V40-4962 Verification of Eligibility for Burial in a National Cem

Form Approved, OMB No. 2900-0232
Respondent Burden: 15 minutes
Expiration Date: Nov 30, 2023
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," identified as (42VA41), Veterans and Dependents National Cemetery Interment Records-VA and (41VA41), Veterans and Dependents National
Cemetery Gravesite Reservation Records, which have been published in the Federal Register in accordance with the Privacy Act of 1974.
RESPONDENT BURDEN: Accordingly, we may not conduct or sponsor, and you are not required to respond to a collection of information unless it displays a valid
OMB number. Public reporting burden for this collection of information is estimated to average 15 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. Your response is required to
obtain the benefit to which you may be entitled. 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 (005R1B), 810 Vermont Avenue, NW, Washington, DC 20420; and to the Office of Management and Budget, Paperwork
Reduction Act (2900-0232), Washington, DC 20503. Please DO NOT send applications for benefits to this address.
SECTION I - FUNERAL HOME INFORMATION
NAME OF FUNERAL HOME CONTACT

NAME AND ADDRESS OF FUNERAL HOME

DATE CALL RECEIVED

TIME

A.M.
P.M.

SECTION II - DECEDENT
LAST NAME, FIRST NAME, MIDDLE INITIAL

DATE OF BIRTH (MM/DD/YYYY)

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

DECEDENT
SON

DATE OF DEATH (MM/DD/YYYY)

DAUGHTER

SPOUSE

VETERAN

OTHER

SECTION III - VETERAN
LAST NAME, FIRST NAME, MIDDLE INITIAL

MARITAL STATUS

SERVICE NUMBER OR SSN

VA CLAIM NUMBER

SEX (Information will be used for statistical purposes only
MALE

FEMALE

UNSPECIFIED OR ANOTHER GENDER IDENTITY

RACE OR ETHNICITY (Optional. You may select more than one. Information will be used for statistical purposes only.)
AMERICAN INDIAN OR ALASKA NATIVE

ASIAN OR ASIAN AMERICAN

NOT HISPANIC OR LATINO

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

MILITARY STATUS

PERIOD OF SERVICE

ON ACTIVE DUTY

BLACK OR AFRICAN AMERICAN
WHITE

ACTIVE DUTY DATES (MM/DD/YYYY)
RELEASED
ENTERED

WWI

VIETNAM

WWII

OTHER (Specify)

HISPANIC OR LATINO

OTHER SERVICE DATES (MM/DD/YYYY)
ENTERED
RELEASED

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

IN RESERVE
VETERAN

KOREAN

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

RELATIONSHIP

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

SECTION V - INTERMENT DATA
INTERMENT
TENTATIVE DATE

TIME

GRAVE/LOCATION

A.M. ACTUAL DATE

TIME

P.M.
GRAVE POSITION

A.M. SECTION

DEPTH OF GRAVE

NUMBER

P.M.

OUTSIDE CONTAINER

CL

LH

VAULT

WOOD

LL

RH

PLASTIC/FIBERGLASS

METAL

CONCRETE

GOVT. GRAVELINER

NO CONTAINER

WAS THERE A
PREVIOUS INTERMENT?
YES

NO

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

VA FORM
FEB 2023

40-4962

DATE(S) OF DEATH

DATE(S) OF INTERMENT

3 FT.

7 FT.

5 FT.

9 FT.

TYPE OF REQUEST
RESERVATION
REOPENER

DISTANCE (MILES) FROM
DECEDENT'S RESIDENCE

HAS FOREMAN BEEN NOTIFIED
OF RESERVED GRAVE?
YES

BURIAL PERMIT

CREMAINS
OTHER (Specify)

URN

NO

ON FILE

NOT FURNISHED FOR RECORD

NOT REQUIRED

SIGNED AND RETURNED

SECTION VI - RELIGIOUS DATA
DENOMINATION OF DECEDENT

RELIGIOUS EMBLEM

COMMITAL SERVICES NAME AND ADDRESS OF OFFICIATING CLERGY
DESIRED?

OTHER (Specify)

CATHOLIC
JEWISH

YES

PROTESTANT

NO

SECTION VII - ELIGIBILITY VERIFICATION

For persons who served honorably with a special guerrilla unit or irregular forces operating from a base in Laos in support of the Armed Forces during
the period February 28, 1962 and May 7, 1975:
AT TIME OF DEATH:
WAS A CITIZEN OF THE UNITED STATES OR AN ALIEN LAWFULLY
ADMITTED FOR PERMANENT RESIDENCE IN THE U.S.
YES

RESIDED IN UNITED STATES

NO

YES

DIED ON OR AFTER MARCH 23, 2018.

NO

YES

NO

EVIDENCE OF SERVICE
ORIGINAL DOCUMENTATION ISSUED BY A GOVERNMENT AGENCY OFFICIALLY DOCUMENTING THE SERVICE TYPE, LOCATION AND DATES SERVED;
AN AFFIDAVIT OF THE DECEDENT'S SUPERIOR OFFICER ATTESTING TO THE TYPE OF SERVICE, LOCATION, AND DATES SERVED;
TWO AFFIDAVITS FROM OTHER INDIVIDUALS WHO WERE ALSO SERVIING WITH SUCH A SPECIAL GUERILLA UNIT OR IRREGULAR FORCES AND WHO
PERSONALLY KNEW OF THE DECEDENT'S SERVICE; OR
OTHER APPROPRIATE EVIDENCE THAT FACTUALLY DOCUMENTS THE SERVICE, LOCATION AND DATES SERVED.
DATE MESSAGE SENT

TIME

A.M.

DATE REPLY RECEIVED

TIME

A.M.

P.M.

WAS DISCHARGE CERTIFICATE FURNISHED?

P.M.

YES

NO

SECTION VIII - MISCELLANEOUS DATA
ARE PALLBEARERS SERVICES REQUIRED?
YES

ARE CLERGY SERVICES REQUIRED?

NO

YES

WILL THERE BE MILITARY HONORS?

NO

YES

NO

SECTION IX - FOR VA USE ONLY (Initial if required and give date when completed)
INITIALS

DATE

ITEM

VA FORM 40-4962, FEB 2023, Page 2

DATE

ITEM

VA FORM 40-4956, RECORD OF INTERMENT

VA FORM 40-4965, INTERMENT RECORD
FOR NEXT OF KIN

VA FORM 40-4960, TEMPORARY GRAVE
MARKER

VA FORM 40-4982, INTERMENT REGISTER

VA FORM 40-4961, STATEMENT OF MARITAL
STATUS
VA FORM 40-4964, CERTIFICATION OF
MONUMENT DATA
REMARKS

INITIALS

VA FORM 40-4987, AGREEMENT FOR BURIAL
OF CREMATED REMAINS
PROOF OF SERVICE