[1]Date : 01/20/98
[2]Page : 1
[4]JFK ASSASSINATION SYSTEM
[5]IDENTIFICATION FORM
[7]AGENCY INFORMATION
[10]RECORD NUMBER : 194-10004-10141
[11]RECORDS SERIES : DOD-AFFILIATED PERSONNEL INCIDENT INVESTIGATIONS
[12]AGENCY PILE NUMBER : PAGES 378-381
[14]DOCUMENT INFORMATION
[16]ORIGINATOR : USA,
[17]FROM : HAYASHIDA, MYRON K.
[19]TITLE : [ RESTRICTED ]}
[20]DATE : 11/26/66
[21]PAGES : 4 ;
[22]SUBJECTS : FROMER, DAVID R.
[24]LEGAL ADVICE
[26]DOCUMENT TYPE : PAPER, TEXTUAL DOCUMENT
[27]CLASSIFICATION : UNCLASSIFIED
[28]' RESTRICTIONS : 3 -
[29]CURRENT STATUS : RELEASED WITH DELETIONS
[30]DATE OF LAST REVIEW : 03/07/95
[31]OPENING CRITERIA :
[32]COMMENTS
[34]NW 60613 Docid:34528582 Page 1
[36]Co |
[38]i
[39]N
[41]STATEMENT O. .ERSONAL HISTORY
[43]INSTRUCTIONS: Read the certification at the end of this questionnaire before entering the required data. Print or type all
[44]answers. All questions and statements must be completed. If the answer is ‘‘None,"’ so state. Do not misstate or omit material
[45]fact since the statements made herein are subject to verification. If more space is needed, use the Remarks section, item 20, and
[46]attach additional sheets if necessary. The information entered hereon is for official use only and will be maintained in confidence.
[48]rint) FIRST NAME—MIDDLE NAME--MAIDEN NAME (If any)—LAST NAME
[49]2. STATUS
[51]Clues. DAVID REED FROMER
[52]OD miss Gcvum [| MILITARY ON ACTIVE DUTY
[53]f 3. ALIAS(ES). NICKNAME(S). OR CHANGES IN NAME (Other than by marriage) 4, PERMANENT MAILING ADDRESS
[54]None 13 Rhonde Way, Mill Valley, Calif.
[56]5. DATE OF BIRTH (Day, month, year) PLACE OF BIRTH (City, County, State, and Country)
[58]21 July 1942 Chicago, Cook, Illinois, USA
[60]RACE HEIGHT WEIGHT COLOR OF EYES COLOR OF HAIR SCARS, PHYSICAL DEFECTS. DISTINGUISHING MARKS
[61]Cauc 67" 1768 Brown Brown Scar above left eye
[62]6. DO YOU HAVE A HISTORY OF MENTAL OR NERVOUS DISORDERS? UO YESHS NO ARE YOU NOW OR HAVE YOU EVER BEEN ADDICTED TO THE USE OF HABIT FORMING DRUGS SUCH AS.
[64]NARCOTICS OR BARBITURATES? oO YES Xo ARE YOU NOW OR HAVE YOU EVER BEEN A CHRONIC USER TO EXCESS OF ALCOHOLIC BEVERAGES? im) YES EXno IF THE ~
[65]ANSWER TO ANY OF THE ABOVE IS "'YES."" EXPLAIN IN ITEM 20.
[67]7U.S. IF NATURALIZED, CERTIFICATE NO. IF DERIVEO, PARENTS’ CERTIFICATE NO(S), | DATE. PLACE, AND COURT
[69]CITIZEN
[70]a” be
[71]r Pre ee
[73]_
[74]= ATION N N NTRY DATE AND PORT OF ENTRY DO YOU INTEND TO BECOME
[75]EGISTRATION NO ATIVE COU! ALU. S. CITIZEN?
[76]YES NO.
[77]8.
[79]MILITARY SERVICE
[80]ARE YOU PRESENTLY ON ACTIVE DUTY IN THE U. S. ARMED FORCES DRAWING FULL PAY? [_] YES KX] NO IF “YES,” COMPLETE THE FOLLOWING:
[81]GRADE AND SERVICE NO. SERVICE AND COMPONENT ORGANIZATION AND STATICN
[83]PLACE CERTIFICATE RECCRDED
[85]ARE YOU PRESENTLY A MEMBER OF A U. S. RESERVE OR NATIONAL GUARD ORGANIZATION? Oo yes [4 No F “YES. COMPLETE THE FOLLOWING:
[86]GRADE AND SERVICE NO, SERVICE AND COMPONENT ORGANIZATION AND STATION OR UNIT AND LOCATION ,
[88]HAVE YOU PREVIOUSLY SERVED TOURS OF EXTENDED ACTIVE DUTY. DRAWING. FULL PAY. FROM WHICH YOU WERE DISCHARGED OR SEPARATED'TO CIVILIAN STATUS? G ves [
[89]IF ‘"YES.*' COMPLETE THE FOLLOWING: :
[91]CCUNTRY ‘ COMPONENT FROM (Date) TO (Date) TYPE DISCHARGES OR SEPARATIONS—GRADE AND SERVICE NO.
[93]9%. EDUCATION (Account for all civilian schools and military academies. Do not include service schools)
[95]ee ee | ves |
[97]| 1947 | 1949 |S Nettelhorst Elem. School, Chicago, Illinois |X| xf.
[99]1950 La Casita Elem. School, Clovis, New Mexico | */ x po
[100]x
[102]1950 1954 Argonne Elem. School, S.F., Calif.
[104]NAME AND LOCATION OF SCHOOL DEGREE
[106]0.
[108]FAMILY (Lise in order given, parents, spouse, guardians, stepparents, foster parents, parents-in-law, former spouse(s) (if divorced give date
[109]and place), children, brothers and sisters, even though deceased. Include any others you resided with or with whom a close relationship
[110]existed or exists. /f the person is not a U. S. citizen by birth, give date and port of entry, alien registration number, naturalization certificate
[111]number and place of issuance.)
[113]RELATION AND NAME PRESENT ADORESS, IF LIVING
[115]13 Rhonda Way
[117]DATE AND PLACE OF BIRTH
[119]12 July 1913
[120]Cincinnati, Ohio
[121]31 Dec 1909
[125]FATHER
[127]IRVING FROMER
[129]MOTHER (Maiden name)
[131]Katherine Rhodes
[133]SPOUSE (Maiden name)
[134]None
[136]OTHER (Specify) Brother
[137]Jon Fromer Chicego, Illinois
[139]Sister 15 Aug 1939 881 Clayton St.
[140]Ann Speke San Francisco, Calif. | San Francisco, Calif.
[142]Calif.
[144]PREVIOUS EDI‘ IONS ARF, OBSOLETE. ’ 7 Exception to Standard Form 86 : é
[145]vi gets eta se OBpage MftONS vend AEEICIAL PISE ONLY” ‘Approved by Bureau of the Budert, Tune 1980
[147]a oro]
[148]GN COUNTRIES (List 4randparents, first cousins, aunts, uncles,
[150]J:ip existed or exists)
[152]OTHER RELATIVES ANO ALIEN FRIENDS LIVING IN FORE!
[154]brothers- and sisters-in-law, and other persons with whom a close relations.
[156]ADDRESS
[158]13. EMPLOYMENT (Show every employment you have had and all periods of unemployment)
[160]Peul Elder Scokstore | mut elder __ 2 P
[161]Dec 59 | Sutter & Stockton Sts.,S al, | Pay de season
[162]San Francisco Council Camp Fire unknoon | End of summer
[163]Girls, SeFe Calif. Camp
[164]Fairmont Hotel Part-time
[165]1861 San Francisco, Calif nknown job :
[166]Foster's Restaurant ‘pertetime job _
[167]an an Sco = P fadi Bacon camp
[168]Madison Soard of Education Rec. ecnoun end of school
[169]Madison, Wisconsin eer
[170]Clark Service Station | a cutter Conflict with
[171]Atwood Ave, ,fladison, Wisconsin Ed Cutte studies
[172]folk trio
[173]1718 Wells St.,Chicago,Illinoia | Bob George 5.F.
[175]SOCIAL SECURITY NO.
[177]DID ANY OF THE ABOVE EMPLOYMENTS REQUIRE A SECURITY CLEARANCE? ( Yes &XNO DO YOU HAVE
[178]ANY FOREIGN PROPERTY OR BUSINESS CONNECTIONS, OR HAVE YOU EVER BEEN EMPLOYED BY A FOREIGN -
[179]GOVERNMENT, FIRM, OR AGENCY? [] YES XX NO HAVE YOU EVER BEEN REFUSED BOND? [_] YES
[180]KKKNO IF THE ANSWER TO ANY OF THE ABOVE IS "YES," EXPLAIN IN ITEM 20.
[182]i
[183]t
[185]Dec 59
[187]It
[189]1960
[191]1961
[193]1962 &
[195]Fall 196
[197]Oct 65
[199]564-538-8137
[201]ons living outside the
[203]“ CREDIT AND CHARACTER REFERENCES (Do not include relatives, former employers, or pers
[204]United States or its Territories. : :
[206]N | YEARS
[207](List 3 credit and 5 character) * KNOWN
[209]None.
[211]. STREET AND NUMBER STATE OR
[212]Malvina Reynolds : 2027 Parker Street : Calif. |
[213]eaphan Negossce ip | Sonore Way =
[215]E
[217]|
[219]Madi Be aith Aver [ca1ie. _|
[221]Archie Brown
[223]CHARACTER
[225]L
[227]NW 88613 Docid:34528582 Page 3
[229]U.S. GOVERNMENT PRINTING OFFICE : 1860 O—S573450
[231]STREET AND NUMBER
[233]city STATE OR COUNTRY
[234]—1s09-| vere prne_trave street [thicago___|fldinoie
[235]Eduarde Street [Clovie 1]
[236]8
[238]iw F4
[240]alifornia
[241]Berkele
[243]1961. - 81 Clayton Street San Francisco
[244]1962, | sd] 29 N. Basset fladison
[245]|
[247]alifornia
[248]elifornia
[249]sconsin
[250]sconsi
[252]| 1942" | i
[253]349 lew Mexico
[254]1950 1960 1932 Cabrilléd Street San_ Francisco
[255]| 1960 | 2850 Azncroft Wa
[259]215 Lake Lawn Avenue
[260]1427 University Avenue adison sconsin
[261]881 Clayton Strest Sen Francisco [California
[262]435 W. North Avenue
[264]| 1963 [1964 |
[266]| 1966 [1965 |
[268]| i966 [| ~=«13 Rhonda Wa Mill Valle
[269]| 1966 [|
[271]a
[273]= 3
[274][o]
[275][a3
[277]io
[278]Ls]
[279]=]
[281]140 Lengdon Street jisconsin
[282]PAST AND/OR PRESENT MEMBERSHIP {N ORGANIZATIONS
[284]ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE COMMUNIST PARTY U.S. A., OR ANY COMMUNIST ORGANIZATIONS ANYWHERE? '
[285]| | ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF A FASCIST ORGANIZATION?
[287]1 :
[288]ARE YOU NOW OR HAVE YOU EVER SEEN A MEMBER OF ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP OR COMBINATION OF PERSONS WHICH ADVOCATES THE
[289]OVERTHROW OF OUR CONSTITUTIONAL FORM OF GOVERNMENT, OR-WHICH HAS ADOPTED THE POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE
[290]OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES, OR WHICH SEEKS TO ALTER THE FORM OF GOVERNMENT OF
[291]THE UNITED STATES BY UNCONSTITUTIONAL. MEANS?
[293]ARE YOU NOW OR HAVE YOU EVER BEEN AFFILIATED OR ASSOCIATEO WITH ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE AS AN AGENT. OFFICIAL, OR EMPLOYEE?
[295]ARE YOU NOW ASSOCIATING WITH, OR HAVE YOU ASSOCIATED WITH ANY INDIVIDUALS, INCLUDING RELATIVES, WHO YOU KNOW OR HAVE REASON TO BELIEVE, ARE OR
[296]HAVE BEEN MEMBERS OF ANY OF THE ORGANIZATIONS IDENTIFIED ABOVE? :
[298]HAVE YOU EVER ENGAGED IN ANY OF THE FOLLOWING ACTIVITIES OF ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE: CONTRIBUTION(S) TO, ATTENDANCE AT OR
[299]PARTICIPATION IN ANY ORGANIZATIONAL. SOCIAL. OR OTHER ACTIVITIES OF SAID ORGANIZATIONS OR OF ANY PROJECTS SPONSORED BY THEM: THE SALE, GIFT.OR bis-
[300]TRIBUTION OF ANY WRITTEN, PRINTED, OR OTHER MATTER, PREPARED, REPRODUCED, OR PUBLISHED, BY THEM OR ANY OF THEIR AGENTS OR INSTRUMENTALITIES?
[302]IF“ YES,” DESCRIBE THE CIRCUMSTANCES. ATTACH ADDITIONAL SHEETS FOR A FULL DETAILED STATEMENT. IF ASSOCIATED WITH ANY OF THE ABOVE ORGANIZATIONS. SPECIFY NATURE
[303]AND EXTENT OF ASSOCIATION WITH EACH, INCLUDING OFFICE OR POSITION HELD. ALSO INCLUDE DATES. PLACES. AND CREDENTIALS NOW OR FORMERLY HELD. IF ASSOCIATIONS HAVE
[304]BEEN WITH INDIVIDUALS WHO ARE MEMBERS OF THE ABOVE ORGANIZATIONS, THEN LIST THE INDIVIDUALS AND THE ORGANIZATIONS WITH WHICH THEY WERE OR ARE AFFILIATED.
[306]18. HAVE YOU EVER BEEN DETAINED, HELD, ARRESTED. INDICTED OR SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING. OR CONVICTED, FINED, OR IMPRISONED OR
[307]PLACED ON PROBATION, OR HAVE YOU EVER BEEN ORDERED TO DEPOSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION OR ORDINANCE (excluding
[308]minor traffic violations for which a fine or forfeiture of $25, or less was imposed)? INCLUDE ALL COURT MARTIALS WHILE IN MILITARY SERVICE. [] YES EXno
[309]IF “YES."' LIST THE DATE, THE NATURE OF THE OFFENSE OR VIOLATION. THE NAME AND LOCATION OF THE COURT OR PLACE OF HEARING, AND THE PENALTY IMPOSED OR OTHER
[310]DISPOSITION OF EACH CASE.
[312]. Sat
[314]wef al
[316]“ - ee — : (
[318]a“!
[320]uve Beth I" AMEBIRSR Pag gg MTN ED HEREIN WHICH MAY arrircY UPON YOUR LOYALTY TO THE UNITED STATES OR UPON YOUR SUITABILITY TO PERFORM
[322]4
[324]A AN | ee
[325]19. ARE THERE ANY INCIDENTS IN YOUR LIFE NOT MENTION ED HERTIN WHICH MAY REFLI -T UPON YOUR LOYALTY TO THE UNITED SfATES OR UPON YOUR SUITABILITY TO PERFOKM
[326]THE DUTIES WHICH YOU MAY BE CALLED UPON TO TAKE OR WHICH MIGHT REQUIRE FURTHER EXPLANATION? Xx YES oO NO ” IF ‘'YES.’" GIVE DETAILS
[328]lam a conscientious objector. My case is in the courts at the present time.
[330]20, REMARKS
[332]I have been advised by my lawyers thet I cannot sign #16 or #17 without
[333].putting myself in jeapatdy. Private attorney - Peter Frarck °
[334]Family attorney - ViosabtiHallinan
[338]David Reed Fromer, born 21 July 1942, in Chicago, Illinois,
[339].@ registrant under the Univers] Military Training Act, wes
[340]_this date given an opportunity .to. execute OD Ferm 398 and
[341]in my presence he refusad to do so, if ite entirety.
[343]RON K. HAYQZSHIDA
[344]1/LT, AGC
[345]ITEM EDUCATION (Continued DEGREE
[347]1960 - 1961 University of California, Berkeley, California No
[348]1961 - 1962 City College of San Francisco, Sen Francisco, Calif. Yes
[349]University of Uisconeiny Madison, Wisconsin
[351])
[353]San Francisco State Col e, San Francisco, Calif. (Ext.)
[354]Roosevelt University, Chi igs g0 Illinois , (
[356]| CERTIFY THAT THE ENTRIES MADE BY ME ABOVE ARE TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND ARE MADE IN
[357]GOOD FAITH. | UNDERSTAND THAT A KNOWING AND WILLFUL FALSE STATEMENT ON THIS FORM CAN BE PUNISHED BY FINE OR IMPRISONMENT OR BOTH
[358](See U.S. Code, title 18, section 1001)
[360]21 Nov.1966 | HVAT eS HAYRSROHS 1/LT, AGG
[361]1515 Clay St., Oakland, Calif.
[363]2. THIS SECTION TO BE COMPLETED BY AUTHORITY REQUESTING INVES eg TIGATION yy
[364]BRIEF DESCRIPTION OF DUTY ASSIGNMENT AND DEGREE OF CLASSIFIED MATTER (top secret, secret, etc.) TO WHICH APPLICANT WILL REQUIRE ACCESS
[366]RECORD OF PRIOR CLEARANCES
[368]DATE OF CLEARANCE TYPE OF CLEARANCE AGENCY THAT COMPLETED INVESTIGATION
[370]* 58]
[372]REMARKS,
[374]Ay
[376]NW 88613 Docld:34528582 Page 5 U.S. GOVERNMENT PRINTING OFFICE : 1960 O—373450