Interment Application
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1
2Washington State Veterans Cemetery
Interment Application
21702 W Espanola Rd • Medical Lake, WA 99022
Phone 509-299-6280 • Fax 509-299-6286
Refer to the instructions on page 2
DECEDENT’S INFORMATION
Last Name________________________ First Name______________________ Middle Name___________________
Residence at time of death: City____________________ County_____________ State__________
ZIP________
Social Security #______________________ Date of Birth_________________
Date of Death_________________
Gender
Male
Female
Decedent Status
Veteran
Active Duty
Spouse
Dependent Child
Marital Status
Never Married
Married
Divorced
Widowed
Legally Separated
Is the Decedent pre-registered?
No
Yes – Confirmation #______________
*Please provide a photocopy of the certified death certificate when it becomes available.
Is an immediate family member interred in this cemetery? _____ If yes, name and relationship:_____________________
Interment Type
Casket
Cremation:
Columbarium Wall
Ground Plot
Scattering Garden
Have military honors already been provided?
Yes
No
Do you wish to have a military honors service at the cemetery?
No If yes, date desired:____________________
Yes
SERVICE RECORD
(You MUST include a copy of each Form DD-214 or equivalent discharge document which verify the dates and rank entered here)
Veteran’s Name____________________________________ Veteran’s Social Security Number___________________
Service Branch________________ Rank at discharge___________ Entry Date_________ Separation Date_________
Service Branch________________ Rank at discharge___________ Entry Date_________ Separation Date_________
Does veteran have a service connected disability?_____ Which VA Hospital is veteran registered with?______________
****Documentation must match rank and dates in this section****
NEXT-OF-KIN CONTACT INFORMATION
Last Name_____________________________________ First Name________________________________________
Address________________________ City____________________ State____________
ZIP________________
Daytime Phone ( ____ )______________ Cell Phone ( ___ )______________ Email Address_____________________
Relationship to Veteran__________________________
FUNERAL HOME INFORMATION
Name______________________________________________ Contact_____________________________________
Address________________________ City____________________ State____________
ZIP________________
Phone ( ____ )______________ Fax ( ___ )______________ Email Address__________________________________
Certification:
I certify under penalty of perjury under the laws of the state of Washington that the foregoing information provided for the
purpose of determining burial eligibility and providing veterans death benefits is true and correct.
I also certify, to the best of my knowledge, that the decedent has never committed a serious crime, such as murder or other offense that
could have resulted in imprisonment for life, has never been convicted of a serious crime, and has never been convicted of a sexual offense
for which he or she was sentenced to a minimum of life imprisonment.
Signature______________________ Date ________ Printed Name___________________
Updated 3/10/2016
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