Form VA-40-4962 VERIFICATION OF ELIGIBILITY FOR BURIAL IN A NATIONAL CEM

Form Approved; OMB No. 2900-0232
Respondent Burden: 10 minutes
NUMBER

VERIFICATION OF ELIGIBILITY FOR BURIAL
IN A NATIONAL CEMETERY

NOTE: Orally summarize the below Privacy Act notice and provide a copy of this form before collecting information from a person.
PRIVACY ACT NOTICE: The information is solicited under Chapter 24, Title 38, United States Code, and will be used in determining the eligibility of the deceased
for burial in a national cemetery, in making a preliminary determination concerning the monument inscription, and in making burial arrangements. Disclosure is
voluntary. However, if the information is not furnished, burial may be delayed. The information may be disclosed outside the VA as permitted by law, or as stated in the
"Notices of Systems of VA Records" which have been published in the Federal Register in accordance with the Privacy Act of 1974.
RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to VA Clearance Officer (723), 810
Vermont Avenue, NW, Washington, DC 20420; and to the Office of Management and Budget, Paperwork Reduction Project (2900-0232), Washington, DC 20503.
Please do not send applications for benefits to these addresses.
SECTION I - FUNERAL HOME INFORMATION
NAME OF FUNERAL HOME CONTACT
DATE CALL RECEIVED

NAME AND ADDRESS OF FUNERAL HOME

TIME

A. M.
P. M.
SECTION II - DECEDENT

LAST NAME - FIRST NAME - MIDDLE NAME OR INITIAL

DATE OF BIRTH (Mo., day, year)

HOME OF RECORD AT TIME OF DEATH (City, County, and State)

DECEDENT
SON

DATE OF DEATH (Mo., day, year)

SPOUSE

DAUGHTER

VETERAN

SECTION III - VETERAN
LAST NAME - FIRST NAME - MIDDLE NAME OR INITIAL
MILITARY STATUS
ON ACTIVE DUTY

MARITAL STATUS

OTHER SERVICE DATES (Month, day, year)

ACTIVE DUTY DATES (Month, day, year)

PERIOD OF SERVICE
WWI
WWII

RETIRED

SERVICE NO. OR SOC. SEC. NO. VA CLAIM NO.

KOREA

ENTERED

RELEASED

ENTERED

RELEASED

OTHER (Specify)

VIETNAM

IN RESERVE

HIGHEST GRADE, RATE OR RANK AND BRANCH OF SERVICE IN WHICH HELD

VETERAN
SECTION IV - NEXT OF KIN
NAME AND ADDRESS OF NEXT OF KIN

RELATIONSHIP
WIDOW
MOTHER

WIDOWER

SON

DAUGHTER

FATHER

SISTER

BROTHER

DATE OF BIRTH OF WIDOW(ER)
(If next of kin)

OTHER
(Specify)

NAME OF MOTHER (If decedent is a child)

SECTION V - INTERMENT DATA
INTERMENT
TENTATIVE DATE TIME

DEPTH OF GRAVE

GRAVE/NICHE LOCATION

A. M. ACTUAL DATE

TIME

A. M. SECTION

P. M.

NUMBER

P. M.

GRAVE POSITION OUTSIDE CONTAINER
CL

LH

VAULT

WOOD

LL

RH

PLASTIC/FIBERGLASS

WAS THERE A PREVIOUS
INTERMENT?

METAL

CONCRETE

GOVT. GRAVELINER

NO CONTAINER

YES

NO

3 FT.

7 FT.

5 FT.

9 FT.

TYPE OF REQUEST
RESERVATION
REOPENER

INFORMATION REGARDING PREVIOUSLY INTERRED FAMILY MEMBER(S)
NAME(S) OF FAMILY MEMBER(S)

DATE(S) OF DEATH

DATE(S) OF INTERMENT

DISTANCE (MILES) FROM DECEDENT'S RESIDENCE

HAS FOREMAN BEEN CREMAINS
NOTIFIED OF
URN
RESERVED GRAVE?

BURIAL PERMIT
ON FILE

YES

NO

OTHER
(Specify)

NOT FURNISHED FOR RECORD

NOT REQUIRED

SIGNED AND RETURNED

SECTION VI - RELIGIOUS DATA
DENOMINATION OF DECEDENT
CATHOLIC

PROTESTANT
OTHER (Specify on
reverse)

JEWISH

RELIGIOUS
EMBLEM

COMMITTAL SERVICES
DESIRED?
YES

NAME AND ADDRESS OF OFFICIATING CLERGY

NO

SECTION VII - ELIGIBILITY VERIFICATION
DATE MESSAGE SENT

TIME

A. M.

DATE REPLY RECEIVED TIME

P. M.

A. M.
P. M.

WAS DISCHARGE CERTIFICATE FURNISHED?
YES

NO

SECTION VIII - MISCELLANEOUS DATA
ARE PALLBEARERS SERVICES REQUIRED?
YES
VA FORM
APR 1992(R)

NO

40-4962

ARE CLERGY SERVICES REQUIRED?
YES

NO

WILL THERE BE MILITARY HONORS?
YES

NO
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SECTION IX - FOR VA USE ONLY (Initial if required and give date when completed.)
INITIALS

DATE

ITEM
VA FORM 40-4956, RECORD OF INTERMENT
VA FORM 40-4960, TEMPORARY GRAVE
MARKER
VA FORM 40-4961, STATEMENT OF MARITAL
STATUS
VA FORM 40-4964, CERTIFICATION OF
MONUMENT DATA

INITIALS

DATE

ITEM
VA FORM 40-4965, INTERMENT RECORD
FOR NEXT OF KIN
VA FORM 40-4982, INTERMENT REGISTER
VA FORM 40-4987, AGREEMENT FOR BURIAL
OF CREMATED REMAINS
PROOF OF SERVICE

REMARKS

REVERSE OF VA FORM 40-4962, APR 1992

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