Free 48554.pdf - Indiana

APPLICATION FORApplication for Burial BURIAL
State Form 48554 (R4 / 6-05) Indiana Veterans State of Indiana

STATE OF INDIANA INDIANA VETERANS MEMORIAL CEMETERY
1415 NORTH GATE ROAD MADISON, IN 47250 Telephone: 812-273-9220 Fax: 812-273-9221

Is the Veteran Deceased? _________

Veteran's Name
First Middle Last

Address
Street City State Zip

Telephone -

Home:

Work: Date Separated Highest Rank Achieved Type of Discharge Service Number (If Any)

Date Entered Service Branch of Service Social Security # Veteran's Date of Birth

Does veteran receive VA Disability Compensation or Pension? If so ­ VA Claim # Veteran was a resident of (for at least 3 years): Indiana Kentucky
Yes or No

Ohio

Does spouse or eligible dependent wish to be buried with veteran? DOCUMENTATION OF DEPENDENT STATUS MUST BE PROVIDED FOR ELIGIBLE DEPENDENT. Name of Spouse
First Middle Last

Date of Birth Signature of Veteran/Spouse/Next of Kin

Social Security Number Date
The above statements are true and accurate to the best of my knowledge.

Please submit this application and a copy of your Discharge or DD-214 (DO NOT SEND ORIGINAL) to:

INDIANA VETERANS MEMORIAL CEMETERY at above-listed Address, Fax, or E-mail: [email protected]
This agency is requesting the disclosure of your Social Security number in accordance with IC 10-5-25. Disclosure is mandatory, this request can no be processed without it.

-------------------------------------------------------------------------TO BE COMPLETED BY AGENCY ONLY: Approved: Indiana Resident
Signature
Invalid without raised Sate Seal Eligibility criteria are subject to change. More specific information is available upon request.

Approved: Out of State Resident

Disapproved:

Date