Free VA Form VA40-0241 - State Cemetery Data - Federal

STATE CEMETERY DATA

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

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 (005R1B), 810 Vermont Avenue, NW, Washington, DC 20420. Please do not send applications for benefits to this address.
1. NAME OF CEMETERY 2. MAILING ADDRESS 3. STATUS OF CEMETERY OPEN CLOSED 4. NAME OF DIRECTOR 5. PHONE NO. (Area Code) 6. FAX NO.

7. E-MAIL ADDRESS

8. WEBSITE ADDRESS

9. DATE OPENED

10. DATE DEDICATED

11. DATE OF FIRST BURIAL

12. DATE OF ESTIMATED CLOSURE
A. FULL CASKETED AREA (Month/Year) B. IN-GROUND CREMATED (Month/Year) C. COLUMBARIUM (Month/Year)

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

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

CEMETERY STATISTICS TOTAL

BURIALS
VETERAN 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) 35A. SUB TOTAL (All previously reported burials) 36. TOTAL BURIALS (Date of opening cemetery to current year - both Veteran and Dependents) 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

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

OPERATING EXPENSE STATISTICS
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)

TOTAL

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 APR 2008

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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40-0241

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. (EXAMPLES: Memorials to Veterans of specific wars 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, APR 2008, PAGE 2. OLD STOCK WILL NOT BE USED. Adobe LiveCycle Designer 7.1 NATIONAL

CEMETERY ADMINISTRATION (VACO)

Department of Veterans Affairs Sample Data Sheet
(Instructions) Department of Veterans Affairs Sample Data Sheet Number 1: Provide the full name of the Cemetery Number 2: Provide the complete mailing address for the cemetery. Number 3: Provide open or closed status of the cemetery. Number 4: Provide the current full name of the director of the cemetery. Number 5: Provide a current and up to date phone number including area code. Number 6: Provide a current fax number to the administrator/ cemetery. Number 7: Provide current up to date e-mailing address for the Director of the cemetery. Number 8: Provide the current Web site address of the cemetery. Number 9: Provide date cemetery opened. Number 10: Provide the dedication date that the cemetery opened. Number 11: Provide the date of the first burial either by full casket or cremation. Number 12: Provide the estimated closure date (Month and Year), based on burial rate (see example: How to Estimate Date of Closure. Number 13: Provide the name of State Agency responsible for the cemetery. Acreage Number 14: Provide the total number of acres for the cemetery (included both developed and undeveloped.) Number 15: Provide the current number of acres that is developed. Number 16: Provide the total number of undeveloped Acres. Casketed Gravesites Number 17: Provide the current number of developed casketed gravesites available. Number 18: Provide the estimated number (phased) gravesites in undeveloped acreage. Number 19: Provide the total number of casketed gravesites maintained to date. Cremation Gravesites Number 20: Provide the current number of in-ground cremation gravesites available. Number 21: Provide the estimated number (phased) cremation gravesites in undeveloped acreage. Number 22: Provide the total number of in-ground cremation burials maintained to date. Columbarium Niches Number 23: Provide the current number of columbarium niches available. Number 24: Provide the estimated number (phased) undeveloped columbarium niches. Number 25: Provide the total number of columbarium niches maintained to date. Total Gravesite Usage Number 26: Provide the current number of casketed, cremation and columbarium (adding blocks # 17, # 20 and # 23). Number 27: Provide estimated number for gravesites in undeveloped acreage (adding blocks # 18, # 21 and # 24). Number 28: Provide total number of casketed, in-ground and columbarium maintained to date (adding blocks # 19, # 22 and # 25). Burials Number 29: Provide the number of first casketed burials for the fiscal year - both Veterans and Dependents. Number 30: Provide the number of first in-ground cremated burials for the fiscal year - both Veterans and Dependents. Number 31: Provide the numbers of first columbarium burials for the fiscal year - both Veterans and Dependents. Number 32: Provide the number of second casketed, burials for the fiscal year - both Veterans and Dependents. Number 33: Provide the number of second in-ground cremated burials for the fiscal year - both Veterans and Dependents. Number 34: Provide the number of second columbarium burials for the fiscal year - both Veterans and Dependents Number 35: Provide sub total (adding blocks # 29 through # 34) - both Veterans and Dependents. Number 35A: Provide sub total (All previously reported burials). Number 36: Provide the total number of burials from date of opening the cemetery to the current date ) - both Veterans and Dependents (adding blocks # 35 and # 36).

Number 37: Provide the number of plot allowance payments received for Veteran burials from the Federal government. Number 38: Provide the total amount that the State charges Veterans and Dependents for burials (Do not include plot allowance). Number 39: Provide total number of State employees in the cemetery office. Number 40: Provide total numbers of State personnel in the field other than the cemetery office. Number 41: Provide the overall number of State personnel (adding blocks # 39 and # 40). Number 42 Provide the amount of State funds obligated for Human Resources (Do not include plot allowance). Number 43: Provide the amount of State funds obligated for other operating costs (Do not include plot allowance). Number 44: Provide the total operating expenses (include burial plot allowances if applicable) (adding blocks # 37, # 42 and # 43). Number 45: How is burial plot allowance money used? (continued from page 1). Number 46: What are your eligibility requirements, including residency requirements. Number 47: Briefly describe any facts of special interest or historical significance relating to the cemetery grounds. (Examples: Cemetery is located near an old Civil War battlefield; is part of the State Veteran's Home; the first interment was Jeremiah Johnson, famous frontiersman and guide for the Union soldiers during the mid 1800's). Number 48: List in general description the different types of buildings located on cemetery grounds. Example: Cemetery has a separate maintenance facility with three heated maintenance bays, a separate administration building and a committal shelter. Number 49: List memorials located at the cemetery. Examples: Memorials to veterans of specific wars or campaigns and monuments placed by Veterans Service Organizations. Number 50: Location of cemetery. Please include precise direction from the nearest large airport to cemetery. Number 51 List the names of all Medal of Honor recipients and other notable Veterans buried in your cemetery. Number 52: Describe use of compensated work therapy program (CWT), volunteer, convict or other supplemental labor. Describe use of contractors to accomplish cemetery tasks. How to Estimate Date of Closure For Casketed Burial Area Add block # 29 for both Veterans and Dependents and use that total to divide into block #17. That total should be added to the current reporting year to obtain the estimated closure date. Example: Block # 29 - (Veterans) 4 and (Dependents) 18 = 22 Block # 17 is 400 Divide 22 into 400 = 18 years Add 18 years to the reporting month and year (April 2008) = April 2026 How to Estimate Date of In-Ground Burial Area Example: Block # 30 - (Veterans) 12 and (Dependents) 6 = 18 Block # 20 is 276 Divide 18 into 276 = 15 years Add the 15 years to the reporting month and year (April 2008) = April 2023 How to Estimate Date of Closure for Columbarium Area Example: Block #31 - (Veterans) 22 and (Dependents) 7 = 29 Block #23 is 640 Divide 29 into 640 = 22 years Add the 22 years to the reporting month and year (April 2008) = April 2030