APPLICATION FOR INTERMENT

ARIZONA VETERANS’ MEMORIAL CEMETERY SIERRA VISTA � MARANA � CAMP NAVAJO � PH: 520-458-7144 PH: 520-638-4869 PH: FAX: 520-458-7147 FAX: 520-638-4899 FAX: AVMC-SV@AZDVS.GOV AVMC-M@AZDVS.GOV AVMC-CN@AZDVS.GOV

DECEDENT NAME: _________________________________________________________________ Legal name First middle last suffix

SSN# ____________________ Date of death ____ ____ ____ Date of birth ____ ____ ____ Gender: M � F � Marital Status: Married � Divorced � Widowed � Never Married � Unknown � Relationship (to Veteran) _________________ � (Spouse and Dependants) A fee is required prior to service. Place of residence ________________________________________________________________________________ Last known: City, State, Zip code, County of decedent

FUNERAL HOME: __________________________ Contact _________________ Phone ______________ Leave blank if family member is making arrangements LEGAL NEXT OF KIN____________________________________ Relationship ____________________ DOB:( spouse only) _____________________ SS#(spouse only) _________________________________________ Mailing Address_______________________________________________________________________ City ___________________________________ State __________________ Zip code ______________ Phone _______________

Email address: ___________________________

Is spouse a veteran ___ If YES, does surviving spouse want “a set aside grave?”___ If YES, provide copy of discharge for both veterans.

VETERAN: __________________________________________________ First middle last suffix Service# __________________________ SSN# _________________________ VA Claim # _____________________

Military Status: Veteran � Retired Military � Active Duty �

Branch of Service: Army � Air Force � Navy � Marine Corps � Coast Guard � Other _______________

Active Duty Dates: Entry ______________________ Discharge ______________________ Highest Rank______________ Entry ______________________ Discharge ______________________ Highest Rank______________ Display war periods on marker? Yes � No � If yes, which war period(s) ___________________ ________________________

Committal Shelter � Veterans Chapel � (Sierra Vista Only) None � Honors _____ Branch of service _____________ (Scheduled by funeral home or family.) Desired emblem of belief (specify) _______________________ Casket � Columbarium Cremation � In-ground Cremation � (Marana & Camp Navajo only) Procession: Scheduled services w/ family____ Direct-to-witness ____ Direct (No witness) ____ Requested date and time for service: _____________________________________________________ Are there any previous interments under this veteran’s eligibility? Name________________________ Date of birth _______________

MONUMENTS MARKERS WILL BE ORDERED ON THE DAY OF INTERMENT. Marker Additional Inscriptions such as “LOVING PARENTS” “IN LOVING MEMORY”: (Two lines- Columbarium niche -13 character spaces per line including spaces. Upright headstones 15 character spaces per line including spaces.)

PLEASE FORWARD ALL AVAILABLE MILITARY DOCUMENTS Military documentation (DD214 etc.) and marriage certificate and or death certificate is required to determine eligibility and for Awards and Highest Rank Held. Information on this form will also be used to order the monument. Please insure that spelling and dates are accurate. I have certified that the above information is correct.

SIGNATURE (NOK): ______________________________________ DATE: ______________________ (Next of Kin or Legal representative)

******************FOR OFFICE USE ONLY************************ SCHEDULING: Day _______________ Date_______________ Time _______________ Section ___________ Row __________ Site _________ Verified Docs_________ Verified by: _______

Revised 3/1/2016

Columbarium Niche Inscription

Upright headstone inscription Flat Marker Inscription No room for additional inscriptions.

I

Arizona State Veteran Cemetery

Check list

Call in to tentative schedule a service date and time.

Interment application completely filled out and signed.

Attached legible copy military discharge paper work (Generally this will be the

DD214 form, Honorable Separation from Active duty, Veteran Affairs certificate of

service etc.)

If married, attach copy of marriage license, certificate of marriage or death

certificate (This document will automatically verify the spouses eligibility for burial

in a veterans cemetery)

If spouse is a military veteran, copy of their military discharge paper work.

Send application of interment and supporting documents. Call to verify receipt of

documents. (See Application of Interment for contact information.)

Military honors scheduled and verified by funeral home. (In the case of the

funeral home not being involved contact AVMC staff.)

Burial interment US Flag has been giving to the family. If not, contact your local

post office and they will provide a burial flag free of cost.

Interment $____ fee has been paid by check or money order made out to SAVMC

and in memo section write the name of the dependent decedent (Dependent

interments only)

Links: Funeral Directors Resources

http://www.cem.va.gov/cem/funeraldirector.asp

Funeral Directors and NOK are responsible for scheduling of any clergy, honor

guards and bagpipers that will be part of the Committal Service. Cemetery

personnel can assist NOK with contact information for service if requested.

Rev 2/19/2016

MARKER INSCRIPTION WORKSHEET

DECEDENT NAME: First Middle INTIAL Last Suffix (i.e. Jr. Sr. II or III)

Columbarium Wall In-Ground

(Optional) Emblem of Belief (See Emblems of Belief Sheet): ___________

Rank:

Branch of Service:

(Optional) War period (Vietnam, WWII, Korea, Iraq etc.)

(Optional) Major Award(s) (Purple Heart, Bronze Star, Silver

Star, LOM, etc.)

Birth Date: ______/_______/___________

Death Date: ______/_______/___________

___________

___________

___________

OPTIONAL INSCRIPTION: Monument markers will be ordered immediately after the date of interment.

In-Ground: (3 Lines of inscription, 15 characters each include spaces between words.)

Columbarium Wall: (3 lines of inscription, 2 lines of 13 characters each & 1 line of 9 characters

include spaces between words.)

Flat Markers – NO SPACE AVAILABLE FOR OPTIONAL INSCRIPTIONS

Signature of next of kin: ______________________________________________ Date________________________

Print Name of Next of Kin:_____________________________________________ Phone ________________________

***Instructions: Marker Inscription Worksheet must be completed and submitted to cemetery

staff no later than the date of interment. Monument markers will be ordered on the day of

interment.

U.S. Department of Veterans Affairs

National Cemetery Administration

AVAILABLE EMBLEMS OF BELIEF FOR PLACEMENT ON GOVERNMENT HEADSTONES AND MARKERS

(1) LATIN (CHRISTIAN)

CROSS

(2) BUDDHIST (3) JUDAISM(Star of David)

(4) PRESBYTERIANCROSS

(5) RUSSIAN ORTHODOX CROSS

(6) LUTHERAN CROSS

(7) EPISCOPAL CROSS

(8) UNITARIAN (Flaming Chalice)

(9) UNITED METHODIST

(10) AARONICORDER

CHURCH

(11) MORMON(Angel Moroni)

(12) NATIVE AMERICAN CHURCH OF NORTH

AMERICA

(13) SERBIAN ORTHODOX

(14) GREEK CROSS (15) BAHAI(9-Pointed Star)

(16) ATHEIST (17) MUSLIM(Crescent and Star)

(18) HINDU (19) KONKO-KYOFAITH

(20) COMMUNITYOF CHRIST

(21) SUFISMREORIENTED

(22) TENRIKYO CHURCH

(23) SEICHO-NO-IE(24) THE CHURCH

OF WORLD MESSIANITY

(25) UNITED CHURCH OF RELIGIOUS

SCIENCE

(26) CHRISTIAN REFORMED

CHURCH

(27) UNITED MORAVIAN CHURCH

(28) ECKANKAR (29) CHRISTIAN CHURCH

(30) CHRISTIAN & MISSIONARY

ALLIANCE

(31) UNITED CHURCH OF

CHRIST

(32) HUMANIST EMBLEM OF

SPIRIT

(33) PRESBYTERIAN CHURCH (USA)

(34) IZUMO TAISHAKYO

MISSION OF HAWAII

(35) SOKA GAKKAI INTERNATIONAL

(USA)

(36) SIKH (KHANDA)

(37) WICCA (Pentacle)

Page 1 of 2

AVAILABLE EMBLEMS OF BELIEF (CONTINUED)

(38) LUTHERAN CHURCH

MISSOURI SYNOD

(39) NEW APOSTOLIC

(40) SEVENTH DAY

ADVENTIST CHURCH

(41) CELTIC CROSS

(42) ARMENIAN CROSS

(43) FAROHAR (44) MESSIANIC JEWISH

(45) KOHEN HANDS (46) CATHOLIC CELTIC CROSS

(47) FIRST CHURCH OF CHRIST, SCIENTIST

(Cross & Crown)

(48) MEDICINEWHEEL

(49) INFINITY (51) LUTHERROSE

(52) LANDINGEAGLE

(53) FOUR DIRECTIONS

(54) CHURCH OF NAZARENE

(55) HAMMEROF THOR

(56) UNIFICATION CHURCH

(57) SANDHILL CRANE

(58) CHURCH OF GOD

(59) POMEGRANATE

(60) MESSIANIC (61) Shinto

Emblem (98) MUSLIM (Islamic 5-Pointed Star) is not shown due to copyright.

February 2015