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Heleased under the John F. Kennedy

Rosassination Records Collection Act of

1992 (44 USC 2107 Note]. Case#:NW

BA613 Date: 03.18-2025

Date

: 01/20/98

Page

:

1

JFK ASSASSINATION SYSTEM

IDENTIFICATION FORM

AGENCY INFORMATION

AGENCY

: INSCOM/CSF

RECORD NUMBER

: 194-10004-10141

RECORDS SERIES

: DOD-AFFILIATED PERSONNEL INCIDENT INVESTIGATIONS

AGENCY FILE NUMBER

: PAGES 378-381

DOCUMENT INFORMATION

ORIGINATOR : USA.

FROM

: HAYASHIDA, MYRON K.

TO

TITLE

: [ RESTRICTED ]

DATE

: 11/26/66

PAGES

: 4

SUBJECTS : FROMER, DAVID R.

LEGAL ADVICE

DOCUMENT TYPE : PAPER, TEXTUAL DOCUMENT

CLASSIFICATION

: UNCLASSIFIED

RESTRICTIONS : 3

CURRENT STATUS

RELEASED WITH DELETIONS

DATE OF LAST REVIEW : 03/07/95

OPENING CRITERIA

COMMENTS :

NW 88613 Docld:34528582 Page 1

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STATEMENT O: ERSONAL HISTORY

INSTRUCTIONS: Read the certification at the end of this

All questions and statements must be completed.

quest answer se or enter se the reguned date

So not attate or omit materil

act sind to ta sement i mede sergin the subjection rifeti heren is or ofe is needed use he Ree ang airied, i confidence.

attach additional sheets if necessary.

1PMRE) FIRST NAME- MIDDLE NAME-MAIDEN NAME (11 AnY) - LAST NAME

DAVID REED FROMER

• MRS.

• MISS

3. ALIAS(ES). NICKNAME(S). OR CHANGES IN NAME (Other than by marriago)

None

S. DATE OF BIRTH (Day, month, year)

21 July

' 1942

RACE

HEIGHT

WEIGHT

Cauc

67"

2.

XI CIVILIAN

STATUS

I MILITARY ON ACTIVE DUTY

4 PERMANENT MAILING ADDRESS

13 Rhonda Way, Mill Valley, Calip.

PLACE OF BIRTH (City, County, State, and Country)

PLACE CERTIFICATE RECCRDED

Chicago, Cook, Illinois, USA

COLOR OF EYES

COLOR OF HAIR

SCARS. PHYSICAL DEFECTS. DISTINGUISHING MARKS

Scar above left eye

NARCOTICS OR BARBITURATES?

ANSWER TO ANY OF THE ABOVE IS "YES." EXPLAIN IN ITEM 20

7. U.S.

NATIVE

IF NATURALIZED, CERTIFICATE NO.

CITIZEN

X

YES

*X

NO

ALIEN

* REGISTRATION NO

NATIVE COUNTRY

IF DERIVED. PARENTS: CERTIFICATE NO(S).

DATE, PLACE. AND COURT

DATE AND PORT OF ENTRY

8.

MILITARY SERVICE

ARE YOU PRESENTLY ON ACTIVE DUTY IN THE U. S. ARMED FORCES DRAWING FULL PAY? YES X NO IF "YES." COMPLETE THE FOLLOWING:

GRADE AND SERVICE NO.

SERVICE AND COMPONENT

ORGANIZATION AND STATICN

DO YOU INTEND TO BECOME

A U.S. CITIZEN?

YES

NO

DATE CURRENT ACTIVE

SERVICE STARTED

ARE YOU PRESENTLY A MEMBER OF A U.S. RESERVE OR NATIONAL GUARD ORGANIZATION?

GRADE AND SERVICE NO.

SERVICE AND COMPONENT

YES L' NO IF "YES." COMPLETE THE FOLLOWING:

ORGANIZATION AND STATION OR UNIT AND LOCATION,

HAVE YOU PREVIOUSLY SERVED TOURS OF EXTENDED ACTIVE DUTY. DRAWING. FULL PAY, FROM WHICH YOU WERE DISCHARGED OR SEPARATED TO CIVILIAN STATUS? DO YES NO

IF "YES." COMPLETE THE FOLLOWING:

| FROM (Dato) ^ TO (Dato)

TYPE DISCHARGES OR SEPARATIONS-GRADE AND SERVICE NO.

EDUCATION (Account for all civilian schools and military academies.

Do not include service schools)

MONTH AND YEAR

GRADUATE

NAME AND LOCATION OF SCHOOL

DEGREE

FROM—

YES NO

1947

1949

Nettelhorst Elem. School, Chicago, Illinois

1949

1950

La Casita Elem. School, Clovis, New Mexico

*

1950

1954

*

XDE

XoE

Argonne Elem. School, S.Fo, Calip.

1954

1957

Presidio f High, SoF•e CalfP.

1957

1960

Geo. Washington High Schoole SeFee Calif.

10.

FAMILY (List in order brenners and sisters.

spouse, guardians,

foster parents, parents-in-law, former spouse(s) (if divorced give date

and place), children,

even though deceased.

others you resided with or with whom a close relationship

existed or exists.

Il the person is not a U.S. citizen by birth, give date and port of entry, alien registration number, naturalization certificate

number and place of issuance.)

RELATION AND NAME

U.S. CITIZEN

YES

NO

FATHER

IRVING FROMER

MOTHER (Maiden name)

Katherine Rhodes

SPOUSE (Maiden namo)

None

OTHER (Specify)

Brother

Jon Fromer

Sister

Ann Spake

DATE AND PLACE OF BIRTH

12 July 1913

Cincinnati, Ohio

31 Dec 1909

Estherville, Iowa

PRESENT ADDRESS, IF LIVING

13 Rhonda Way

mill Valley, Calif

13 Rhôde Way

mill Valley, Call.

11 May 1946

Chicago, Illinois

15 Aug 1939

San Francisco, Calif.

881 Clayton St.

San Francisco, Calip.

881 Clayton St.

San Francisco, Calif

X

378

NW 88613 Deld: 3432838&3PagENgUS EDIONS AR, OBSOLETE MEAN MEEICIAN LISE ONLY"

Exception to Standard Form 86

Approved by Bureau of the Rudgee. June 1960

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OTHER RELATIVES AND ALIEN FRIENDS LIVING IN FOREIGN COUNTRIES (List grandparents, first cousins, aunts,

brothers- and sisters-in-law, and other persons with whom a close relationship existed or exists)

RELATIONSHIP AND NAME

AGE

OCCUPATION

ADDRESS

None

CITIZENSHIP

12.

DATES

FOREIGN TRAVEL (Other than as a direct result of United States military duties)

PURPOSE OF TRAVEL

COUNTRY VISITED

FROM-

TO

None

13.

EMPLOYMENT (Show every employment you have had and all periods of unemployment)

FROM-

MONTH AND YEAR

TO

NAME AND ADDRESS OF EMPLOYER

NAMSUPERVISODIATE

Paul Elder Bookstore

Dec 59

Dec 59

Sutter & Stockton Sta., SoFe, Cale

Paul Elder

San Francisco Council

Camp Fire

Summer 60

Cirlo, SoFo, Calli.

Unknown

Fairmont Hotel

1960

1961

1962

San Francisco, CallPe

Unknown

Foster's Restaurant

1961

Summer

1961 &

San Francisco, Calife

Unknown

S. F. Boys' Chorus

1962

1963

San Franciaco, Calif.

Madi Bacon

Madison Board of Education Rec.

1962 &

Fall 1962

Madison, Wisconsin.

Unknown

Clark Service Station

Atwood Ave. Madison, Wieconsin

Ed Cutter

Self-employed - musicians in

Polk trio

Cooks Cupboard

Oct 65

Jun 66

1718 Wells St., Chicago, Illinoia

Bob George

REASON FOR LEAVING

End of holiday

sea80n

End of summer

Camp

Part-time

job

Part-time job

End of summer

camp

end of school

year

Conplict with

studies

Return to

S.F.

SOCIAL SECURITY NO.

114.

DID ANY OF THE ABOVE EMPLOYMENTS REQUIRE A SECURITY CLEARANCE? • YES ENO

DO YOU HAVE

ANY FOREIGN PROPERTY OR BUSINESS CONNECTIONS, OR HAVE YOU EVER BEEN EMPLOYED BY A FOREIGN

GOVERNMENT, FIRM, OR AGENCY?

HAVE YOU EVER BEEN REFUSED BOND? DJ YES

IF THE ANSWER TO ANY OF THE ABOVE IS "YES," EXPLAIN IN ITEM 20.

564-58-8137

CREDIT AND CHARACTER REFERENCES (Do not include relatives, former employers, or persons living outside the

United States or its Territories.

NAME

(List 3 credis and 5 character)

YEARS

KNOWN

STREET AND NUMBER

(Business address preferred)

CITY

None

STATE O

TERRITOR

CREDIT

CHARACTER

Malvina Reynolds

Stephan Negoesco

Madi Bacon

Richard Corsal

Archie Brown

10

10

4

2027 Parker Street

Sonora Way

1120 Kaith Avenue

1827 bayton toot

379

sui

Berkeley

Corte fladera

Berkeley

•CallPe

• Calife

Calif.

fattf:

U.S. GOVERNMENT PRINTING OFFICE: 19800-573450

NW 88613 Docld:34528582 Page 3

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15.

MONTH AND YEAR

FROM-

1942

1949

1950

1960

1961

1962

1963

1963

1964

1965

1966

1966

10-

1949

1950

1960

1961

1962

1964

1965

1966

16.

NAME AND ADDRESS

UST ALL RESIDENCES FROM 1 JANUARY 1887

STREET AND NUMBER

2817 Pine Grove Street

Edwarde Street

1932 Cabrillö Street

2850 Bzncroft Way

881 Clayton Street

219 N. Basset

215 Lake Lawn Avenue

1427 University Avenue

881 Clayton Street

435 W. North Avenue

13 Rhonda Way

140 Langdon Street

PAST AND/OR PRESENT MEMBERSHIP IN ORGAMIZATIONS

TYPE

(Social, Irasornal, prolossional, orc.)

CITY

STATE OR COUNTRY

Chicago

illinois

Clovis

New Mexico

San Francisco CaliPornia

Berkeley

California

San Francisco

California

Madison

Wisconsin

Medison

Wisconsin

Madison

Wisconsin

San Francisco

California

Chicago

Illinois

Mill Valley

CaliPornia

Madison

Wisconsin

OFFICE HELD

MEMBERSHIP

FROM:

то-

17.

YES

•NO

ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE COMMUNIST PARTY U.S. A... OR ANY COMMUNIST ORGANIZATIONS ANYWHERE?

ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF A FASCIST ORGANIZATION?

ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP OR COMBINATION OF PERSONS WHICH ADVOCATES THE

OVERTHROW OF OUR CONSTITUTIONAL FORM OF GOVERNMENT, OR WHICH HAS ADOPTED THE POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE

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

THE UNITED STATES BY UNCONSTITUTIONAL MEANS?

ARE YOU NOW OR HAVE YOU EVER BEEN AFFILIATED OR ASSOCIATED WITH ANY ORGANIZATION OF THE TYPE DESCRIDED ABOVE AS AN AGENT, OFFICIAL, OR EMPLOYEE?

ARE YOU NOW ASSOCIATING WITH, OR HAVE YOU ASSOCIATED WITH ANY INDIVIDUALS, INCLUDING RELATIVES, WHO YOU KNOW OR HAVE REASON TO BELIEVE. ARE OR

HAVE BEEN MEMBERS OF ANY OF THE ORGANIZATIONS IDENTIFIED ABOVE?

HAVE YOU EVER ENGAGED IN ANY OF THE FOLLOWING ACTIVITIES OF ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE: CONTRIBUTION(S) TO. ATTENDANCE AT OR

DISPOSITION OF EACH CASE.

390

!

NW 88643H BOCYd:512528582U7ag8°7 MENTIOTED HEREIN WHICH MAY BEFITET UMEN YOUR LOYALTY TO THE UNITED STATES OR UPON YOUR SUITABILITY TO PERFORM

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J NO * IF "'YES." GIVE DETAIL!

Iam a conscientious objector. My case is in the courts at the present time.

20. REMARKS

I have been advised by my lawyers that I cannot sign #16 or #17 without

putting myself in jeapardy. Private attorney - Peter Franck

Family attorney - Viocabt, dallinan

David Reed Fromer, born 21 July 1942, in Chicago, Illinois,

In my presence he refused to do.so, in ite entirety.

21.

Д

MYRON K. HAYASHIDA

1/LT, AGC

ITEM #9 EDUCATION (Continued)

1960 - 1961

University of California, Berkeley, CaliPornia

1961 - 1962

City College of San Francisco, San Francisco, Calif

1962

-

1964

1964 -

1965

Francisco, Calif. (Ext.)

1965

Chicago

1966

-=

Present Univeraity of Wisconsin, medison, Wisconsin

DEGREE

No

Yes

No

No

(See U.S. Code, title 18, section 1001)

DATE

RE OF PERSON COMPLETING FORM

Savid Reed Frome

21 Nov.1966

MYRON EN PAYASHYDESS

1515 Clay St.,

oakland,

AGC

and, catff.

SIGNATURE OF WITNESS

THIS SECTION TO BE COMPLETED BY AUTHORITY REQUESTING INVSSTIGATION

Ohn Latay and

BRIEF DESCRIPTION OF DUTY ASSIGNMENT AND DEGREE OF CLASSIFIED MATTER (Rop secret, secres, erc.) TO WHICH APPLICANT WILL REQUIRE ACCESS

RECORD OF PRIOR CLEARANCES

DATE OF CLEARANCE

TYPE OF CLEARANCE

AGENCY THAT COMPLETED INVESTIGATION

REMARKS,

NW 88613 Docld:34528582 Page 5

381

U.S. GOVERNMENT PRINTING OFFICE: 1960 0- 973450

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