APPLICATION FOR INTERMENT

ARIZONA VETERANS’ MEMORIAL CEMETERY SIERRA VISTA � MARANA � CAMP NAVAJO � PH: 520-458-7144 PH: 520-638-4869 PH: 928-214-3479 FAX: 520-458-7147 FAX: 520-638-4899 FAX: 928-214-3479 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.

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. Flat marker 2 lines 27 character spaces per line)

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 and the decedent/veteran has not committed a capital crime or serious sex offense, under Federal or State law.

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

Columbarium Niche Inscription Upright headstone inscription Flat Marker Inscription

928-214-3473

11/17/20173/9/2018

Fee Validation Code

9/23/2019

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 AVMC

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.

STATE CEMETERY

Interment Statement for Divided Cremated Remains

INSTRUCTIONS: CEMETERY STAFF INSERT CEMETERY AND DECEDENT'S NAME

NEXT OF KIN ( OR AUTHORIZED REPRESENTATIVE) SIGN AND DATE

I understand the Arizona State Veterans' Cemetery is accepting all the

cremated remains of ____________________for interment.Decedent's Full Name

I further understand that if there were remains divided before placement none

of the retained/removed cremains will be added later to the gravesite or original

container being interred at this state cemetery.

By placing a portion of the above named decedent's cremated remains in this

state veterans' cemetery, I understand that any remaining cremated remains

are not eligible for interment or memorialization in any other VA National

Cemetery or state cemetery.

In addition, I understand that no matter the future disposition of the remaining

cremated remains, i.e., interment in a private cemetery or scattering, my loved

one is not authorized to receive an additional Government-furnished headstone,

marker or niche cover.

Next of Kin Signature Date

Relationship to Decedent: -----------..,....,...---,.,....,....,-,-------,--

For Cemetery Use Only

MARKER INSCRIPTION WORKSHEET

LAST NAME: ________________________________________________________

FIRST NAME & INITIAL: ________________________________________________________ (include suffix, ie. Jr., Sr., II, III)

RANK: __________________________ BRANCH: ______________________________

WAR TIME: ________________________________________________________

BIRTH DATE: __________________________ DEATH DATE: __________________________

Optional Additional Inscription for Columbarium Wall :

Optional Additional Inscription for Upright Granite:

In-ground Cremated Remains Marker

No Optional Additional Inscription available when spouse’s name added

PLEASE NOTE IF DOCUMENTATION PROVIDED FOR MEDAL RECIPEINTS, ONE LINE OF OPTIONAL INSCRIPTION WOULD NEED TO BE REMOVED FOR ALL OF THE ABOVE MARKER TYPES.

Signature of next of kin: _______________________________________ Date: __________________

EMBLEM OF BELIEF: _____________________________________ MAJOR AWARDS: ____________(Purple Heart, Bronze Star, Silver Star ect.)

____________

U.S. Department of Veterans Affairs

National Cemetery Administration

AVAILABLE EMBLEMS OF BELIEF FOR PLACEMENT ON GOVERNMENT HEADSTONES AND MARKERS

(1) LATIN (CHRISTIAN)

CROSS

(4) PRESBYTERIANCROSS

(2) BUDDHIST (3) JUDAISM(STAR OF DAVID)

(5) RUSSIAN ORTHODOX CROSS

(6) LUTHERAN CROSS

(7) EPISCOPAL CROSS

(10) AARONICORDER

CHURCH

(8) UNITARIAN (FLAMING CHALICE)

(9) UNITED METHODIST

(11) MORMON(ANGEL MORONI)

(12) NATIVE AMERICANCHURCH OF NORTH

AMERICA

(13) SERBIAN ORTHODOX

(16) ATHEIST

(14) GREEK CROSS (15) BAHAI(9-POINTED STAR)

(17) MUSLIM(CRESCENT AND STAR)

(18) HINDU (19) KONKO-KYOFAITH

(22) TENRIKYO CHURCH

(20) COMMUNITYOF CHRIST

(21) SUFISMREORIENTED

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

MESSIANITY

(34) IZUMO TAISHAKYO

MISSION OF HAWAII

(35) SOKA GAKKAI INTERNATIONAL

(USA)

(32) HUMANIST EMBLEM OF

SPIRIT

(33) PRESBYTERIAN CHURCH (USA)

(31) UNITED CHURCH OF

CHRIST

(28) ECKANKAR (29) CHRISTIAN CHURCH

(26) CHRISTIAN REFORMED

CHURCH

(27) UNITED MORAVIAN CHURCH

(25) UNITED CHURCH OF RELIGIOUS

SCIENCE

(30) CHRISTIAN & MISSIONARY

ALLIANCE

(37) WICCA (PENTACLE)

(36) SIKH (KHANDA)

Page 1 of 2

(46) CATHOLIC CELTIC CROSS

(45) KOHEN HANDS (47) FIRST CHURCH OF CHRIST, SCIENTIST (CROSS & CROWN)

(48) MEDICINEWHEEL

(49) INFINITY (51) LUTHERROSE

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

AVAILABLE EMBLEMS OF BELIEF (CONTINUED)

(52) LANDINGEAGLE

(53) FOUR DIRECTIONS

(54) CHURCH OF NAZARENE

Updated February 2019

(55) HAMMEROF THOR

(56) UNIFICATIONCHURCH

(57) SANDHILL CRANE

(58) CHURCH OF GOD

(59) POMEGRANATE

(60) MESSIANIC

(41) CELTIC CROSS

(42) ARMENIAN CROSS

(39) NEW APOSTOLIC

(40) SEVENTH DAY ADVENTIST CHURCH

(38) LUTHERAN CHURCH

MISSOURI SYNOD

(44) MESSIANICJEWISH

(43) FAROHAR

(61) SHINTO (62) SACRED HEART (63) AFRICANANCESTRAL

TRADITIONALIST

(65) DRUID (AWEN)(64) MALTESE CROSS

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(67) POLISH NATIONAL CATHOLIC CHURCH

(66) WISCONSINEVANGELICAL LUTHERAN

SYNOD(68) GUARDIAN ANGEL (69) HEART (70) SHEPHERD AND

FLAG

(74) FAITH AND PRAYER

(71) AFRICAN METHODIST EPISCOPAL (AME)

(72) EVANGELICAL LUTHERAN CHURCH

(73) UNIVERSALIST CROSS

ADDITIONAL INSCRIPTION EXAMPLES

BELOVED HUSBAND AND FATHER TWO HEARTS REJOINED LOVED HUSBAND DAD & GRANPA TIL WE MEET AGAIN (GRAMPA or GRAMPY or PAPA or OPA or UPPA) HUSBAND FATHER GRANDFATHER HUSBAND DAD GRAND & GREAT HUSBAND DAO BROTHER & SON HUSBAND & DAO NOT FORGOTTEN BELOVED HUSBAND & SOUL MATE WONDERFUL LOVING HUSBAND LOVING DAD ETERNAL spouse

FATHER GRANPA GREAT GRANPA GREATEST DAD IN THE WORLD BELOVED MOTHER GRANDMOTHER (GRANDMA or GRAMMY or NANA or NANNY or OMA) GOD GRANT ME SERENITY CARING LOVING MAN & FATHER A GREAT MAN & FATHER A MAN OF FAITH ALIVE IN CHRIST A MEMORABLE JOURNeY A SON NEVER FORGEiS STORY TO TELL HAND TO GIVE A WONDERFUL FRIEND ABIDE IN ME AND I IN YOU ACTA NON VERBA- IN PEACE & WAR (ACTION NOT WORDS) ADVOCATE FOR THE ABUSED GO HAND IN HAND WITH GOD ALWAYS A GENTLEMAN ALWAYS A HELPING HAND ALWAYS CHERISHED ALWAYS DID THE RIGHT THING AN ANGEL SENT TO ALL AWAITING RESURRECTION BECAME A MARINE AT AGE 17 BEST FRIEND & LOVING FATHER BLUE ANGEL #5 GONE HOME CELEBRATING IN ETERNITY COMPLETED LIFES JOURNEY CONDUCTED LIFE HIS OWN WAY DEDICATED TO GOD & FAMILY GOD BE WITH YOU UNTIL WE MEET FAITHFUL MISSIONARY GOD BLESS AMERICA

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GRACIOUS LADY IN PINK GREAT - OUTDOORSMAN HE LIVED LIFE ON HIS TERMS HE NEVER MET A STRANGER HERO TO FAMILY & COUNTRY HIS IRISH SPIRIT LIVES ON HIS LITTLE BRIDE HONEST & PATRIOTIC HOW GREAT THOU ART I COR 13 IS HOW HE LIVED IN LOVING REMEMBRANCE IN THE ARMS OF JESUS & MARY KIND & GENTLE SPIRIT WINGS OF FREEDOM LOVE & SPIRIT SHINE THROUGH LOVE LAUGHTER FRIEND TO ALL VICTORIOUS IN LIFE LOVED BEYOND DESCRIPTION LOVED UNCONOITIONALL Y USAF CIVILIAN AWARD FOR VALOR LOVED SO MUCH FINALLY HOME MISSED BEYOND BELIEF. IN OUR HEARTS FOREVER MY SPIRIT LNES FOREVER NEVER GIVE UP ON LIFE NOW IN HIS SERVICE NURSE CARING IN HEAVEN OUR ANGEL FROM GOD RETURNED PEACEFULLY HONORING GOD PEARL HARBOR SURVIVOR REMEMBERED WITH LOVE REST WITH GOO BELOVED BELOVED SYMPHONY OF LIFE ROLL WITH THE PUNCHES SERVANT OF GOD PROV 31:10-31 SERVANTS HEART LOVED BY ALL SERVED IN LUZON & NEW GUINEA SPECIAL KIND & GENEROUS MAN STRONG LOVING GIVER OF LIFE WIND BENEATH OUR WINGS THE LORD IS MY SHEPHERD THINK BEYOND THE MOMENT TO HONOR WITH DIGNITY

·All exceptions at directors discretion

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