Form 40-0241 State Cemetery Data

FORM APPROVED OMB NO. 2900-0559
RESPONDENT BURDEN: 60 MINUTES
FISCAL YEAR ENDING (State) (Include
month and year)

STATE CEMETERY DATA

RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average 60 minutes per response. Statutory
authority for the State Cemetery Grants Program is 38 U.S.C., subchapter 2408. This form is approved under OMB No. 2900-0559, and when form is
completed it provides VA with data regarding the number of interments conducted at states veterans cemeteries each year.
VA may not conduct or sponsor, and you are not required to respond to, this collection of information unless it displays a valid OMB Control Number.
Responding to this information collection is voluntary. Send comments regarding this burden estimate or any other aspects of this collection of
information, including suggestions for reducing this burden, to VA Clearance Officer (005E3), 810 Vermont Avenue, NW, Washington, DC 20420.
Please do not send applications for benefits to this address.
2. MAILING ADDRESS

1. NAME OF CEMETERY

3. STATUS OF CEMETERY
OPEN
CLOSED

5. PHONE NO. (Area Code)

4. NAME OF DIRECTOR

7. E-MAIL ADDRESS

6. FAX NO.

8. WEBSITE ADDRESS

9. DATE ESTABLISHED BY LAW

10. DATE DEDICATED

11. DATE OF FIRST BURIAL

12. DATE OF ESTIMATED CLOSURE

13. NAME OF STATE AGENCY RESPONSIBLE (Organizationally) FOR CEMETERY (For example: Department of Veterans Affairs. Include Director's name, telephone
no., and fax no.)

ACREAGE

CEMETERY STATISTICS
TOTAL

BURIALS
VETERAN

14. TOTAL ACREAGE OF CEMETERY SITE
15. CURRENT DEVELOPED ACREAGE
16. UNDEVELOPED ACREAGE PLANNED FOR FUTURE
GRAVESITES

CASKETED GRAVESITES
17. NUMBER OF CURRENTLY DEVELOPED CASKETED
GRAVESITES AVAILABLE
18. ESTIMATED NUMBER (PHASED) GRAVESITE YIELD IN
UNDEVELOPED ACREAGE
19. TOTAL NUMBER OF CASKETED GRAVESITES
MAINTAINED TO DATE

CREMATION GRAVESITES
20. NUMBER OF IN-GROUND CREMATION GRAVESITES
CURRENTLY AVAILABLE
21. ESTIMATED NUMBER (PHASED) CREMATION GRAVESITES
YIELD IN UNDEVELOPED ACREAGE
22. TOTAL NUMBER OF IN-GROUND CREMATION
GRAVESITES MAINTAINED TO DATE

COLUMBARIUM NICHES
23. NUMBER OF COLUMBARIUM NICHES CURRENTLY
AVAILABLE
24. ESTIMATED NUMBER (PHASED) UNDEVELOPED
COLUMBARIUM NICHES
25. TOTAL NUMBER OF COLUMBARIUM NICHES
MAINTAINED TO DATE

TOTAL GRAVESITE USAGE
26. NUMBER OF CURRENTLY DEVELOPED GRAVESITES OF
ALL TYPES (including columbarium niches) AVAILABLE
27. ESTIMATED NUMBER OF GRAVESITES OF ALL TYPES
IN PHASED DEVELOPMENTS IN UNDEVELOPED ACREAGE
28. TOTAL NUMBER OF GRAVESITES OF ALL TYPES
(including columbarium niches) MAINTAINED TO DATE
VA FORM
DEC 2003 (RS)

40-0241

DEPENDENT

29. NUMBER OF FIRST CASKETED BURIALS
COMPLETED THIS FISCAL YEAR
30. NUMBER OF FIRST IN-GROUND
CREMATED BURIALS THIS FISCAL YEAR
31. NUMBER OF FIRST COLUMBARIUM
INURNMENTS FILLED THIS FISCAL YEAR
32. NUMBER OF SECOND CASKETED BURIALS
COMPLETED THIS FISCAL YEAR
33. NUMBER OF SECOND IN-GROUND
CREMATED BURIALS THIS FISCAL YEAR
34. NUMBER OF SECOND COLUMBARIUM
INURNMENTS FILLED THIS FISCAL YEAR
35. SUB TOTAL (Item numbers 29 through 34)
36. TOTAL BURIALS (Cumulative from opening of
cemetery, including current year)
37. NUMBER OF PLOT ALLOWANCE PAYMENTS
RECEIVED FOR VETERAN BURIALS
38. AMOUNT CHARGED FOR BURIAL;
CASKETED OR CREMATED
(Do not include burial plot allowance)

$

$

39. NUMBER OF STATE PERSONNEL IN THE OFFICE
40. NUMBER OF STATE PERSONNEL IN THE FIELD
41. TOTAL NUMBER OF PERSONNEL

OPERATING EXPENSE STATISTICS

TOTAL

42. STATE FUNDS OBLIGATED FOR HUMAN RESOURCES
(Do not include burial plot allowance)

$

43. STATE FUNDS OBLIGATED FOR OTHER OPERATING
COSTS* (Do not include burial plot allowance)

$

44. TOTAL OPERATING EXPENSE
(Include burial plot allowance if applicable)

$

* In estimating operating costs, take into account equipment replacement
cost, fuel expense, vehicle maintenance and repairs, ground maintenance
supplies (fertilizer, lime, turf replacement, etc.), office supplies,
personnel travel expenses, building maintenance expenses.
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NATIONAL CEMETERY ADMINISTRATION (VACO)

45. HOW IS BURIAL PLOT ALLOWANCE MONEY USED? (CONTINUED FROM PAGE 1)

46. WHAT ARE YOUR ELIGIBILITY REQUIREMENTS, INCLUDING RESIDENCY REQUIREMENTS

47. BRIEFLY DESCRIBE ANY FACTS OF SPECIAL INTEREST OR HISTORICAL SIGNIFICANCE RELATING TO THE CEMETERY (For example, cemetery is located near
an old civil war battlefield or is part of the state veterans home. Our first interment was Jeremiah Johnson, famous frontiersman and guide for Union soldiers during the mid
1800's.)

48. LIST IN GENERAL DESCRIPTION THE DIFFERENT TYPES OF BUILDINGS LOCATED ON CEMETERY GROUNDS (For example, the cemetery has a separate
maintenance facility, with three heated maintenance bays, a separate administrative building, and a chapel.)

49. LIST MEMORIALS LOCATED AT CEMETERY SUCH AS MEMORIALS TO VETERANS OF SPECIFIC WARDS OR CAMPAIGNS AND MONUMENTS PLACED BY
VETERANS SERVICE ORGANIZATIONS

50. LOCATION OF CEMETERY (Please include precise directions from the nearest large airport to cemetery.)

51. LIST THE NAMES OF ALL MEDAL OF HONOR RECIPIENTS AND OTHER NOTABLE VETERANS WHO ARE BURIED IN YOUR CEMETERY

52. DESCRIBE USE OF COMPENSATED WORK THERAPY PROGRAM (CWT), VOLUNTEER, CONVICT OR OTHER SUPPLEMENTAL LABOR. DESCRIBE USE OF
CONTRACTORS TO ACCOMPLISH CEMETERY TASKS.

VA FORM 40-0241, DEC 2003, PAGE 2. OLD STOCK WILL NOT BE USED.

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