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Get Hq3867.PDF. Certification For Death Claim Payment

GNATED BENEFICIARY DATE SOCIAL SECURITY NUMBER ESTAB'D DATE OF DEATH UNDESIGNATED BENEFICIARY NAME OF BENEFICIARY OR CLAIMANT RELATIONSHIP CLAIMANT ADDRESS I CERTIFY that the records of the U. S. Coast Guard show that each beneficiary named above has qualified to receive unpaid pay and allowances that might be due the decedent and that the requirements of applicable law and regulations have been satisfied. I CERTIFY that the records of the U. S. Coast Guard show that the decedent did not.

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