Va Form 40-1330 - Application For Headstone Or Marker
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1
2Form approved, OMB No. 2900-0222
Respondent Burden: 15 minutes
Department of Veterans Affairs
IMPORTANT: Please read the General Information Sheet before completing this form. Type or print
clearly all information except for signatures. Illegible printing could result in an incorrect headstone or
1. TYPE OF REQUEST
marker or delivery. Blocks outlined in bold are optional inscription items. Unless indicated otherwise
INITIAL (First time) REQUEST
all other blocks must be completed. MILITARY DISCHARGE DOCUMENTS OR RELATED
SECOND REQUEST
SERVICE INFORMATION IS REQUIRED.
CORRECTED APPLICATION OR REPLACEMENT
2. NAME OF DECEASED TO BE INSCRIBED ON HEADSTONE OR MARKER (NO NICKNAMES OR TITLES PERMITTED)
3. GRAVE IS:
FIRST (Or Initial)
MIDDLE (Or Initial)
LAST
SUFFIX
CURRENTLY MARKED
(with privately purchased marker)
.
NOT MARKED
VETERAN’S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
PERIODS OF ACTIVE MILITARY DUTY (For additional space use Block 27)
4. VETERAN’S SOCIAL SECURITY NO. OR SERVICE NO. (Failure to complete
will delay processing.)
6A. DATE(S) ENTERED
6B. DATE(S) SEPARATED
MONTH
DAY
YEAR
MONTH
DAY
YEAR
5A. DATE OF BIRTH
5B. DATE OF DEATH
MONTH
DAY
MONTH
DAY
YEAR
YEAR
8. BRANCH OF SERVICE (Check applicable box(es) - must be consistent with rank in Box7)
7. HIGHEST RANK ATTAINED (No pay grades)
MARINE
COAST
ARMY
MERCHANT
OTHER
ARMY
NAVY
CORPS
GUARD
AIR FORCE
AIR FORCES
MARINE
(Specify)
9. VALOR OR PURPLE HEART AWARD(S) (Documentation must be provided)
10. WAR SERVICE (Check applicable box(es))
BRONZE
MEDAL OF
DST SVC
NAVY
AIR FORCE
SILVER
PURPLE
OTHER
WORLD
PERSIAN
OTHER
STAR
(Specify)
(Specify)
MEDAL
KOREA
VIETNAM
HONOR
CROSS
CROSS
CROSS
STAR
HEART
WAR II
GULF
Tin Star
11. TYPE OF HEADSTONE OR MARKER REQUESTED (Check one)
12. DESIRED EMBLEM OF BELIEF
FLAT
FLAT
UPRIGHT
FLAT
BRONZE
UPRIGHT
EMBLEM NUMBER
BRONZE
GRANITE
MARBLE
MARBLE
NICHE
GRANITE
NONE
(Specify) (See reverse side of this form for authorized emblems)
B
G
U
F
Z
V
__________
13a. NAME AND MAILING ADDRESS (No., Street, City, State, and
13B. DAYTIME PHONE NO. OF PERSON TO CONTACT
16. ARE YOU:
VETERANS
ZIP Code) OF PERSON TO CONTACT FOR ADDITIONAL
FOR ADDITIONAL INFORMATION
SERVICE
NEXT OF KIN
INFORMATION
OFFICER
14. E-MAIL ADDRESS (Optional)
CEMETERY
FUNERAL
OFFICIAL
DIRECTOR
15. FAX NO. (Optional)
OTHER (Specify)
CERTIFICATION: By signing below I certify the headstone or marker will be installed in the cemetery listed in block 21 at no expense to the
Government and all information entered on this form is true and correct to the best of my knowledge.
17. SIGNATURE OF PERSON WHOSE NAME APPEARS IN BLOCK 13A
18. DATE (MM/DD/YYYY)
19. NAME AND DELIVERY ADDRESS OF BUSINESS (CONSIGNEE) THAT WILL
20. DAYTIME PHONE NO.
21. NAME AND ADDRESS OF CEMETERY WHERE
ACCEPT PREPAID DELIVERY (No., Street, City, State and ZIP Code); P.O. BOX
(Include Area Code)
GRAVE IS LOCATED (No., Street, City, State and
IS NOT ACCEPTABLE
ZIP Code)
CERTIFICATION: By signing below I agree to accept prepaid delivery of the headstone or marker.
22. PRINTED NAME AND SIGNATURE OF PERSON REPRESENTING BUSINESS (CONSIGNEE) NAMED IN BLOCK 19
23. DATE (MM/DD/YYYY)
CERTIFICATION: By signing below I certify the type of headstone or marker checked in block 11 is permitted in the cemetery named in block 21.
24. PRINTED NAME AND SIGNATURE OF CEMETERY OR OTHER RESPONSIBLE
25. DAYTIME PHONE NO. (Include Area Code)
26. DATE (MM/DD/YYYY)
OFFICIAL
27. REMARKS (Optional inscription space will vary in size according to the type of marker)
28. CHECK BOX BELOW IF REMAINS ARE
NOT BURIED AND EXPLAIN IN
BLOCK 27 (e.g., lost at sea, remains
scattered, etc.)
REMAINS NOT BURIED
REMAINS NOT BURIED
STATE VETERANS’ CEMETERY AND GRAVE LOCATION (Cemetery Use Only)
29. ID CODE
30. SECTION
31. GRAVE NO.
VA FORM
40-1330
APPLICATION FOR STANDARD GOVERNMENT HEADSTONE OR MARKER
AUG 2005 (RS)
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