T/Sgt Radio Repairman____________174 ____________________________________________________"
SUMMARY OF MILITARY OCCUPATION AND CIVILIAN CONVERSIONS (Shown by title)
Radio Repairman Electrical engineer
Installed, tested and repaired radio transmitting Radio engineer
and receiving instruments and related equipment Radio operator
in connection with the maintenance of Army communications. Used various testing meters and devises; isolates defects and repairs or replaces them.
SUMMARY OF MILITARY OCCUPATIOH AHO 0 I V ILI AH COHYERSIOHS (Shown by title) '
If original is lost or destroyed, no reproduction is possible; no copy is retained by the War Deoartment.
____________________________________________________________________________________________________________J
* THIS I NF"RVA I 1 UN U\sE.U ON bULUIEH'S bTMFMENT. (Indicate hy • any items not supported l.y military records )
DATE OF SEPARATION SIGNATURE OF SOLDIER SIGNATURE OF SEPARATION CLASSIFICATION OFFICER
24 Nov 1944 Z/V- ALBERT A. FOSTER
W.D..A.G.O. FORM NO. 100 15 July 19HH 1st Lt. , A UP
24-0643O-6OM
W.D..A.G.0. FORM NO. 100 15 July 19UU
•-----... 2«-»6430-gOH
NOTES: 1. If soldier is discharged on CDD, Veterans Administration copy is sent to the Veterans Administration Area Office.
2. If discharged other than CDD, Veterans Administration copy is sent to Veterans Administration Regional Office, nearest contemplated residence of dischargee.
3. If an interview with the soldier is not practicable, complete Form 100 from WD AGO Forms 20 and 24, and state in signature box "Form completed from Forms 20 and 24. No interview."
17
TM 12-235
1 JAN 45
REPORT OF PHYSICAL EXAMINATION OF ENLISTED PERSONNEL WD AGO FORM 38
REFERENCE: CIRCULAR 333.WD 1944
I — ....... 0 b
REPORT OF PHYSICAL EXAMINATION OF ENLISTED PERSONNEL .
PRIOR TO DISCHARGE, RELEASE FROM ACTIVE DUTY OR RETIREMEwfS^F 61252
1. Last nom»—First name—Middle initial 2. Army Serial No. "3Tg737^
Marshall John M 12 345 678 Pvt^^^ Ord Unasgd
5. Permanent mailing address 6. Color 7. Age in 8~Se"x~I 9 Sy^h.iis Register >
r~r» InS/R? cloeedmS/R? | |
215 High Street Hartford Conn. W 24 M Yroicnt time, disabled or suffering from any wound, injury, ordiceuse whether o.- not incurred in tho military service. IL yOj. Lit those condl- Yes or No ‘
~H~ Ust all si iH t dZg1___________nd 1 ri—. SI te 1_—
Incurrot?. Answer yes or no in columns 1 to 4. • injuries v/ere £prs » AMS « IMS ‘ PD»
Fracture of left leg in 1934___________________________________________Yes Yes No Yes
(_________________________________________RECORD OF PHYSICAL EXAMINATION
Psychiatric Diagnos.s 23. Teeth—Indicate restorablo carious leetfi by O. nonrestoroble conous teeth by I. missing natural teeth by X
.teeth replaced by denture ^horizontal line over) X as XX! and teeth replaced by fixed bridge (oval to Vi TlTOl *] 4^1
None Include abutments) as (4 X 6)
13. Neurological Diagnosis RIGHT EXAMINEES LEFT
> 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Negative 16 13 * 13 12 11 10 9 9 ** is *®~
14. Eye abnormalities 24. Mouth and gum abnormalities ? 34. Dental prothesis, serviceability* " '
None None None
15. Ear.noae.throat abnormalities —- 25. Musculoskeletal defects 35. Vision ——--------------------------------------
‘=a^~LjtelJ healfH ~ ~ T
None —. . .
T6.~Skin~ ------------------------- REPORT OF BOARD OF REVIEW ■
(See Instruction 2)
Normal_____________________________ From a careful consideration of the case and a critical examination of the enlisted person, we find that Ye* or No
17. Varicose veins °
1. He meets physical and mental standards for discharge. YeS
Norje 2. He meets physical and mental standards for discharge except as follows: Yes
18. Hernia I
on e
None
20. Gemto-urinary (and pelvic for women 3. The defect, wound, injury, or disease is likely to result in untimely death.
4. The defect, wound, injury, or disease is likely to result in permanent disability. Normal 5. In our opinion, the defect, wound, injury, or disease was incurred in line of duty in the military ser/ice of the United No
21. Venersal dlaoaies States.
Location None 22. F«®t ' -----------------------------------------------------------------------------
^°rt D1 ARMY SEPARATION SEROLOGY REPORT A 61252 ■
Normal_____________________________ Da,° _____________________________________
Entor rvmarka or other defects (continue c ' ■ _ .... , .. , .
X-Ray reveals well hei 21 Novl i. Lo.i nom»-Middi. imuoi 2. 3. e^im.ni. ona•.,.«»-----------------------------
fracture of left tibii ------------------
*o55ra^i=sss------ ------ Marshall John M 12 345 678 Pvt Ord Unasgd
1NSTRUCTIO -------------------------------------------------------------------------------------------------------------------------------------------------
1. Tl,l, r.no,l S. P~n.™nl~aUl^odd»- 6. Color 7. U> » S« 9. Srphllu-R-aitor ■
2C November 44 Ft Dll , w.d..a.c.o.no.J-------------------- 7 E 215 High Street Hartford Oann. W 24 U "9o“
15 May 1914 31 Eoeh ____________________________________________________________________________________________________________________________________________
Thu form supersedes all TREATED 1N ARMY
previous editions of W. D.. A. G. - Blood for serology of the above-named Individual forwarded far examination: (Date)__________________________________________________ (Indicate by check)
O. Form No. 38. which will not ------------------------------------------------- ‘Wkl.u.JZZ-i—VZZ—i—m
lx> used after receipt of this Findings: MoIoria .L NZ.
revision. Serology report I
_® SyphlUs I y»« I NoP
TO: SPECIAL LABORATORY EXAMINATIONS A 61252 '
V _____________Examination For:
x*.r_______________________
____ E. K. G.____ _________________B. M R.__________ _________________ Blood smears____ _________________Blood chemistry__ Blood count_____________________
s Urine_______________________ Urinalysis ~
Feoes Other, ExamiMr -----------------------
_______________________________________________________________________ I 20 NOV 1944
Complete and return for entry ca Farm 38. Do not hie' ~~ '————————- ■ —
TO: SPECIAL LABORATORY EXAMINATIONS A 61252 I
F / Examination Fan
Z Frac It tibia F“’d‘”a* — J-
NOTES: 1. WD AGO Form 38, Report of Physical Examination, is used for final type physical examination in discharges or releases from active duty other than discharge under AR 615-361 (CDD) in which case WD AGO Form 40 is used.
2. The AGO copy will be forwarded with the Service Record and allied papers.
18
1 JAN 45
TM 12-235
PREVIOUS EMPLOYER CARD WD AGO FORM 519
HEADQUARTERS
Tilton General Hospital, Fort Dix, N. J.
ERENCE: CIR. 424, WD
1944
NAME Lloyd M. Carpen ter DATE OF BIRTH 28 Aug 1915 DATE OF SEPARATION 24 Nov 1944
In order to assist military personnel to return systematically to gainful civilian occupations, you are informed that the individual named above has been separated from the service.
This card is intended as a service both to the veteran and to bis previous*employer. Tlie veteran has received complete data with res|»ecl to bis military service. It is therefore urged that no correspondence be entered into with the commanding officer of the installation named above. Correspondence, if unavoidable, should be addressed to “The Adjutant General, War Department, Washington 25, D. C.”
PREVIOUS EMPLOYER CARD
W. D., A. G. O. Form No. 519 j September 1944
NOTE: If dischargee was employed at time of entry into the military service WD AGO Form 519, Previous Employer Card, will be prepared and mailed to organization which employed the dischargee at time of entry into service.
IDENTIFICATION DISCHARGEE CERTIFICATE
IDENTIFICATION DISCHARGEE CERTIFICATE
REFERENCE: CIR. 358, WD 1944
Prepared by Separation
Classification Interviewer
Certificate of Army, Navy, Marine Corps or Coast Guard Officer
THE HOLDER
is traveling at own expense and is entitled to SPECIAL COACH FARE authorized account;
(a) Discharge, or
(b) Retirement or release from active duty and not entitled to travel on transportation requests;
if presented within 30 days from date of discharge, retirement or release.
From Fort. Dix New Jersey _.
ToSanFrancisco California.
24 N<
Member 1$>44_
O' WEXLER, 1st Lt. MAC
Ass t. _ UPO, _ _TLlton_ General .Hosp
Signed by Personnel Officer
Ticket Agent will take up thia Certificate, noting thereon form and number of ticket issued, and forward with ticket report to Auditor, stamping back hereof with regular ticket dater.
When this certificate is properly executed and presented with officially executed discharge, retirement or release papers, it becomes a specific request of the United States Government that the holder when traveling at own expense, be authorized to purchase a oneway coach ticket at the special reduced fare authorized, account discharge or retirement or release.
The United States Government will not be responsible for the payment of fare for ticket issued in accordance with this certificate.
NOTE: Identification Dischargee Certificate is prepared and given to dischargee if he desires to obtain the special fare one-way coach ticket to the place of enlistment or induction or his chosen place of employment. (See Circular 358, WD 1944.)
19
™ '2'235 1 JAN 45
NOTATION OF DISCONTINUANCE OF ALLOTMENTS IN SERVICE RECORD
___LI - ___________________ I
national service life INSURANCE I
Z/AzrjT fj< 1 or p„ for „ (dUw,;
Claaa jXnaoraoco deduction of $.7_*_^p _ month., coanmencmt-?.€.(?...ipirin,___________
for payment of monthly prenu^h>\£ A Discontinued ______ r““"------,\------- W. D„ A. C. O. Form No. 30, mailed to
Veterans’ Administration, Washington, D. C, on_______ !>____
by____________________________________________________
(Name and grade of forwardinc officer) ” ”
r- I
Class r 10
5d^!^_^77"per month for months, commencing ___ , 19^^
N°TE: A'lo/m®n*s wiH be closed out by stamping one Discontinued Jr_, 19_ , zeason ____________________ or the following legends diagonally across the
W. D, A. G. O. Form No. 30, mailed to Finance Officer, U. S. Army, Washington, allotment entries in the Service Record:
(Name and grade of forwarding officer) "Discharged" — if discharged
------------------------------"Released - ERC" - if transferred to Enlisted "Released — NG" — if reverted to the National
-----Guard.
CLASS E ALLOTMENTS
Class E allotments of pay authorised as follows: —_
per month for
Discontinued ____, 19. , reason_________________
W. D., A. G. O. Form No. 30, mailed to Finance Officer, U. S. Army, Washington, D.C,---------,19...., by____________________________
(Name and grade of forwarding officer) Acknowledgment of ditcontinuance received..........19.
__________
EXTRACT FROM SERVICE RECORD WD AGO FORM 25
21
\ EXTRACT FROM SERVICE RECORD /
(See S^c. Ill AR 345-125)_OF_ /
Last Na\j First Name Middle Initial Army Serial Number
Civilian Addre^^Street and Number f
Civilian Address—CitWand State
Detain d. or Current Enl. CiWjan Occupatioj^. Army Civilian o AGCT ’Spec. Serial No. 2 Grade
Data of Birth j Hais^Color | Race
Ft J Eyes Hair
NOTE: Extract from Service Record will not be prepared '
for any discharge or release from active duty when Form 53 series is prepared. Distribution of homD.;.lo«?iC,o, .
Form 53 series will serve to notify all interested \~
agencies. See CDD Transfer Order following . ........................................./V....
to transfer personnel from attached status to y^is form supanades W. D., A. G. O. Fo
Til Ind. FINAL INDOBSX \'< ,\ V \t% \ V4 \_ . o \ \
--------------------------------------- -------------------------------------------s \
------------------------------------—.... -—\'&AwA\“ t 4 A \
t._____________________________ ______________________________—tsA vA>\ v \t\ \ V v \«'\ \
- --------- \ y . v \ \-2. V. • v \ >
This aoUier wm traacferred to__ __________________________________________________________________\ \r.-xW A V_ <5 V \ >
------------- \ \»i®\ \pq\ \c yik\ \’s \j <_> \ »
per_________________ _ To Tht Adjutant Gtnfral: \ y-b\.\£> X X^ *’£) \ %
lhk------------------------------\\ % v \\ X
---------------------_ _ \ ¥^rt\ V’ftv o\ \” J-> W \ \ \
...... ~ <6S>\ \ M O') \% \° \ \ \
---- y^-ru v'Ay.jy \s \\ \
Dua United Status; if nothing, so stale —____.—— -==A\teG\^AU * >;A\ \
----- ---- ___________________________________________________________________________\to\W \ v a \i <^\ \
--------------------------------------- --------- ------------------------.«b-*T-----------------------------------_\ \-AV\ V \
(Plaoa) \ V Ao-g \ \ ■£ >» V* _\ \ %
--------------------------------------- fteteinadinaorvie. days te maku guod thno last (A. W. ItlX \S?\ *0 \ X \
Absent from duty days subsequent to normal date of uspiraX \\T^^X ,A X c \t> %eu W
enlistment. \ \ >\t X 5JA \ a> \* VtVi >
— X Xa •X'f\X^’M*^- 2A X \° X w
__ Retained in service days for ceovenienee of the Goverameot m\ \^> ift\ ° \q •• V X > \ x %
__________ ■ •-------------------------- -:-----------------------------------------A M mXW\ \X 'b o- wx^lvW X
HUAU \C •> \t \>VOO; >
E&cieocy rating as soldier------------------------------------------------” v V V'V'A \ \- * W X \
•Fmal statement furnished. *PaM ec final «y refl. \ X a \ \% >
•Oj>jwrBe certificate furnished, W. A. u.0 .Ferm No. 55, SA, 57. X ^X ° tfX^X^^x** J\ '$) \ X X X°'^-°'^ W
---------------------------------------o-^usm..;IMUv,nA.-----------------------------------------------------------\Av° *• \\Lv^\
=iif== W\
........................................ ^igo\
--------------------------------------- ------------------------------------------------------------------------------ \
Thia soldier ■ Class E aHotmect running which has been deducted from hm .. \ \ Xv'J^X \ \
pay to inclade_______________________- ------------------------------------------------------------------------------ X \ V" \ \
Thia aeldMr has authorised a Claaa D deduction for Gorwumen* inauraoce which Era X \ V\\ \ V \ V* \
been ., A. U. O. Form ' March 31, 1942
No. 2
NOTES: 1. Given to persons being transferred to Enlisted Reserve Corps for use in reporting changes of address to Commanding General of Service Command of residence.
2. Additional copies mailed to Reservist by Commanding General of Service Command for completion and report by 1 May and 1 November of each year.
IDENTIFICATION CARD, ERC WD AGO FORM 166
IDENTIFICATION CARD—ENLISTED RESERVE CORPS
REFERENCE: AR 150-5
This is to Certify. That -J?.hn M. Marshall____________Pvt__________Ord________
_ _ „ , _ z — « (Name) (Grade) (Arm or service*)
Serial No. .12.__3.45.-478__ Home address ._Har.tford,_.jConn,_________________
j transferred to] * , , . th»CI,y> (State)
was 1 enfcaddrx j grade shown m------------------------------------------------
Enlisted Reserve Corps of the Army of the United States, on the _„21st___day of
INSTRUCTIO
f Immediately
Enlisted Reserve t the commanding | J stating his new pl i cate copy of the i in the event he
J W. D„ A. G. 0.1
which may be obt * it may be by letti Rivht. thumb nrint
___November one thousand nine hundred and fQX.ty—fQUX_____________, for the period of______yaaa___. When^^^rrec^|*he was 24years of age, and
by occupation a p.liMber________________ He has..bXO.Vtn eyes, black..
hair, ..Diddy.. complexion, and is .5._feet .4- inches in height.
Dates of immunization: Smallpox l._jtec._42___Typhoid _J._Xte.C-42____
_____________ Other -TtetanUS- .19.42______________________Blood type
HQ"
Given at Headquarters _______, ...N-®K--JfiXfifiy__, this
..21s tday of ...NQ.V_Snib.er , one thousand nine hundred-ana forty—four • Cross out words not applicable. ■'1 • L j i
FOR THE COMMANDING OFFICER____________
W. D., A. O. O. Form No. 166— October 22, 1942 FRANCIS JONES,
personnel Officer
NOTE: Prepared for enlisted personnel being transferred to the ERC only.
22
1 JAN 45
TM 12-235
LAPEL BUTTON AND RECORDS TO BE GIVEN TO DISCHARGEE ON SEPARATION OR RELEASE
/
r— o f
\ ^05? I
\ <<> ¥'°'^2h^ f
I C^AVC ///, S-A c M’x ^x / * —^+-^££*5 b~^*Tu7Tr~~-J K
\ /
/} Won«abk^//
s»8-"'/ ,‘!^^»>ss^
824890 0 - 45 -5
23
1 JAN 45
TM 12-235
CHAPTER 2
DISCHARGE BECAUSE OF DISABILITY k A
3. Many major changes in procedure covering discharge because of disability have been made. To carry out these changes effectively, a time schedule has been established which provides that the patient be discharged on the morning of the third day after the Board of Medical Officers has recommended discharge.
4. Major changes in procedure are as follows:
a. The method of requesting clinical records from other hospitals and the photostat of the original report of physical examination on entrance into the military service has been simplified.
b. The transfer of a patient to the Personnel Section, Station Complement, or Detachment of Patients, is effected as soon as it is anticipated by the Ward Officer that the patient will go before a C.D.D. Board. To accomplish this, a new form has been designed, “Diagnosis Slip” WD AGO Form No. 176 (Tentative). Pending publication of WD AGO Form 176, hospitals may reproduce this form locally. If the discharge is not approved, the patient is reassigned to duty with his former organization or is assigned in accordance with directives.
c. Only the original of WD AGO Form 40 will be signed by the President and Recorder of the C.D.D. Board. The Personnel Officer will sign all copies certifying them as true copies of the original.
d. The Patients Property Slip, WD AGO Form 8-111, has been redesigned to meet more adequately current requirements. Pending publication of the new form, the WD AGO Form 8-111, dated 13 June 1944, will be used. Use of Patients Property Slip, MD 75, will be discontinued.
5. In order to accomplish discharge within 72 hours, it is necessary that all steps in the discharge process be completed in accordance with the C.D.D. Time Schedule. The following are key steps, since subsequent operations cannot be started until these are completed:
a. Prompt submission of the Diagnosis Slip, WD AGO Form 176 (Tentative), not-
ing anticipated cases to be discharged on
C.D.D.
b. Prompt transfer of patient to the Station Complement or Detachment of Patients, once C.D.D. is anticipated, if such action has not already taken place.
c. Form 40 will be prepared, completed and signed by members of the C.D.D. Board before the board adjourns.
d. A list of cases approved for discharge will be prepared and distributed the day the C.D.D. Board meets.
e. The final payroll will be prepared the day after the C.D.D. Board meets and action taken to complete the other personnel records.
f. Action will be taken to furnish each dischargee the opportunity to hie a claim with the Veterans Administration and to insure that all rights and benefits from that organization have been fully explained to the soldier.
g. Passes will not be issued after the patient appears before the C.D.D. Board.
6. Prompl and speedy cooperation must be assured between all interested parties in order to guarantee the expedition of the various actions to be completed to effect separation from the service.
25
TM 12-235
1 JAN 45
TIME SCHEDULE FOR
ACTION TAKEN BY .AFTER ADMISSION 0 DAY PRIORTO BOARD .MEETING
WARD OFFICER - Prepares Diagnosis Slip within 24 hours after admission of patient. - Orders X-Rays or other laboratory examinations if necessary. - Notifies AAF Liaison Officer of contemplated disposition of AAF patients and arranges interview to obtain necessary concurrence. - Prepares CDD Work Sheet, completes Clinical Records, submits with CDD Work Sheet through Chief of Service to CDD Board.
REGISTRAR — Receives Diagnosis Slip and checks for those cases in which CDD is contemplated. - Types and transmits CDD Transfer Order & Request for Photostat without delay. Requests clinical records from other Army hospitals. - Clarifies line of duty status when necessary. — Sends letter and affidavits to nearest relative regarding mentally incompetent cases suitable for home care, if necessary. — Requests designation of VA facilities in those cases to be transferred to care of VA. c
CDD BOARD - President or Secretary of Board requests Form 40's from Personnel Section for those men to appear before the board.
ENLISTED MAN’S FORMER ORGANIZATION — Within 48 hours after receipt of CDD Transfer Order completes Service Record, allied papers and clothing clearance and transmits. - Drops from morning report on effective date of transfer. — If soldier already attached to Detachment of Patients of Hospital, upon receipt of transfer order —drops from Morning Report as transferred and attached unassigned to Detachment of Patients or Station Complement. < 4
PERSONNEL SECTION — Personnel Officer signs CDD transfer order and transmits to man's former organization. — Picks man up on Morning Report on effective date of transfer. — Checks records for accuracy and completeness upon receipt. - Checks clothing account. - Upon receipt of phone call or message, prepares Form 40's (from Service Record) for those men to be boarded.
INTERVIEWERS * t 4 K
DISBURSING OFFICER
C.O. OF HOSPITAL OR DESIGNEE (STATION AND CONVALESCENT HOSPITAL ONLY)
C.O. POST, CAMP OR STATION, OR DESIGNEE (C.O. OF GENERAL OR REGIONAL STATION HOSPITAL)
26
1 JAN 45
TM 12-235
PROCESSING MEDICAL DISCHARGES
r DAY BOARD MEETS AFTER BOARD MEETS
FIRST DAY SECOND DAY THIRD DAY
-Arranges for patient to appear at CDD Board meeting. — Prepares patient to leave on morning of third day.
■ — Receives Form 40, Clinical Rec-ord, and Work Sheet. — Checks Form 40 for accuracy and completeness. - Initials all copies Form 40. - Transmits copy 1, Form 40, to approving authority for signature. — Transmits copy 2 and 3 to Personnel Section. — Prepares and distributes list of approved cases. — Receives Pension Application or statement for Veterans Administration. — Arranges for attendants and transportation for those patients to be discharged to custody of parents or relatives or to be transferred to a Veterans Administration facility. - Assembles records to be transmitted to Veterans Administration area office or facility. - Sends records to Veterans Administration area office or facility within 24 hours after patient leaves hospital.
- Checks clinical records and work sheet for completeness. -Approves or disapproves CDD, and determines if additional hospitalization is necessary. — Clerk completes Form 40 from approved work sheet while Board is meeting. - President and Recorder sign Form 40's for all approved cases before leaving.
♦
- Receives copies 2 and 3, Form 40. -Checks soldier's clothing for shortages; checks in clothing soldier is not authorized to retain. - Interviews dischargee to secure further information necessary to prepare report for separation. -Gives soldier WD Pamphlet 21-4. — Prepares: Form 30-S, Form 371, and Form 53-55 or 53-56. -Signs copy 1, Form 40, certifies copies 2 and 3 as true copies. - Sends signed discharge certificate to Disbursing Officer for entry of financial items on report of separation. - Prepares Enlisted Man for discharge. — Checks to see he is properly clothed. -Gives him Form 100, Form 100-1 and Lapel Button. -Prepares all necessary records for transmittal to AGO within 48 hours after discharge.
I. F ■ • - Red Cross worker picks up CDD work sheets from Registrar. -Aids man in preparing VA Form 526, or statement that soldier does not wish to file claim. - Returns CDD work sheet to Registrar. - Separation Classification Officer interviews soldier, prepares WD AGO Form 100, 100-1, 519 and other papers. — Gives soldier various tests and vocational counseling if desired. - Veterans Administrative Contact Representative, if present, ex-plains Gl Bill of Rights to dischargee and assists him with other questions pertaining to Veterans Benefits and Insurance. — United States Employment Ser-vice, War Manpower Commis-sion, and representatives from other agencies, if present, may interview dischargee and explain employment opportunities, etc.
— Receives Final Payment Roll late on first day or early on second day from Personnel Officer and starts computation. - Computes pay roll. -Gives man his Discharge Certificate. - Pays Enlisted Man ( if mentally competent) in morning so man can leave post early in day.
— Signs original Form 40. •
-Signs original Form 40. - Signs Discharge Certificate.
27
DOCUMENT WARR flFFIPFR OFFICE OF THE REGISTRAR
U U U U HI L 11 1 n h n u urriuLn PREPARATION DISTRIBUTION
R*
TM 12-235 1 JAN 45
DISCHARGE BECAUSE
SECTION 1 —INITIATION OF CDD CASE
1 WD AGO 8 111 frw^M,
PATIENTS PROPERTY SLIP 2 p^X'romh J_________k
WD AGO FORM 8-111 > sup
Soldier
- Lists all clothing and other property in EM's possession at time of admission to the hospital.
- Copy 1 used in clearing clothing at time of discharge.
- Copy 2 is patient's receipt for property stored in baggage room or ward clothing room.
WD AGO 8 176 I WD AGO 8 176 I WO AGO 8 176
DIAGNOSIS SLIP DIAGNOSIS SUP DIAGNOSIS SUP ■ DIAGNOSIS SUP File
WD AGO FORM 8-176 J P
— Prepares within 24 hours — If slip indicates that disposition is to — Files
after admission to the hos- be CDD, action indicated in Section
pital. Revised slip submitted 2 or Section 2A is taken.
upon any change in anticipated disposition.
— See Note 2 relative to Army Air Force personnel.
SECTION 2 —REQUESTING ORIGINAL INDUCT ON RECORD
1 BEQUEST fr^_^^_ 1 REQUEST fr
[2 REQUEST fr | [2 REQUEST
REQUEST FOR I --------- ----------I --------------------------Tj"
PHOTOSTAT work hie copy J| I work hie copy
OF PHYSICAL EXAMINATION
- Requests photostat of original report _ Copies 1 and 2 sent to The Ad-
of physical examination on entrance jutant General.
into military service. _ Work File copy sent to Person-
-See Note 3. ne| Section.
SECTION 2A—REQUESTING INDUCTION RECORD-TRANSFER ORDER
TRANSFER ORDER AND transfer order-fr^^^Mi 1 transfer order fr—■
REQUEST FOR 2 transfer order 2 transfer order ,
PHOTOSTAT I, 3 transfer order fr"— I, |3 transfer order fr—J
COPY 1-TRANSFER ORDER I, [4 request fr1MM n R[I1IHST "k
COPY 2-TRANSFER ORDER L [5 rTodeti fr_ ' F7--------------------777777-"k^—
COPY 3-TRANSFER ORDER 1 [7-----------\ ----—--------V-
COPY 4-REQUEST FOR work hie copy J 6 work file copy I
PHOTOSTAT I, wm flLf COPV I"1*"
COPY 5-REQUEST FOR
PHOTOSTAT
COPY 6-WORK FILE COPY
• - Directs transfer of enlisted man from
his former organization to station —Copies 1, 2 and 3 sent to Percomplement of detachment of pa- sonnel Section.
tients, and requests photostat of — Copies 4 and 5 sent to The Ad-original report of physical examina- jutant General's Office.
tion on entrance into service. - Work File copy sent to Person-
- See Note 3. net Section.
28
1 JAN 45 TM 12-235
OF DISABILITY
NOTE 1
1 WD AGO 8-111 ■ Clearance of an enlisted man's clothing account may be effected:
P^tltNtSJROPESIY ■ & the Unit Personnel Section of the Station Complement (or De-
tachment of Patients), or
B. by the enlisted man's former organization.
-Uses in clearing man of his clothing at time (1) when a|| fhe en|isted man,s c|othing Qnd equipment is taken to
of discharge. (See Note 1.) t^e hospital prior to his discharge, the Unit Personnel Section (or
Detachment of Patients) will effect clearance based on WD AGO Forms 32 and 8-111.
(2) When only part of the enlisted man's clothing and equipment is taken to the hospital and the balance remains with his former organization, the organization will record as "turned in" on Form 32, items not taken to the hospital. The Unit Personnel Section (or Detachment of Patients) will subsequently credit the man with those items which he has with him.
(3) Shortages under (A) and (B) above will be adjusted by a statement of charges or by report of survey in accordance with AR 615-40.
(4) Clothing and equipment turned in will be disposed of in accordance with procedures set forth in AR 615-40 and WD TM 38-403.
NOTE 2
Army Air Forces Personnel. Ward Officer will notify the Army Air Forces Liaison Officer of any AAF personnel who are to appear before the CDD board, so that he may concur in mode of disposition, for the AAF.
• NOTE 3
A. If soldier is already on "attached unassigned" status and Service Records have been received by Personnel Section, action indicated in Section 2 will be initiated.
B. If soldier has not been transferred, or is on "attached" status, action indicated in Section 2A below will be initiated.
Il BEQUEST
' REQUEST FOB
PHOTOSTAT
File
-Copy 1 used as searcher's file copy.
- Copy 2 used in transmitting photo-
— Used as check list and suspense copy. stat to Requesting Hospital. (See
Sec. 7.)
1 TRANSFER ORDER j|
1 TRANSFER ORDER |
2 TRANSFER ORDER TRANSFERORDER I
, TRANSFER ORDER File
f I ' -Takes action to effect transfer r-z----------------“K k
r> t 4 REQUEST Retains
- Drops man from morning report. ------------------■. p
I- Effects transfer by indorsement in service Record. X photostat
(No further Special Orders necessary.)
^yiserams —Clears man of financial accounts and clothing.
(See Note 1.) -Copy 4 used as searcher's file copy.
— Copy 5 used in transmitting photostat to Requesting Hospital. (See Sec. 7.)
- Personnel Officer signs copy 1. “ photostat to Requesting
„ „ . , , . . । । , Hospital. (See Sec. 7.)
-Copy 3 is used by morning report clerk to pick up man on morning report.
- Work File copy used as check list and suspense copy. Destroyed on discharge of soldier.
29
1 JAN 45
TM 12-235
DISCHARGE BECAUSE
DOCUMENT WARD OFFICER CHIEF OF SERVICE PRESIDENT OR SECRETARY OF CDD BOARD CERTIFICATE OF DISABILITY DISCHARGE BOARD
SECTION 3 —R REQUEST FOR CLINICAL RECORDS OF PREVIOUS HOSPITALIZATION FOR MEN TO BE DISCHARGED ON CDD QUESTING CLINICAL RECORDS FROM OT IER ARMY HOSPITALS • 4
CLINICAL RECORD
- Files with current clinical record.
SECTION 4—ACTION BY WARD OFF
CER AND COD DOARD
CLINICAL RECORDS
CDD WORK SHEET
CLINICAL RECORD
CDD WORK SHEET
CLINICAL RECORD
CDD WORK SHEET
CLINICAL RECORD
COD WORK SHEET
— Initiates CDD Work Sheet from clinical records.
-Approves, disapproves or changes.
- Upon receipt, President or Secretary of Board takes action noted below, calls Personnel
names of men to be seen by the board.
TELEPHONE CAlt
- Calls Personnel Section.
CERTIFICATE OF DISABILITY FOR DISCHARGE
WD AGO FORM 40
WD ADO 4D CERTIFICATE OF DISABILITY FOR DISCHARGE
1 WD AGO 40
2 WO AGO 40
- Notifies other member of Board of time of meeting.
I, 5
WO AGO 40 CERTIFICATE OF OISABILHY FOR DISCHARGE
1 CLINICAL RECORD
2 CDD WORK SHEET
I 3 WD AGO 40
, [4 WD AGO 40
3
- Board meets within 24 hours after receipt of 40. — Makes recommendations. -Secretary of Board completes Date of Meeting, Diagnosis, and LOD Status while Board is meeting on other cases.
- President and Recorder sign copy 1 of Form 40 before leaving meeting.
- If CDD is disapproved, returns records to Ward with recommendations as to disposition of patient.
30
1 JAN 45 ™ 12-235
OF DISABILITY (CONTD)
i I—। n—|i
----atllllEST -fcTll A [2 REQUEST 2 R[QUEST (Qu I
’l 3 I I ' n---------------------- h CLINICAL RECORD ■ ■•File
• CLINICAL RECORD J" 3 REQUEST FOR | k
CLINICAL RECORD^ CLINICAL RECORD |"4 File ■"
___' ~ Uses copy 1 to transmit clini-
_ .... cal records to requesting hos-
- Requests clinical records from , affer iate nota.
other Army hospitals where -Forwards copies 1 and 2. tion as to disposition of recman has been hospitalized as ord on WD AGO 8.24.
shown on Diagnosis Slip. (See Sec. 1 above.)
1 REQUEST h ' REQUEST FOR I t
I Destroyed ------ -------V _T^ CLFNICAL RECORD 1^—I
J CLINICAL RECORD I"H
CLINICAL RECORD
- Sends to Ward Officer for filing with current clinical record. _ Forwards Clinical Records with
request within 48 hours.
TELEPHONE CAI I I
wmbbbbbbbJI
- Receives call and initiates action below.
. 1 WO AGO 40 |
BMM 2 WO AGO 40 ||
________________ I I 3 WD AGO 40 ■
J 1 CLINICAL RECORD || Lb| “I’lslmi’n’' J y
2 COO WORK SHEET
k l, [3 WD AGO 40 k See
>—---———— ----"k •• Section - Personnel Section prepares
4____W° >C° 4°__6 5 WD AGO Form 40 from the
X -5 ce*tifAic*te°of I Service Records for men to
\ l_ DistBiiin I be seen by CDD Board
I FOR DISCHARGE ■ .... ., ', .....
omitting the following items:
Date of Board Meeting;
— Takes action shown in Sec. 5. Diagnosis; Items pertaining
to Line of Duty; Approval dates; and Date of Discharge.
31
TM 12-235 1 JAN 45
SECTION 5 —APPROVAL AND DISPOSITION OF CERTIFICATE OF DISABILITY FOR DISCHARGE FORM 40.
M CLINICAL RECORD CLINICAL RECORD
- Prepares list of approved cases and _ Holds until discharge is effected for Register Card, WD AGO Form 8-24 compilation of records to be for-
from clinical records as shown be- warded to Veterans Administration,
low.
list X-Ray Clinic
ust II mbi^— Patients' Baggage Room
i mbbbbbmA Dental Clinic
LIST OF APPROVED 1------------------------"k '
CLASSES FOR CDD list Of
I, APPROVED CLASSES mi^^bb4 File
- Distributes to interested agencies and departments.
- Other copies may be made to meet demands of individual station.
1 wo ago 8 24 Surgeon General
[2 A F
REGISTER CARD wo ago 8 24 II
WD AGO 8-24 register ci«o File
- Prepares Form 8-24 from clinical record for Report to The Surgeon Gen-CLINICAL RECORD era I. L
COO WORK SHEET
n WO AGO 40 I—
From CDD L 1 Cj ^WTo
Board J rz-------—---------“k I
L 3 WD AGO 40 ■ I
L—_—— CERTIFICATE Of ■ I
_ DISABILITY ■ ■ _____________________
X T WD AGO 40
2 WD AGO 40 11 p
- Receives above records from ceitihcah'of
CDD Board. tomI'crahe I l_L__
-Gives CDD Work Sheet to Red Cross worker who as- .. . .x.
APPLICATION FOR sists in the fi|j of ion - Distributes to approv.ng authont.es
PENSION FROM applications. and Personnel Section
VETERANS -Personnel Section may begin effect-
ADMINISTRATION ing discharge.
V.A. FORM 526 or STATEMENT THAT MAN DOES NOT ELECT TO FILE CLAIM SOLDIER'S QUALIFICATION CARD WD AGO FORM 20 coo work sheet
File^™ CLINICAL RECORD , 2 WO AGO 40 ft, WD AGO 20 | j r-
,, ,4 1 VA526I
APPLICATION FOR
’ | M PENSION OR STATEMENT I
— Holds for transmission to the Veterans Administration when discharge is effected.
-Files CDD Work Sheet.
32
1 JAN 45 TM 12-235
• --------------------I ____________________„
CDD * *»”I 1 ^77----------k .
- fl I- _____________________K et:»f 14Hold
7 77777 k^—
- Red Cross uses in interviewing.____________________________________et’|I$Hiiin°f I r
- Returns to Registrar after action 7 wiisoio k b F” bischarse I
shown below. “fisIftiW' |——- Personnel Officer signs when
foi oischarce ■ received and holds for trans-
k J — Signs and orders discharge. mission to The Adjutant Gen-
™-Signs and approves -Commanding Officer of eral with Service Record.
discharge. General, Regional-station
-Applies to Station hospital, or his designee. 2 wo ago 40
K Hospitals only. R~ w0 |so „
K CERTIFICATED!
r L DISABILITY ■ L c;.
FOR DISCHARGE ■■ rile
k — Starts preparation of sepa-
application !■■■ ration forms upon receipt.
FOR PENSION ■ (See Part 1.)
■ - Personnel Officer certifies as
"■A true copies.
’ statement k ■ ~ - Forwards copy 2 for trans-
(S01D1ER does not J I .mission to the Veterans Ad-
WISN TO FILE CLAIM),^ _■ ... ..
^^■bbbI ministration.
• D , _ .., . ............ wo ago to |
- Red Cross Worker assists soldier in SOLDIER s A
completing alternative forms. QUALIFICATION CARO
— Sends completed application for
pension VA Form 526, or statement - Forwards to Registrar for
from soldier that he does not wish transmission to the Veterans
to file claim at the present time, to Administration.
Registrar.
33
TM 12-235
1 JAN 45
TRANSFER TO A DETACHMENT OF
DOCUMENT
UNIT PERSONNEL SECTION OF STATION COMPLEMENT OR DETACHMENT OF PATIENTS TO WHICH TRANSFER IS TO BE EFFECTED o
SECTION 8—TRANSFER TO DETACHMENT OF PATIENTS OR STATION COMPLEMENT.
CDD TRANSFER ORDER
~j TRANSFER ORDER
P II
TRANSFER ORDER J
- Registrar of hospital prepares for signature of Personnel Officer. (See Section 2A.)
SERVICE RECORD AND ALLIED PAPERS
NOTE
CDD transfer order may be used to effect transfer to "attached unassigned" status or to change status from "attached" to "attached unassigned".
EXTRACT FROM SERVICE RECORD WD AGO FORM 25
<''
RECORDS JACKET
WD AGO FORM 201
WO IGO 201 RECORDS JACKET
SECTION 9—SEPARATION PROCEDURE
(See Chapter 2 of this Manual).
-Checks to insure that all required records are received and that they are complete and accurate.
- If man is not discharged, transfers man to former or other organization in accordance with existing directives. (See AR 615-361.)
34
1 JAN 45 TM 12-235
PATIENTS OR STATION COMPLEMENT ______________________________________________________________________________________'
~j TRANSFER ORDER h_________________________ j 1
-----------------TRANSFEROROER ■ k
) 2| I----------------------►
• 1"
_ . . n . . r i . । i l- x —Drops man from morning report effective the date stated on
- Takes steps to effect transfer and to clear man of his accounts. rnn T f O <4
— CDD Transfer Order serves as authority to effect transfer ranS er r er’
- No further special orders required.
- Retains copy 2 and transmits copy 1 to man's immediate commanding officer.
WD IGO 24 | L
SERVICE RECORD I
WD AGO 20 ■
SOLDIERS 1 k
QUALIFICATION CARD ■
1 WD AGO 625 ■ .
APPLICATION FOR ■ ■■■■■■■■■■■■■■■■■J
DEPENDENCY BENEFITS I F
----------------- WO AGO 32 -■ INDIVIDUAL CLOTHING ______A S EQUIPMENT RECORD
- Records items turned in when organization clears man of his
WO *G0 8 in B property account.
’^register"* I ~ f>rePares necessary statement of charges or report of survey.
-Sends completed form to Unit Personnel Office for inclusion with other records.
OTHER I______________k
ALLIED PAPERS ■
WD AGO 25 ■
EXTRACT FROM J k r i
SERVICE RECORD
- Prepares Extract from Service Record.
- Effects transfer by indorsement in Service Record.
— Sees that the following are accomplished prior to transfer:
1. That the man has been properly cleared.
2. That all financial statements are complete, up to date and accurate.
3. That records of courts-martial completed have been properly noted in the Service Record, and those pending forwarded for necessary action.
4. That the transfer indorsement in the Service Record is complete.
• 5. That the Service Record and allied papers have been reviewed
for accuracy and completeness.
WO AGO 201 I A w r V
RECORDS ■
— Transmits Service Record and allied papers in Records Jacket, WD AGO Form 201.
35
TM 12-235 1 JAN 45
PATIENT’S PROPERTY SLIP, WD AGO FORM 8-111
REFERENCE: AR 40-590 nr...,,. ____________________ —,U
»o. 8 in Carpenter, Lloyd M. 1 iw te;*
13 294 | 32 033 197 | T/Sgt
A Omiutsm s»An
■ II*" I • 3 be £*ven to patient; copy a will be re
that clothing and eguipment tained with the patient’s records. If articles are stored
locations other than the ward a check mark will be in-are checked in at the hospital. 5e7\dc°lu’m "j ‘f '"dica“ tKosc °rt*cics-____________
2*1 • || . .1 ■ »C. S ART KIES *0. S ARTICLES Mo S ARTICLES
. This may be done at the bag- -------~~~---------------------------------
gage or supply office, admit- z:77:77" .77:............ 777
ting office or on the ward, 7 77? 7“" z .7'.?'. 7 77?7.
dependent upon local prac- / <77.77. ' £ ;.’777
tice. £ 777. _ _ 7 7’77...
3. Both recipient and also the Zr7777.«„ 7.7“ 1 ^7,77..
patient, if physically able, sign 777.7?” : ?7 ........................
slip to verify accuracy. 1 *77?...... 77................................
4. WD AGO Form 8-111, 13 June t 777:7 //7 77”
1944 will be used pending x 77.77.... 7!777*'
publlCatlOn of the revised dale , olhtr than that slated ado*. designate other locations .hare article!
form illustrated. _____________
SigMture of reop.enZ? T Signature of patient
r_ .............. J
DIAGNOSIS SLIP, WD AGO FORM 8-176
(TENTATIVE) -------------------------------------------------------------------1
rara---- 11. LAST NAME, FIRST NAME, MIDDLE INITIAL I I ■■
FORM 8-176 „ . __ , „
tentative Carpenter, Lloyd M. _____________________
J8 Novamter 19«** 2. REGISTER NO. fj. ARMY SERIAL NO. I*. GRADE
..13 2R4 [ 32 033 197_| T/Sgt .
5. ORGANIZATION AND ARM OR SERVICE ONLY WHEN
DIAGNOSIS —----------------r,----------------------H<«ii
SLIP 6* AG£ P-,UCeJ®’l£N«JkVsazno- dtiax* I
tion to arrange for transfer of y
patient for CDD, to secure t.---------------------------------------------------
clinical records, to clarify LOD, etc., as indicated by en- 77
tries on the WD AGO Form 8 1 TTZ 1&. IS INVESTIGATING OFFICER REQVIRtOY Q YES 00 NO
“I/O* 17. PROBABLE DISPOSITION (Chech one) IN APPROX INAT ELY OATS.
□ FULL OU’Y O tINITEO DUTY □ RETIREMENT
325 COO TO OWN CARE □ TRANSFER TQ VAF □ TRANSFER TO QTNER HOSPITAL
18. HOSPITAL RECORDS REQUESTED HOSPITAL OAT£
36
1 JAN 45 TM 12-235
MORNING REPORT, WD AGO FORM 1
REFERENCE: AR 345-400
MORNING REPORT !S° 15 Nov_____________________~i
urbanization. Detachment of FATtient^M0WTH)___ND 2 UoveffltoerJ^—\ 1
___---— ZZZ-----' \ 02 033 ---- \ I
—-----\ I
\ __— r"ZL I B0,e,*^j±__—- - A 1
\ \ xer, Lloyd_M--- 1 , t \ ---- \ 1
---S^'O* __________-1 \
— - PHYSICAL E*w'n ___- \ 1
/ I T —ZZ <~~~~~ZZZ, photostat o -------- ^qspiTA-^ \ 1
/ / . \ tlLTOX 0’5SCT‘ \ I
/ /—72»nter , '-~i-------— J „ nf.Vl lEBSKY I I
/ / ’I?, ——---. .—Z2t~~~--«5®2rb \ l
/ /—■———____ / As»- —A
/ / -_ / '—& 031 in / DatE ----j P"
/ / --- - p«oros77T^~-~^J^er i4 I
---7~__C7 / AmMT^W^ / /
REgis^rar / I
NOTE: Prepared in one operation with CDD Transfer Order, if necessary, and work file copy.
Last Name First Name M. Initial Carpenter, Lloyd M A.S N. 32 033 197 DATE 12 November 44
Organization 317th Infantry Grade T/Sgt Date of Hospitalization 10 November 44
Service Record Received Case typed by:
Form 40 Initiated
2nd Indorsement dated Case checked by:
Form 53-55 or'53.56
Form 370 or 371 Remarks: U
Form 100
Form 30-S
Lapel Button
Date of Discharge
Record to AGO
NOTE: Prepared with other forms; forwarded to Personnel Section to be retained as file copy.
39
TM 12-235 1 JAN 45
REQUEST FOR CLINICAL RECORDS FROM OTHER
ARMY HOSPITALS PERTINENT TO CDD CASE__^
REFERENCE: CIR. 13, WD 1944 _________
-- —~H. I »-' " * *P * 112 1 1
. -___—u io — 11
nr' ~L Ti
1 1 LaslName - First Name - Middle Initial A. S. N. Date of Hospitalisation Dot* of Request to
\ /M. 32 033 197 10 November 44 12 November 44
\ /r^^L^r PERTINENT TO CDD CASE
\ I TRANSMITTING HQ?PLIAL |
V7 ___ OF H6§P"iTal R
// / /?_ * ■*-—General Hospital 11
// / 1
// / nicai * iom '^rr>-77—._____ 11
---------'* DUpi ln I n,'r -'''■-^ / / /
NOTES: - *<> //
1. Prepared as soon as possible / //
from the Diagnosis Slip for each "^D / /
hospital from which clinical //
records are desired. //
2. Three copies are prepared;
copies 1 and 2 are forwarded to the hospital; copy 3 is retained as a suspense copy.
LIST OF APPROVED CDD CASES
1^--
MEN TO BE DISCHARGED FRIDAY 24 NOVEMBER 1944 AT 1100
1. Carpenter, Lloyd M. 32 033 197 T/Sgt W-6
NOTE: Sufficient copies prepared to suit local needs in order to notify all interested parties of date of discharge. List is prepared from approved cases; no additional data will appear on this list.
40
1 JAN 45
TM 12-235
CDD WORK SHEET
Register No. 13294 TILTON GENERAL HOSPITAL Ward No. 6 CDD WORK SHEET
Last Name - First Name - Middle Initial ASN Grade Date of Board—
Carpenter, Lloyd M. 32033197 T/Sgt 21 Nov 44
FINDINGS: (Record those disabilities which incapacitate soldier for further service. If there is more than one incapacitating defect, designate as A,B,C,D, etc., State diagnoses according to "Standard Terms for Diagnosis" - including how, when, and where incurred in injuries. Add additional statement as to manifestations and how each defect incapacitates and also statement as to basis for LOD findings. Be concise but accurate and complete.) Arthritis, chronic, non-suppurative, moderate, sacro-iliac joint, right, secondary to fracture, compound, ilium, right, incurred in combat, 15 July 1944, near St. Lo, France J from enemy bullet, caliber JI, point of entrance on lateral aspect of right ilium. M Manifested by pain and tenderness in the right sacro-iliac region aggravated by walking 1 ■ Enter only those diagnoses which incapacitate soldier for further military service.
or strenuous physical activity. Considered LCD Yes because incurred as a result of
enemy action.
(Additional diagnoses and remarks may be completed on the rever se of this form)
Date Became Unfit for Duty Date of Onset Due to Mi s— conduct Incurred While AWOL Incurred in Authorized Military Activi tv Aggravated by Active Service E P T S In Line of Duty
Enter One Date Enter Each Date
Yes No Yes No Yes No Yes No Yes No Yes No
15 July 44 A 15 Jul44 B C D X X X X X X
See Cir. 458 WD 1944, relative to determination of line of duty
additional information to re completed in ALL CASES:
1. Age 29 2. Race ___________. 3. Length of Service 3 11/1^. Present job
with organization Radio repairman________________________ ~_____________________.
5. X-Ray of chest has been taken within 90 days: Date of last report 15 Nov 44
6. Soldier (can) («a«««t) be released from military control without danger to himself or others. Transfer to VAF Other institution (is) (is not) nec-
essary .
7. Escort of ____officers and/or__________enlisted men (wili) (will not) be required.
8. Permanent address for mailing purposes (ASK THE SOLDIER). 411 Hiffiland Ave.,
San Francisco, California
NOTES: 1. Prepared by ward officer from clinical records.
2. Submitted to CDD Board with clinical records through Chief of Service for approval.
41
TM 12-235
1 JAN 45
CERTIFICATE OF DISABILITY FOR DISCHARGE WD AGO FORM 40
REFERENCES: AR 615-361 AR 40-1025
CIR.458,WD, 1944 AS AMENDED
CIR. 435, WD, 1944
CERTIFICATE OF DISABILITY FOR DISCHARGE
REPORT OF BOARD OF MEDICAL OFFICERS (HET UHOER PROVISIONS OF SECTIOH U. AR SIS-300)
LAST NAME - FIRST NAME - MIDDLE INITIAL
Carpenter, Lloyd M
317th Infantry
STEP 2: Typed from CDD Work Sheet at Board Meeting.
STEP 5: CO or hjs designee signs original only. This signature not necessary when CO of hospital is also discharge authority.
STEP lb: Items 23, 24, 25, 26, 32, and 33 will be completed at the same time as the upper portion of this Form.
T/Sgt
Elton GH Fort Dix NJ
15 July 1944
4. DATE OF SOARD MEETIM9
21 November 1944
2.HHY SERIAL luHIEI^l. HAVE
32 033 197
STEP 1: Typed by Personnel Section from Service Record
STEP 4: Registrar reviews for accuracy and initials.
APTtl CAIEFIL COIIIOEIITIOI IF ILL IIF.IHATI.I ..TAl.I.lt All A CIIVICAl EIIHIIATIAI. IE FIUTIII IUIVI HAL VHFIV FU HI LI TUV
IIIVICE ICCAUHOF: , ., . _ _ „ „ _
(.95) Arthritis. Result of Battle Traumatism..
Arthritis, chronic, non-suppurative, moderate, sacro-iliac joint, rifjit, secondary to fracture, compound, ilium, right, incurred in combat, 15 July 1944, near St. Lo, France, from enemy bullet, caliber 31, point of entrance on lateral aspect of right ilium,
BISEASE OR INJURY
15 July 1944
DATE BECAME UNFIT FOR DUTY
Incurred in authorized military activity - Yes
X-RAY OF CNEST HAS BEER TAKEN WITNIN SO BAYS AND REPORT ____________IM ACCORDANCE WITH THESE FINDINGS. WE RECOWMEN
EALY.
C.
APPROVAL C. O. HOSPITAL
.. PRESIDENT'S SIS ~7?2a. ■ type, i MARTEN J. Captain, M,
TN8 ADJUTANT OtNl
DATE INDIVISUAL ENTERED ACTIVE SERVICE
30 Nov 40
BATE INDIVIDUAL WAS BISCNARSEO
TTPtt FAKE A.O HAH
MB N’T NS 11
None
11. TYPED NAME
HENRY L. SMITH 1st Lt., M. C.
APPROVAL: DISCMARtt AUTMORI
18 ■ MTt 22 November 1944
.ARC All UAH
er of Colonel TURNB Uh CI L E. MI LT , Capt. Executive Officer
headquarters 1257 SCSI) niton GH Fort pix NJ lMTt 25 November 4/
25- DATE OF LAST DISCHARGE. IF ANY ]«• IF ABSENT FROM UNIT WHEN DISEASJ WAS CONTRACTED •> INJURY RE" CEIYES, STATE CAUSE. PLACE, ANO DATE
Elton GH, Ft Dix NJ
»»x
NAS INDIVIDUAL DUN ON FOUIRB OUTTT
P*rTICIP*T(M IIACTIM obmiSai&dSSSik
24 NOV 44_______________________________________________________________________________________________
PERMANENT ADDRESS FOR HAHINS PURPOSES (OR LEGAL GUARD I AH OR VETERAHS' FACILITY IF FURTHER CARE REQUIRED)
411 Highland Avenue, San Francisco, San Mateo, California
INDIVIDUAL WAS GIVER OPPORTUNITY TO APPLY FOR PENSION - IMDIV^yjAL WAS FURBISHED WITH A DISCHARGE CERTIFICATE
0. WEXLER, 1st Lt., MAC, Asst, UFO
.1. ».u. 4fau. 11 w'Lrmr
DIViylAL WAS FURNISHED WITH A prtniaci .FFieti'l iiuitik WO AGO 100 ■ . .. .. , • z .
separation Iimb^^mI Application for pension of state-
X QUALIFICATION RECORD I ment (VA 526)
Clinical records from other hos-
— Holds for transmittal to Veterans' Admin- pitals
istration. Clinical records from discharg-
ing hospital
Letter of transmittal in duplicate.
request ~^bbbm^ Destroys IMMBBHBMMBBBBBRBBi^BMBBIMHBII^^BBHMBMMHRB ■rbrhbrrbbbhrbmbb^^^^^mr bbbbA PHOTOSTAT OF I_______________k
' INDUCTION PHYSICAL
[i TRANSMITTAL k^^_ , , .
------------------ Holds pnotostat for transmittal to Veterans
2 TRANSMITTAL 1—_ . , .7. ..
-------—----------■v" Administration.
I 3 I
-W TRANSMITTAL —
] TRANSMITTAL k—_____________________
B 2 TRANSMITTAL ^RBBB—^^^^^**
— Prepares transmittal (let- " ^3
ter) to VA. TRANSMITTAL
, - Forwards
t |2 h . p |
File X— TRANSMITTAL I ■BBRMMBI TRANSMITTAL
-Acknowledges receipt on copy 2
- Files signed copy. of transmittal letter.
— Returns to discharging installation.
47
TM 12-235 ] JAN 45
TRANSFER OF A PATIENT TO A
SECTION 1 —INITIAL PROCEDURES FOR TRANSFER TO VETERANS ADMINISTRATION FACILITY.
DIAGNOSIS SLIP WD AGO 8-176 I 4 WO AGO 8-176
WD AGO FORM 8-176 DUBNOSIS ItlP "7 01,6,10515 5110 I
-Submits within 24 hours after - Registrar notes proposed disposition and arranges for such disposition,
admission to Registrar. Revises - If patient is a mental case, requests information for letter to parents, nearest
slip upon change of diagnosis relative or legal guardian from the ward officer,
or disposition.
LETTER TO NEAREST - Recommends man be sent to care ------------------ ------
RELATIVE, OR LEGAL of Veterans Administration Fa- letter ■
GUARDIAN, ADVISING clll,yor to care of fam,|y- 2 | |
FURTHER CARE IS relatives
NECESSARY. (See Cir. 298, WD 1944.)
— Prepares and signs letter, allowing 10 days for reply.
— Prepares request for designation of VA Facility and sends to VA, Washington, D. C. at the same time that letter is transmitted to relatives.
APPLICATION FOR ~ | I — |
HOSPITAL TREATMENT application for ————m—m application for i^——
OR DOMICILIARY CARE hospital treatment^O f hospital treatment I
VA FORM P-10
- Initiates VA Form P-10 and has - Completes all items exceot 5, 8, 9, 10 and 12. HL
soldier sign if he is mentally com- -Forwards VA Form P-10 to relatives, if man is mentally incompetent, for
petent. completion.
- If soldier is mentally incompetent, -If form is completed by patient, holds for transmission to the Veterans Ad-sends to Registrar for transmis- ministration with other records,
sion to relative for completion of affidavit as to financial re- ------------------.
sponsibility. AFFIDAVIT ■ ——
AFFIDAVIT OF PARENT, [ [2 “affidavits — — — — — — — — — — — — — —I
NEAREST RELATIVE OR !j parent OR JRlaJ
LEGAL GUARDIAN l[6u “A"01*'1
- Prepares affidavits if care by family is recommended by ward officer.
- Sends to nearest relative who signs indicating agreement to assume responsibility for care of patient.
Files with , ------------------
.. . । , 1 AFFIDAVIT ■
clinical record -----------■.
? AFFIDAVIT h j 201 File fc-ip----------—-----Ik 4-——
RETURN ENVELOPE _ T S 3 VA P io I T
rDnt. OPI ATIVP To Ward Officer for APPLICATION FOR
FROM RELATIVE completion of med- 4_3 HOSPITAL treatment |
ical information. ' - If relative signs affidavits, patient is discharged to their care. — If soldier is to be released to care of nearest relative, VA Form P-10 is destroyed.
- If soldier is transferred to a VA Facility, VA Form P-10 is held for transmission to the Veterans Administration with other records. (See Page 46 )
REQUEST FOR request
DESIGNATION OF 2 request i
VETERANS ~3 request for h
ADMINISTRATION 1 designation of
FACILITY
- Sends at the same time as letter is sent to relative.
— If family agrees to assume responsibility for patient, designation is cancelled by letter to the VA, Washington, D.C.
- Same procedure followed if decision is made as to other disposition by the CDD board.
48
1 JAN 45 TM 12-235
VETERANS ADMINISTRATION FACILITY
1 LETTER |ll^— 1 LETTER File
2 letter Retains 1 affidavit ■
] AFFIDAVIT 2 AFFIDAVIT
I, 2 AFFIDAVIT \ VA P-10
\ **|, '° I—— —-4 S |
f I F 1 RETURN ENVELOPE
RETURN ENVELOPE
— Receives letter and makes decision.
-Encloses return envelope, affidavits and - Signs affidavits and returns within 10 days. VA Form P-10 “ " a"ernate decision is made, notifies Reg-
■Mails letter, VA form P-10 and affidavits, istrar.
if home care is recommended by the ward officer.
•
I I I I I ■ I
1
- Distributes forms received in envelope from near- - Mails form in return envelope,
est relatives.
1requesth
1 REQUEST ____________ _______________________________________________________k [2 REQUEST FOR b
2 request I—I ' *1 BtvT?«mnBf
*1 3 REQUEST FOR I 1
DESIGNATION OF Suspense
M V* FACILITY I ’ r
- Locates and designates space in proper facility.
- Notifies requesting hospital of designation. (See Section 2.)
- Mails two copies of request.
— Groups all requests in one envelope to the VA, Washington, D.C., daily.
- No other records need accompany this request.
49
TM 12-235 1 JAN 45
TRANSFER OF A PATIENT TO A
SECTION 2-ARRANGEMENTS FOR TRANSFER TO A n—b
VETERANS ADMINISTRATION FACILITY r P
NOTICE OE T-a 1
DESIGNATION OE g,
FACILITY - Receives notification of desig-
VA FORM 2834 nation of facility.
] YA 2034
^^F 2 VA 2834 I t
NOTICE OF DESIGNATION Cjle *1 OF FACILITY I"? r"e
- Phones Detachment Commander for names of attendants.
- Sends one copy of VA 2834 to personnel section for the purpose of having special orders issued.
"j SPECIAL ORDERSb SPECIAL ORDERS FOR mb ---------—-------"k
TRAVEL IH 2 SPECIAL ORDERS | j
Lbbb SPECIAL ORDERS File ^b
- Receives Special Orders.
- Requests reservations, tickets and transportation requests to M|»
. cover the trip from the Trans-
portation Officer. Notifies Transportation Officer if litter or ambulance case.
To attendant TRANSPORTATION Prior to -----------------
RESERVATIONS departure. reservations
RAILROAD TICKETS AND d V"eh TICNHS I ,
TRANSPORTATION ’ Ambbbbhbbm
REQUESTS (See Cir. 405, WD, 1944) -Notifies Chief of Service,Ward
Officer and attendants of transportation arrangements, and time of departure. I TELEPHONE CALL I
-Arranges for patient to leave "Calls Ward Officer to notify him
hospital dressed in proper to PrePare for departure of
clothing. P°tlent______________________________________ ▼
NOTICE OF ARRIVAL TO J b
__________________________________________________________________________OF TIME OF ARRIVAL k TELEGRAPHIC NOTICE I VETERANS FACILITY *bm| of time of arrival ■
- Prepares telegram stating exact , time of arrival, station, car - Sends by commercial wire,
number, and if ambulance needed.
NOTICE OF TRANSFER -----------------k ----------------k
TO PARENT, TELEGRAPHIC NOTICE I . TELEGRAPHIC NOTICE
kicadcct DCI ATiwc TO PARENT, RELATIVE Jbbbbbbbb TO PARENT, RELATIVE ■ BMB^MBBNBM
NEAREST RELATIVE on guardian f qr guardian I
OR LEGAL GUARDIAN -Advises parent or guardian of _ . . ...
address of facility and date of " Sends by ^mmerc.al wire, transfer; telegram is sent on day of departure. 50
1 JAN 45 TM 12-235
VETERANS ADMINISTRATION FACILITY (CONTD)
1 V* 2834
^^■■■BBIB^^^^MRRMBHBBHBRIBMBII^MBBB BM V* 2834 I
NOTICE OF DESIGNATION '
-Advises hospital of designation
I of facility which will receive
panenr.
— Transmits VA 2834 in duplicate.
- Receives form and uses as a basis of preparing or requesting special orders.
] SPECIAl ORDERS
— | 2 SPECIAL ORDERS
I I, 3 SPECIAL ORDERS
pA P I
^BBiL SPECIAL ORDERS
-Prepares special orders, or re-quests that they be prepared by higher authority.
-Additional copies may be prepared to meet needs of indi- -----------------<
vidual station. special orders
BB^ SPECIAL 0R[IEIIS
- Obtains necessary transportation upon receipt of spe- ---------------------------------------
cial orders.
— Other copies as necessary. NOTE
| . See Page 46 relative
bbb reservations 1 to transfer of records.
TICKETS 1 T/Rs J I MEAL TICKETS
-Forwards reservations to Registrar.
_________________________________________________ ___________________________________________________________________A TELEGRAPHIC NOTICE y TIRE Qf ABR|VAl
-Arranges to meet train with necessary transportation and escorts.
A TELEGRAPHIC NOTICE
T^^BBBMMIBH^^^MBBBBBRBBBI^B ■BBBBR^^^^MRBH^Bi BHBBB TO RELATIVE ■
~ 08 GUARDIAN
-Advises parent or guardian of address of facility and date of arrival thereat.
51
TM 12-235 1 JAN 45
___________________________________TRANSFER OF A PATIENT TO A
SECTION 3 —RECEIPT FROM VETERAN’S FACILITY FOR PATIENT AND PROPERTY
] RECEIPT FOR CASE RETURN ENVELOPE |m——
[2 RECEIPT FOR CASE 1 RECEIPT FOR CASE —
RECEIPT FOR CASE FROM ........\ L F I, |2 ...LIP.... ..SI V ___________
VETERANS FACILITY k • »■P |3 % A R|e W —
PREPARED ——J 1 ’
TELEGRAM ’l PREPARED I
TELEGRAM
- Prepares receipt from Veterans Facility. _ Sends with attendant to the facility.
- Prepares telegram to be completed and - Encloses addressed return envelope,
sent collect by the attendant upon effect- |f n0 attendant/ see note.
ing delivery to the facility. If patient proceeds without attendant, he is given prepared telegram which is completed and dispatched upon arrival by VAF. h
r r PREPARED 11————
TELEGRAM |
— Receives wire. — Forwards wire to Personnel Section.
--------------------------------------------------------
__________________. I
2 ■
—— SIGNED RECEIPT ■
FOR CASE ■ Y
- Receives receipt by mail. - Sends to Personnel Section.
to* SECTION 4 —TRANSMITTAL OF RECORDS AT TIME OF DISCHARGE TO VETERAN'S FACILITY
See Sect. 1. Receipt and Transmittal of Records to Veterans Administration Area Office or Facility. Page 46.
52
1 JAN 45 TM 12-235
VETERANS ADMINISTRATION FACILITY (CONTD)
RETURN ENVELOPE
.. 1 RECEIPT TOR CASE fj|e
^^^^BBI^^^KBRBBMWWB^^B^KMMBMHB^^^^^^^^^^MM^ 2 RECEIPT FOR CASE
’"’ PREPARED
TELEGRAM
— Receives patient and signs receipt.
— Returns copy 2 to attendant who mails in return envelope to hospital
PREPARED | j
telegram I
-Attendant completes prepared telegram when delivery is effected and sends collect to hospital by commercial wire.
t PREPARED I L c-l
TELEGRAM l^“"r
-Notes date of arrival and begins to accomplish discharge papers. ___________
RETURN ENVELOPE | n “k
SIGNED RECEIPT |
FOR CASE I 7
-Attendant mails signed receipt.
If no attendant, see note. Page 47
L 2 S|EH£D receipt I k
■■■■FOR CASE ■"‘r
— Files with completed records of case.
NOTES
1. Discharge is completed in accordance with the procedure established in Part 1 , — after the Veterans Administration receipts for the patient.
2. Final payment and discharge records are to be disposed of as directed in AR 615-361, without delay.
53
TM 12-235 , JAN 45
LETTER TO RELATIVES-IN CASE OF MENTALLY INCOMPETENT SOLDIERS
REFERENCE: AR 600-500, WD CIRCULAR 200, 1044
Office of the Registrar TILTON GENERAL HOSPITAL FORT DIX. N. J.
5 November 1944
Mrs. Mary Jane Doe 1440 Oak Street Newark, N. J.
Dear Mrs. Doe:
You were notified on 29 October that your husband, John J. Doe, had been admitted to this hospital for observation and treatment of a mental condition. Since that time he has been studied very carefully and it has been determined that he is suffering from "Psychosis, unclassified". Although he has shown considerable improvement, his discharge from the military service has been recommended, but his condition is such that further hospital care is necessary.
He shows the following symptoms which are believed to make home care inadvisable at this time: He is extremely dull, withdrawn, childish and shallow with signs of extreme nervousness and at times depression.
Under existing statutes he is eligible for treatment in a Veterans' Administration facility, and authority for his transfer to a Veterans hospital is being requested. Regulations provide, however, that you may elect to receive him at home to provide care for him there or in a private institution at your own expense, if you prefer receiving him at home and are willing and able to provide the proper care and treatment for him, please sign and execute before a notary public the inclosed form of agreement and return it to this office. If not, please state that fact in your reply and complete and sign before a notary public the inclosed application for Veterans hospitalization and return it with your reply. In either case, your reply within 10 days is requested. It is recommended that you consult your physician before making a decision. Receiving your husband at home at this time does not in any way interfere with his right to be hospitalized in a Veterans' Asministra-tion facility in the future, should such care be necessary.
If you signify your willingness to receive him, he will be accompanied home at Government expense and discharged from the service to your custody upon arrival. You will be notified beforehand of the date of his arrival.
A postage-free envelope is inclosed for your reply.
Very sincerely yours, incis-
0. WEXLER 1st Lt., MAC Registrar
NOTE: Forwarded as soon as diagnosis and proposed disposition are determined. Copies of affidavit and VA Form P-10 are inclosed, for completion by relatives.
54
1 JAN 45
TM 12-235
AFFIDAVIT FOR ASSUMPTION OF RESPONSIBILITY
REFERENCE: AR 600-500
AFFIDAVIT
STATE New Jersey)
)
COUNT! OF Essex )
Personally appeared before me the undersigned authority for administering oaths in like cases, one _____Mary Jane Doe______________________, who resides at
1440 Oak Street, Newark, N. J.______________, who having been duly sworn ac-
cording to law deposes and says:
That (he) (she) is the wife__________________of John J. Doe_________________,
that (he) (she) desires and is willing to assume responsibility for and control over (hie) (her) husband___________ upon the latter's discharge from the U.S. Army
that (he) (she) has been informed of the patient's right to hospitalization by the Veterans Administration, that (he) (she) is familiar with his present mental condition and is willing and financially able to assure him such care as may become necessary, and that (he)(she) will place him in a reputable institution for care and treatment, if necessary.
Furtiier deponent sayeth not.
Sworn to and subscribed before me this /J day of 19
This form should be accomplished before a notary public or any local person legally authorized to administer oaths.
NOTES: 1. Information is taken from Service Record or interview with patient.
2. Prepared by Registrar for signature of nearest relative or guardian and forwarded with letter.
3. If nearest relative signifies assumption of responsibility and patient is suitable for home care (See AR 600-500) designation of VA facility will be cancelled and patient discharged to the custody of the person assuming responsibility.
55
TM 12-235 1 JAN 45
* \
APPLICATION FOR PENSION OR COMPENSATION FOR
REFERENCES: AR 615-361 ---------------------------------
CIR. 13, WD 1944 I
VETERANS ADMINISTRATION
Adjudication Form 026
Rovbed October 1M4 [
Claim No._______________
VETERAN’S APPLICATION FOR PENSION OR COMPENSATION FOR I
DISABILITY RESULTING FROM SERVICE IN THE ACTIVE
MILITARY OR NAVAL FOJ STATES I
“7 ihereb, --------- I
PENALTIES PROVIDED IN PUBLIC ACf I
/ ' h* eon,
The assignment or transfer of any right J Zfe9 C or
person who shall pledge or receive a pledge co 3—J. 6 n2ie~~~—
or who holds the same as collateral securit conviction shall be fined a sum not exceeds wt®dStai^? I
Any person who knowingly or willfully 144 0 n -f
any false or fraudulent affidavit or writing/ ate °^biriS^~~~~~LNativ / ’ A °r ■
any person who knowingly certifies that V 15 A„r.. —8'-/°£n / ’ War Nt ■
affidavit, etc., appeared before him and / '~1919 / jy o/bfrtK —1—Waoe~~ K
not so appear, shall be punished by fine a 8~ se~—Z//T—'—7_ 9*ark, A. j '— _ g
than 5 years. / y* ~~~—-—-.7/’ —~ ■
Any fiduciary or other person havi/ 9- "_ I
ward, who shall embezzle the same or f» /'*rhito Tift I
by fine not exceeding $2,000 or implied x f
at the discretion of the court. / 62 /J2-Co/Or—' - f
That whoever in any claim for W ' Bro^es —- I
it to be false, shall be guilty of perjurf Linc°i’ ** 7^^e^~'7ZZ~~''—-~~4~Bro*ii —__ /
imprisonment for not more than 2 yd Ta~p~—® , Aa»» / tSS^SfrrP^~^m^—-P^udcty 00 /
That if any person entitled to p7 -------------j.. / yVe I
happening of any contingency, there/1 / 1- d*e®aT)2r--TL_59s or 7,7 f
by a fine of not more than $2,000 d —v-Z7_ Aa 0 °ak s+ °f —— /
While a claimant has a right/ ——-..J///—N ° ~~ '---------------- /
pension claim agent to assist him in '——-_J7~~ ~~~~~—~Z7~ ~~~——Z7S»«~—"• J. I
and any attorney or agent so emJ ~~~~~~g&nfe /
paid by the Veterans Administraf ZZ~~~~ ~~~ZZ/~ -——ZZZZ~/———at‘°a I
Any person who shall known/ f*^/7r^T utl . Z/ r^J . ^—-ZZ2j7^~T7^1lnf J ^Pe°rd«e^aod /
agree to, arrange for, or in anywis ,y0 ee-r'dc0. , - ——__7/~~~—’"■■■7 ~Z//~ /~2i££®^le f Wfc
declaration, certificate, statemeif *** an77ZZ) -—Z/T// Z'Z)/ ----- f
• any claim for benefits under thi/ **_____________ Wd72ft^~—7-—- f
in addition to any and all othe/ W ° —_ / J / ’—- f
conviction thereof shall be pun 2s~&-___ ~~~ ~---------------------— f
than I year, or both. / /
You must furnish all tiJ ——. /
answered fully and dearlyJ Wo / /
you do not know the answe/ — - I m / ~Ye, ’ laao»iS, I
NOTES: 1. Prepared by the patient with the assistance of the Red Cross.
2. If patient is mentally incompetent, form may be completed for him by VA Contact Representative or any person acting for the claimant.
56
/
1 JAN 45 TM 12-235
I
DISABILITY VA FORM 526 AND STATEMENT IN LIEU THEREOF
I
Names and addreaaea of all dvffian physicians who hare treated you for any sickness, disease, or injury, prior to, during, or since your service.
34. Namm_________________ 35. PanaaMT Appanaa________36. Disability 37. Datb
Dr, Ricardo Roe Unknown - In Army Wervousneaa 1940-41
Names and addresses of ail persona other than physicians who know any facta about any sickness, disease, or injury which you had prior to, during, or since your service.
38. Name_________________ 39. Present Appbkss________ 40, Disabilttt______41. Date
Mary Jane Boa____________1440 Oak St., Newark, NJ______Nsr.vjiaaneaa______1940-41
mikIf you served in World War I or II, give the names and addresses of employers and your monthly earnings for the 24 I months preceding your entrance into the active military or naval service. If self-employed, so state.
42. Emplotu Namb and Address 43. Occupation and 44. Duties Pebpobmed 45. Dates
Earnings
Atlas Trucking Co.________________ Driver Drove truck__________1939-42
Newark, N. J. 632 wkly.
46. If you served in World War II, state the following: Highest grade completed in;__
Gbammab School Hjoh school Oollbob Umivxxaitt 47. State any special study (as business, professional, trade,
tj academic)
___________________________________________None _____________________________________
48. State where you studied 49. Length 50. Did you graduate 51. Did you complete
a of special from special special study ?
Public School 6 study school?
52. What is your trade or vocation? 53. Are you 54. If employed, state employer’s name
employed?
No
55. What Is your entire income per month? State sources of your income. 56. What is the value
of your estate from all sources?
$_________________________________________________________________________|$ 500.00__
57. State names and addresses of former employers for last .12 months:______________
DATES OF EMPLOYMENT EARNINGS TIME LOST
__________NAME AND or EMPLOYER_______ llmm I l
(1) Non._______________________________________________________________J_ l_________
01___________________________________________________________________________________
<3) । . Illi
58. Aj^-—' Wiished hospitalisation If so, state what institution and address of same
Wby the United States , \&otvc’ rvbion thereof? n°
name of spouse of each marriage
°T * \ 8 Feb 39, Newark, N. J. - Mary Jane Jones
. or ______"" I---------------------------------------------------------------
\lution ot your naarriages
_,—_ n*® at>W °’ • ■ ' / e:i*te12itd that T aellity: I
\ -^8W*“5 nr,., T l t”e ShouJrf >
/
<2. I
A. \ I
• -----------------------------------------------------------------------------------/
\ I
I
NOTE: VAF statement is completed in one copy in lieu of VA Form 526, if the dischargee does not wish to file claim at the time of discharge.
57
TM 12-235
1 JAN 45
REQUEST FOR DESIGNATION OF VETERANS ADMINISTRATION FACILITY
OFFICE OF THE REGISTRAR 1257th SCSU TILTON GENERAL HOSPITAL FORT DIX, NEW JERSEY
5 November 1944 (Date)
SUBJECTS Request for Designation of Hospital.
T0 The Medical Director, Veterans Administration, Washington, 25, D. C.
1. The following identified soldier, who has been under observation in this hospital, is ready for transfer (at Army expense) to a facility of the Veterans Administration where he will be discharged for disability. You are requested to designate that facility.
Last Name - First Name - Middle Initial Doe, John J. Sex Male Female A.S.N. 24 681 093 Grade Pvt.
Soldier’s Home Address 1440 Oak Street, Newark, New Jersey Organi zation 181st Infantry Regiment
Birthplace Newark, N. J. Date 15 April 1919 Race White Present Disability Psychosis, unclassified
Type of Proposed Discharge Honorable Discharge* -Blue ■Pioehange LOD Yes* -He- Current Enlistment Began At Newark, New Jersey Date 10 May 1942
Name of Nearest Relative Mary Jane Doe Relationship Wife Address of Nearest Relative 1440 Oak Street, Newark NJ
Marital status 1 Wi d 0 wo ci * I Married .Divorced Prior Service None Under Observation Since 28 October 1944
2. The following records will be forwarded to the Manager of the designated facility:
a. Veterans Administration Form P-10, fully executed and sworn to.
b. Veterans Administration Form 526, prepared upon soldier’s request or statement to Veterans Administration that man does not wish to file VA Form 526 (Exhibit C, Cir. 13, WD, 1944).
c. All available clinical records (original), including x-ray films.
d. Copy of Certificate of Disability for Discharge (TO AGO Form 40).
e. Photostat of original report of physical examination upon entrance into military service. (Will be forwarded when received)*
f. WD AGO Form 20, Soldier's Qualification Card.
g. Copy of Separation Qualification Record, TO AGO Form 100.
3. Affidavit has been made on Form P-10 that soldier is not financially able to pay the necessary expenses of hospital or domiciliary care.
For the Commanding Officer:
$~Ia)
0. WEXLER
1st Lt., MAC
♦Line out words not applicable. Registrar
NOTES: 1. Prepared in duplicate by Registrar from information on Service Record, hospital records or data secured by interview with patient.
2. Copy 1 is forwarded to Veterans Administration, copy 2 is retained as a suspense copy.
3. If a soldier is to be discharged on a blue discharge certificate, a brief statement as to basis for discharge is to be inclosed with this form.
58
1 JAN 45 TM 12-235
NOTIFICATION OF DESIGNATION OF FACILITY VA FORM NO. 2834
VETERANS ADMINISTRATION
WASHINGTON 25. D. C.
Commanding Officer, Tilton General Hospital Fort Dix, New Jersey
Your file reference:
In reply refer to:
John J. Doe 24681093
801 - File
Dear Sir:
In compliance with your request of 5 November 1944 for my designation of a hospital for the treatment of the captioned patient, you are informed that the Veterans Administration Facility, lyons, New Jersey is designated. Please in-
form the Manager of that Facility as to the contemplated date and hour of arrival of this patient.
The reservation of a bed for this patient will be void
thirty (30) days from the date of this letter.
Very truly yours,
Medical Director.
NOTE: Form is prepared in duplicate by Veterans Administration.
59
TM 12-235
1 JAN 45
APPLICATION FOR HOSPITAL TREATMENT
I
REFERENCE: AR 615-361
VETERANS ADMINISTRATION
Form P-10-Rev. Aug. 1M3
APPLICATION FOR HOSPITAL TREATMENT OR DOMICILIARY CARE
Penal Provisions Applicable to Title I, Public No. 2, 73d Congress
SECTION IS. Any person who shall knowingly make or eaose to be made, or conspire, combine, aid or assist in, agree to, arrange for, or In anywise procure the making or presentation of a false or frandnlent affidavit, declaration certificate, statement, voucher, or paper, or writing purporting to be such, concerning any claim for benefits under this title, shall forfeit all rights, claims, and benefits under this title, and, in addition to any and all other penalties imposed by law, shall be guilty of a misdemeanor, and upon conviction thereof shall be punished by a fine of not more than $1,000 or imprisonment for not more than one year, or both.
REDUCTION OF PENSION, COMPENSATION, OR EMERGENCY OFFICERS’ RETIREMENT PAY
WHILE RECEIVING HOSPITAL OR DOMICILIARY CARE
Where any disabled veteran having neither wife, child, nor dependent parent is being furnished hospital treatment, institutional or domiciliary care by the United States or any political subdivision thereof, the pension, compensation, or emergency officers' retirement pay shall not exceed $20 per month, provided that the amount payable for such disabled veteran entitled to pension for disability the result of injury or disease incurred after active military or naval service shall not exceed $8 per month, and provided further, that where any disabled veteran who is being furnished hospital treatment, institutional or domiciliary care by the United States or any political subdivision thereof, has a wife, child, or dependent parent the pension, compensation, or emergency officers* retirement pay may, in the discretion of the Administrator, be apportioned on behalf of such wife, child, or dependent parent, in accordance with instructions issued by the Administrator.
The applicant should forward this form, when fully executed, with a certified copy of his discharge from last period of service, to the Veterans Administration facility nearest his home, which is located at - lyons* frlnw Jersey .............................................
(Location of facility)
1.1, ..Ifcft ....John c-no. (Print) (Last name) (First name) (Middle name) hereby apply for admission to a Veterans Administration facility for (hospital treatment) CdMItdntticXKEaDOf 15 April 1919 White Male Newark, N. J. I44O Oak St.x Newarkx N. J. (Date of birth) (Color) (Bex) (Place of birth) (Present place of reeid’enoe) 2. My entire service in the active military or naval service of the United States has been as follows:
ysnaoax. Bbrial No. Dischargxo Rank and Organization Character or D18CHAROK
Date Place Date Place
10 May Newark, N.J. 326 21 Nov 44 Ft. Dix, N.J. Pvtr-181 Inf. Honorable
Notk.—If you served under a name other than the one used in this application, Indicate the name under which you served and tb«j period of service____
None
3. Have you filed claim for other benefits? ....^.9.. If “Yes” at what Veterans Administration office?_______
(Yes or no) (Location')'
What office has your case file?________________________________________________________________________________________
(Location)
4. (a) Do you receive pension? ... Amount per month, $------------------ (5) Do you receive compensation? Amount
(Yee or no) (Yee or no)
per month, $---------------- (c) Do you receive retirement pay? Amount per month, $__________________ (d) Do you
(Yes or no)
receive Government Insurance pay? ..No.......... Amount per month, $___________________ (e) From what other source do you receive
(Yes or no)
income? Amount per month, $_____________________ Social Security No
...None
(Source of Income)
5. What do you believe to be the total value of your property, both real and personal? ........................ Do you care
(Amount)
to qualify your answer to the question immediately preceding? ...No _ ..............■___________________________________
* Delete inapplicable phrase.
NOTES: 1. Information on pages 1 and 2 is completed from the Service Record or information secured by interview with patient or by his relative or guardian.
2. Ward Officer completes page 3.
3. If soldier is mentally competent he may sign on page 2.
4. If soldier is mentally incompetent the form will be completed exclusive of items 5, 8, 9, 10, 12, and the medical certificate. The form will be sent to the nearest relative for completion and authentication of items 5, 8, 9, 10, and 12 with the letter to the relative. Upon return, the medical certificate will be completed by the ward officer.
5. If the applicant has no relatives, the form may be executed for him by a friend, . by the commanding officer of the hospital or his designee.
6. If discharge is for disability incurred or aggravated in line of duty, it is not essential that items 8 and 9 be completed.
60
1 JAN 45
TM 12-235
OR DOMICILIARY CARE VA FORM P-10
6. Are you single?___________ Married?._____X&S.. Widowed?............... Divorced?...
(Write “Yes” in proper space)
wife?_____X®2? (b) Have you any child or children under 18 years of age?-No.________ If “Yes,” state number of children..................
(Yes or no) (Yes or no) (Number)
and their ages______________________________ (c) Have you other persons dependent upon you?—X^S if “Yes,” state relation-
(Agee) ,v------'
ships ...Mary...Jane Doe - Wife
(a) If married, are you living with your
A careful physical (inc
(1) Brief history :
Numerous n
(2) Symptoms: remember mos regardless c childish, si emotional re is
quite ap;
(3)
Physical findi
«)
Diagnosis: f
(5)
Strike the cla
need an p.ttenc
(Relationships)
7. Give the name and address of your wife, or nearest relative, or guardian:
Aai^Jane Doe Wife__________________________________________________________
1440 Oak Street, Newark, N. J.
w.......(Narn®) (Relationship) (Address)
8. Are you entitled to hospital care by membership in a lodge, society, community group treatment plan, etc., or as a beneficiary of an insurance company, workmen’s compensation commission, industrial accident board, etc.?------------------------No-------- If “Yee,” give namo of
(Yes or no)
agency or organization----------------------------------------------------------------------------------------------------------------
9. Are you financially able to pay the necessary expenses of hospital or domiciliary care?—--------------
(Yes or no)
10. Are you able to pay transportation fcuct from a Veterans Administration facility?. .No----------
(Yes or no)
11. (a) Have you received hospital care as a patient of the Veterans Administration?------N.9... If “Yes,” state when........................
(Yes or no) (Give most recent datef)
and where----------------------------------------------------------------------------------------------------------------------------------------------
(Name of hospital)
(6) Have you received domiciliary care in a Veterans Administration facility?.._N.Q................... If “Yes,” state when___________—.........
(Yes or no) (Give most reoent dates)
and where----
(Give name of Veterans Administration facility)
(c) Have you within the last 12 months, while hospitalized as a patient of the Veterans Administration, left the hospital: (1) Without official leave: (2) against medical advice; or, (3) been discharged for any disciplinary reason?.......MP________ (d) Have you within
(Yea or no)
the last 12 months, while under domiciliary care in any Veterans Administration facility, (1) been dropped from the rolls for absence without leave or demanding papers; or, (2) have you been given an enforced furlough; or, (3) requested and received your discharge while under sentence or on an enforced furlough?.______.V.9.—. (e) If your answer to either (c) or (d) above is “Yes,” state when
(Date)
and why __________
where
(Facility where action occurred)
(Um one of reasons above. If answer to (4) (2), or (4) (3) Is “Yas," state length of such furlough)
12. This application is made with notice of Public Law No. 382 approved December 26, 1941 (38 U. S. Code 17—17j) which in effect provides that upon the death of any veteran receiving care or treatment by the Veterans Administration in any institution leaving no widow (widower), next of kin or heir entitled to inherit, all personal property, including money or balances in bank, and all claims and choses in action, owned by such veteran, and not disposed of by will or otherwise, will become the property of the United States as trustee for the Post Fund.
I ■ aJ. AajuxJ Snd unJerstAnfl aN questions and answers on this form. The answers to all questions are true and com-
plete to the best of my knowledge and belief. The foregoing questions and answers are made a part hereof with full knowledge of the penalty provided for making a false statement as to material fact in this application. The penal provisions appearing on page 1 hereof and the statement in item 12 have been read | me, and are fully understood.
Witnesses to signature by mark (X)
store of applicant or representative)
(Signature)
(Address)
(Signature)
(Address)
Subscribed and sworn to before me this ....XQ______day of
P<5^,...A440..?ak. Street ............
(Number) (Street)
Newark, New Jersey
(State)
19.44., by ...Mary._Janes Doe
_____________„________________, claimant, to whom the statements herein were fully made known and explained. I certify that the questions and answers thereto have, in my presence, been the claimant.
[seal]
* Strike out inapplicable words or phrases.
Notary Public.
luring his travel. The proposed attendant’s name is________
address-------------------------------------------------------- The attendant (is not) a relative of the patient.
It is proposed that tray»Hjp the hospital will be made by (tadxkXtacX (automobile).
.Ifijfe_y.f81b.er 1.9.44—--------------------------------------Jll.tan..£ieneral..Ho£pi_tal,..I'iir.t.Dix, N.J.
(Date) (Signature orexaminiog physician) (Street) (Glfy) (Stater
EARL SAXE, Major, M.C.
61
TM 12-235
1 JAN 45
TELEGRAPHIC NOTIFICATIONS REGARDING TRANSFER OF • PATIENT TO VETERANS FACILITY
REFERENCE: AR 615-361
ba
^^■TnmTTHTTWTWTTrTTH^^H
X .X'° °°X "'X
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\ -t'S* KmnffntTWrWElFnn!^. X X. XXX X X. X,
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WAB DEPAKTMZNT ■ '
'M MESSAGEFORM Date,?1 NOVEMBER 1944..... H ° Of
I M.No...?ffl_-.BQ£)..AlQHM._s!______________________________ Telephone No. 24125_ I
I OHce ofori^...l257.th..,7C5.U...ak7!>N...Gffim.k.JWFUlL.. BSS.S.TRAR...________ ■ jV
UnuarMTvkT) (PI.Imoo) (Branch) (Button) (Symbol) Zb
M AddreBi FORT DTX NEW JERSEY............. ■
PRICIDIMCI M
*O: I I WM OB RADIO XS3XXHAL >fflJTAXTMA£~~M jV
1 COMMANDING OEH CER 1 U»v^._ AfrBaiL_ M /f
ULTUN GENERAL HOSPITAL ftfatty Sjwatalin< prao.dw» B /^
wfl t« mm! "Mrad." ■ Jf
MESSAGE: GOVEPJJMQ.' T WIRE - COLLECT /f
PRIVATE JOHN J DOE DELIVERED TO VETERANS ADMINI STRAIT CH FACILITY LYONS JV
NEW JERSEY /Jo. a < 2z~-*—^-»ISir>P RECEIPT MAILED A/.^*M- ■<■?
(Enter hour and date) (Date)
______..., /_____________________________________________
(Signed - Mamey rynk ana* ASN of attendant) r JHH oovEnma.-? wire - collect
________________________________________
62
1 JAN 45
TM 12-235
TRANSMITTAL OF CASE RECORDS TO VETERANS ADMINISTRATION AREA OFFICE OR FACILITY
OFFICE OF THE REGISTRAR 1257th SCSU TILTON GENERAL HOSPITAL FORT DIX, NEW JERSEY
SUBJECT: Transmittal of Case Records of:
Last Name - First Name - Middle Initial Doe, John J.
20 November 1944 (Date Prepared)
Grade
Pvt.
A. S. N.
32 681 093
TO: Veterans Administration Facility, Lyons, N. J.______________________________
(Enter facility or area office to which records are to be sent)
1. Transmitted herewith are records pertaining to the above named soldier who (waa) (will be) discharged because of disability under the provisions of AR 615-361, on 21 November 1944____________________
(Date)
a. । x । Veterans application, for disability compensation or pension VA Form 526.
b. I I Statement to Veterans Administration that man does not wish to file
VA Form 526. (Exhibit C. Cir. 13)
c. Q Photostat of original report of physical examination on entrance into military service.
d. I xl Copy of Certificate of Disability for Discharge WD AGO Form 40.
e. Q Veterans Administration Form P-10.
f. I x I Soldier’s Qua!i fl cation Card, WD AGO Form 20.
g. I x I Original Clinical Records marked: "Loaned to Veterans Administration".
(1) Tilton General Hospital, Fort Dix, N. J.____________
Hospital
(2) Station Hospital, Pine Camp, N. Y.__________________
Hospital
H)______________________________________________________
Hospital
Copy of Separation Qualification Record WD AGO Form 100.
2.
Any records subsequently received will be forwarded promptly.
3-
Type of Discharge is:
Honorable (White)
Not Honorable (Blue)
For the Commanding Officer5
Signature or Stamp of Recipient
Title"
'0. WEXLER' 1st Lt., MAC Registrar
By
Stamping of duplicate copy constitutes
Administration. Copy 3 is retained as
receipt. Send Copies 1 and 2 to Veterans suspense copy.
NOTES: 1. Prepared in triplicate to effect transfer of records to Veterans Administration facility if patient is transferred to VAF or to the Veterans Administration Area office if soldier is discharged to his own care.
2. Copies 1 and 2 are forwarded to Veterans Administration, copy 3 is held as suspense copy and is subsequently transmitted to The Adjutant General with Service Records. Copy 1 is stamped or signed by recipient (Veterans Administration) and returned to transmitting hospital.
63
TM 12-235
1 JAN 45
RECEIPT FOR PERSON AND PROPERTY
Veterans Administration
Name of Veterans’ Facility
Lyons New Jersey
City State
TO; The Registrar, Tilton General Hospital, Fort Dix, New Jersey
1. This will acknowledge receipt of the following person:
Last Name - First Name - Middle Initial Grade ASN
Doe, John J. Pvt 32 681 093
and his personal effects listed below.
2. Clothing and Property List.
No. Description No. Description No. Description
1 1 1 1 1 1 1 1 2 2 1 4 2 4 2 Bag, Barracks Belt, Web Shoes, Service Cap, Garrison Cap, Cotton, Khaki Cap, Service & Insignia Coat, Wool Overcoat Mackinaw Shirts, O.D. Shirts, Khaki Trousers, O.D. Trousers, Khaki Undershirts, cotton Drawers, cotton Glov es Handkerchief Necktie Socks Towels .
Date of Arrival at Facility Signature of Recipient
Title
Send copies 1 & 2 to Veterans' Facility. File copy 3. Have VA sign and return copy 1.
NOTES: 1. Prepared prior to transfer of patient to Veterans Administration Facility.
2. Prepared in triplicate. Copies 1 and 2 are forwarded and the recipient checks the property, signs copy 1 and returns it to the discharging hospital. Copy 3 is retained as suspense copy.
3. Money and valuables will be forwarded to the facility to which the patient is transferred by registered mail (Par. 10b AR 600-500)
4. This form may be altered for use in securing receipt for patients property from nearest relative or guardian if patient is discharged to custody of relative or guardian.
64
1 JAN 45
TM 12-235
FINAL DISPOSITON OF RECORDS
65
WD WD WD WD WD WD WD WD WD WD WD WD WD WD WD wn WD UA UA IADC1 Inckl CLIN- nA1
RECORDS AGO AGO AGO AGO AGO AGO AGO AGO AGO AGO AGO AGO AGO AGO AGO PAM- ™ VA fopm Rht E me
TO FORM FORM FORM FORM FORM FORM FORM FORM FORM FORM FORM FORM FORM FORM FORM PHLET M0 »UI- DIM. R[C Mt
8-24 8-111 8-176 20 24 30-5 32 381 40t 53 SER. 53-2 100 166 201 519 21-4 IUN LtKL ORDS 10
TAG 1 * 1 §§ 1 112 1
VET. ADM. 4
NEW YORK__________________________________________________________________________________________________
VA AREA
OFFICE OR 1* 2§ 2 5 2 111 11
FACILITY
SURGEON ~ 7
GENERAL 1 ____________________________________________________________________________________________
ODB 4 5
NEWARK, N. J.________________'_____________________________________________________________________________
GOV'T. INS. 9 -
ALLOT. DIV,_______________________________________________________________________________________________
SERVICE ,
COMMAND_____________1_____________________________________________________________________________________
REGISTRAR .
OF HOSPITAL 1
DISBURSING ~
OFFICER_______________________________________________________________2__________________________________
AG OF STATE (NG CASES)________________________________________1_______________________________________________________
SOLDIER 1 111 !*★ 11
CLINICAL 9 ,
RECORDS__________________________________________________________________________________________________
STATE DIR. . . 6,7,
SEL. SERV.__________1_________________________8___________________________________________________________
PREVIOUS . ,
EMPLOYER__________________________________________________________________________________________________
Work
r„r n r Sheet _ _
FkE 2 6 & Lab. 3 3 2
Slips
_™________________________________It_________________steel_________________________________________________
NOTES: ★ — If transferred to or remaining assigned to ERC or RAR to: Commanding General §§ -If man has been naturalized while in the United States Army the original । of Service Command of place of residence of man; if discharged on CDD to: tificate of naturalization will be withdrawn from the Service Record and f
Veterans Administration Facility or Area Office; if discharged to accept a com- sented to him at time of honorable discharge.
mission to: AGO; all other men released from active duty to: State Director of . Selective Service having jurisdiction over man. ▼“Prepared only in cases of former National Guardsmen discharged or rever
f - WD AGO Form 40 to be used in CDD, WD AGO form 38, used for all other. to National Guard status.
§ - Prepared only if dischargee wishes to file pension application. ★★-WD Pamphlet 21-4 given only to those soldiers discharged on honorable <
| — Destroyed unless statement of charges levied against man, then forwarded charge. WD Pamphlet 21-24 given to those soldiers discharged on blue i
with Service Records. charge certificate.
■iliililiii
1001899275