OMB Number: 2900-0080
Estimated burden: 5 minutes
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals
who must complete this form will average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts
and fill out the form. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing
the burden, may be addressed by calling the Health Benefits Contact Center at 1-877-222-8387.
PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Chapter 23 and 24, Title 38,
United States Code, "Veterans' Benefits", and will be used to initiate, authorize and document funeral arrangements. This information
may be disclosed when consistent with a "routine use" of this system of records 24VA136, "patient Medical Record-VA" as set forth in
the Compilation of Privacy Act Issuances. Disclosure is voluntary. However, failure to furnish the information may result in a delay in
burial. Failure to furnish this information will have no adverse effect on any other benefit to which you or the deceased may be entitled.
(This is a mandatory field.)
SOCIAL SECURITY NUMBER (mandatory)
NAME OF DECEASED (Last, First, Middle Initial)
PLACE OF DEATH
DATE OF DEATH (mm/dd/yyyy)
MILITARY SERVICE VERIFIED
NAME AND ADDRESS OF FUNERAL DIRECTOR TO WHOM REMAINS ARE TO BE RELEASED
PART I - COMPLETE WHEN GOVERNMENT TRANSPORTATION IS REQUESTED
METHOD OF SHIPMENT
AIR FREIGHT/AIR CARGO
U.S. POSTAL SERVICE (CREMATED REMAINS)
NAME, ADDRESS AND RELATIONSHIP OF ESCORT
NAME AND ADDRESS OF CONSIGNEE
PART II - COMPLETE WHEN BURIAL IS DESIRED IN NATIONAL CEMETERY
WILL ATTEND GRAVE-SIDE
GRAVESIDE DESIRED BY
DATE BURIAL DESIRED
The following burial information was explained to me:
a. It is my privilege to select a funeral director of my own choice.
b. Government burial allowance is authorized not to exceed $300.00 plus certain costs of transportation.
c. A plot or interment allowance can be authorized not to exceed $300.00 if burial is not in a National Cemetery.
d. An amount not to exceed $2000.00 is payable as a burial allowance in lieu of the basic $300.00 and plot
allowance if the veteran's death was from a service-connected disability.
e. The burial and plot allowance may not be paid to the extent that they were paid by the deceased's employer or by a State agency or
political subdivision of a State.
I have read and understand the foregoing statements. Arrangements made for disposition of the remains of the deceased are consistent
with my wishes.
SIGNATURE OF NEAREST RELATIVE (or Acting Authority) AND RELATIONSHIP
SIGNATURE OF EMPLOYEE (Witness)
JUNE 2007 (R)