Free VA Form VA4962 - Verification of Eligibility for Burial in a National Cemetery - Federal

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

VERIFICATION OF ELIGIBILITY FOR BURIAL IN A NATIONAL CEMETERY

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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 TIME A. M. P. M. SECTION II - DECEDENT LAST NAME - FIRST NAME - MIDDLE NAME OR INITIAL HOME OF RECORD AT TIME OF DEATH (City, County, and State) DATE OF BIRTH (Mo., day, year) DECEDENT SON SECTION III - VETERAN LAST NAME - FIRST NAME - MIDDLE NAME OR INITIAL MILITARY STATUS ON ACTIVE DUTY RETIRED IN RESERVE VETERAN SECTION IV - NEXT OF KIN NAME AND ADDRESS OF NEXT OF KIN RELATIONSHIP WIDOW MOTHER WIDOWER FATHER SON SISTER DAUGHTER BROTHER OTHER (Specify) PERIOD OF SERVICE WWI WWII VIETNAM MARITAL STATUS SERVICE NO. OR SOC. SEC. NO. VA CLAIM NO. OTHER SERVICE DATES (Month, day, year) ENTERED RELEASED DAUGHTER SPOUSE VETERAN DATE OF DEATH (Mo., day, year) NAME AND ADDRESS OF FUNERAL HOME

ACTIVE DUTY DATES (Month, day, year) KOREA ENTERED RELEASED

OTHER (Specify) HIGHEST GRADE, RATE OR RANK AND BRANCH OF SERVICE IN WHICH HELD

DATE OF BIRTH OF WIDOW(ER) (If next of kin) SECTION V - INTERMENT DATA INTERMENT TENTATIVE DATE TIME A. M. ACTUAL DATE P. M. GRAVE POSITION OUTSIDE CONTAINER CL LL LH RH VAULT WOOD METAL GOVT. GRAVELINER DATE(S) OF DEATH
HAS FOREMAN BEEN CREMAINS NOTIFIED OF URN RESERVED GRAVE?

NAME OF MOTHER (If decedent is a child)

GRAVE/NICHE LOCATION TIME A. M. SECTION P. M. CONCRETE NO CONTAINER WAS THERE A PREVIOUS INTERMENT? YES NO NUMBER

DEPTH OF GRAVE 3 FT. 5 FT. 7 FT. 9 FT.

TYPE OF REQUEST RESERVATION REOPENER

PLASTIC/FIBERGLASS

INFORMATION REGARDING PREVIOUSLY INTERRED FAMILY MEMBER(S) NAME(S) OF FAMILY MEMBER(S) DISTANCE (MILES) FROM DECEDENT'S RESIDENCE DATE(S) OF INTERMENT BURIAL PERMIT ON FILE NOT REQUIRED

YES DENOMINATION OF DECEDENT CATHOLIC JEWISH PROTESTANT OTHER (Specify on reverse) TIME RELIGIOUS EMBLEM

NO

OTHER (Specify)

NOT FURNISHED FOR RECORD SIGNED AND RETURNED

SECTION VI - RELIGIOUS DATA COMMITTAL SERVICES DESIRED? YES NO WAS DISCHARGE CERTIFICATE FURNISHED? YES NO NAME AND ADDRESS OF OFFICIATING CLERGY

SECTION VII - ELIGIBILITY VERIFICATION DATE MESSAGE SENT A. M. P. M. ARE PALLBEARERS SERVICES REQUIRED? YES VA FORM APR 1992(R) NO ARE CLERGY SERVICES REQUIRED? YES NO DATE REPLY RECEIVED TIME A. M. P. M. SECTION VIII - MISCELLANEOUS DATA WILL THERE BE MILITARY HONORS? YES NO AdobeFormsDesigner

40-4962

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 REMARKS 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

REVERSE OF VA FORM 40-4962, APR 1992

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