Va Form 40-4970 - Request For Disinterment

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Form Approved OMB No. 2900-0365

Respondent Burden: 10 minutes

REQUEST FOR DISINTERMENT

PRIVACY ACT NOTICE: The information requested is required to authorize disinterment of remains from a national cemetery under Chapter 24, Title

38, United States Code. The information may be disclosed outside VA as permitted by law, or as stated in the "Notices of Systems of VA Records" which

have been published in the Federal Register in accordance with the Privacy Act of 1974. The disinterment will not be permitted unless the data or a court

order is submitted.

RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average ten minutes per response including the time

for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of

information. This form, when completed in accordance with VA disinterment regulations, will permit VA to authorize disinterment. This form is approved

under OMB No. 2900-0365. VA may not conduct or sponsor, and you are not required to respond to this collection of information unless it displays a valid

OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for

reducing this burden, to VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not

send applications for benefits to this address.

TO:

I hereby request authority for the disinterment of the remains of my

____________________________________, ________________________________________________________________________________________

(Relationship of deceased)

(Name and rank of deceased)

from the ________________________________________________________________ National Cemetery, I understand tht the expenses of the

disinterment cannot be borne by the Government.

This disinterment is requested for the following reason:

On Page 2 of this form is (are) affidavit(s) from all living immediate family members (must include the person who initiated the interment, if living, even

if not a member of the immediate family).

I hereby certify that the individuals shown on Page 2 of this form constitute all the living immediate family members of the deceased as follows:

Surviving spouse (whether or not remarried), all adult children of the decedent, appointed guardian(s) of minor children, the appointed guardian of the

surviving spouse or of the adult child(ren) of the decedent. In the absence of a surviving spouse and children, the decendent's parents will be considered

"immediate family members."

Witness my signature this _______________ day of _________________________________, 20 ___

(Signature)

Sworn to and subscribed before me this __________ day of _____________________________, 20 ___

[SEAL]

(Notary Public)

My commission expires ________________________________________________

VA FORM

40-4970

SUPERSEDES VA FORM 40-4970, MAR 1997,

Page 1 of 2

JUL 2010(RS)