Burial Allowance Application - Saginaw County Soldiers & Sailors Commission Page 2
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1
2AFFIDAVIT OF MORTICIAN
STATE OF MICHIGAN )
)ss
COUNTY OF SAGINAW)
_______________________, being duly sworn, deposes and says that he/she is _____________________
(name of mortician)
(owner or partner)
of ____________________________ that he/she or his/her employees provided funeral and burial services
(name of funeral home)
for the within named Deceased. And that the attached itemized statement of expenses and services is correct.
The named Deceased Did
Did Not
have any type of Pre-payment Funeral Agreement.
If yes, amount of prepaid agreement $_________________
There is an unpaid balance of $___________________
Subscribed and sworn to before me this
__________Day of _______________
_______________________________
___________________________________
Signature of Mortician
Notary Public, Saginaw County, Michigan
My Commission expires ______________
ASSIGNMENT OF BURIAL ALLOWANCE PAYMENT
In consideration of the performance of services in and about the funeral and burial of:
___________________________________________________,
(name of deceased)
Expenses there of having been charged to me, I do hereby assign and transfer to:
_______________________________________________________________ all of my right and interest in
(name & address of mortician/mortuary)
the claim for Saginaw County Burial Allowance under Section 35.801, CL 1948, as amended by Act 235 of 1959.
Witnesses:
____________________________
_______________________________
Signature of Person incurring Funeral Expenses
____________________________
REPORT OF SOLDIERS RELIEF COMMISSION
To the Saginaw County Board of Commissioners:
I, ________________________, a member of the Saginaw County Soldiers & Sailors Relief Commission, have
investigated the within claim pursuant to Section 35.801, CL 1948 et seq, as amended by Act 235 of 1959, being
an act to provide for payment by counties of certain funeral expenses of ex-service persons or their spouses or
widows/widowers, and I herewith submit the following report:
The facts and particulars set forth in the above application in the case of _____________________ are, to the best
of my knowledge and belief, a true statement of the material facts in this case, except as noted under REMARKS
hereinafter.
I further report that, to the best of my knowledge, the deceased:
Left no dependent(s) and did not leave sufficient estate to meet all lawful claims, including burial expenses.
Left the surviving dependent(s) listed upon the within application and did not leave an estate, including real
and personal property, exceeding the sum of $40,000.00 over and above all encumbrances.
REMARKS:
Dated this ______ day of_________, 20
.
______________________________
Signature of Soldiers Relief Commission
of Saginaw, County, Michigan
AMOUNT APPROVED FOR PAYMENT: $____________
Revised 11/09 (all other forms obsolete)
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