Preregistration Application

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Washington State Veterans Cemetery

Pre-Registration Application

21702 W Espanola Rd • Medical Lake, WA 99022

Phone 509-299-6280 • Fax 509-299-6286

REQUEST TYPE

INTERMENT TYPE

(Check all that apply)

Pre-registration of Veteran

Casket

Cremation:

Columbarium Wall

Pre-registration of Spouse

Undecided

Ground Plot

Scattering Garden

Pre-registration of Dependent Child

Refer to the instructions on page 2.

Please complete an Interment Application for a deceased veteran or spouse.

VETERAN’S INFORMATION

Last Name________________________ First Name______________________ Middle Name___________________

Address________________________ City____________________ State_____________

ZIP_________________

Daytime Phone ( ____ )______________ Cell Phone (___)______________ Email Address_______________________

Gender

Male

Female

Date of Birth______________________ Social Security #__________________________

Marital Status

Never Married

Married

Divorced

Widowed

Legally Separated

SERVICE RECORD

(REQUIREMENT:

A copy of

each

Form DD-214 or equivalent document to verify

dates/rank/character of service

entered here)

Service Branch________________ Rank at discharge___________ Entry Date_________ Separation Date_________

Do you have a service connected disability?_____ Are you registered at a VA Hospital?_____ Which one?___________

CONTACT INFORMATION

(Complete only if someone other than the Veteran should be contacted about this form)

Last Name________________________ First Name______________________ Middle Name___________________

Address________________________ City____________________ State_____________

ZIP_________________

Daytime Phone ( ____ )______________ Cell Phone (___)______________ Email Address_______________________

Relationship to Veteran___________________________________

Use Contact Information for

All Mailed Correspondence

Telephone Contact Only

Both

SPOUSAL/DEPENDENT INFORMATION

(REQUIREMENT:

For Spousal application, a copy of the Marriage License/Certificate is required with

this form. For dependent application, a copy of the birth certificate and documented proof of dependency, if over the age of 18, is required with this form.)

Last Name________________________ First Name______________________ Middle Name___________________

Address________________________ City____________________ State_____________

ZIP_________________

Daytime Phone ( ____ )______________ Cell Phone (___)______________ Email Address_______________________

Gender

Male

Female

Date of Birth______________________ Social Security #__________________________

Marital Status

Single

Married

Divorced