B. Information About the Decedent (Continued)
10. Father's Full Name
Living
B.
Living
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
Deceased
11. Mother's Maiden Name
Living
C.
Living
Deceased
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
12. Marital Status at Time of Death
a. Married
c. Widowed
Living
Deceased
D.
b. Divorced
d. Single
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
13. Military Service Serial Number (If different from Social Security #)
Living
Deceased
E.
14. Date Entered Active Duty Service (mm/dd/yyyy)
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
15. Place Entered Active Duty Service (City/State/Country)
24. Total Number of Brothers and Sisters (If none, write "None")
16. Date Released From Active Duty Service (mm/dd/yyyy)
25. Complete the Following for Each Brother and Sister
17. Branch of Service
18. Type of Discharge
A.
Living
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
20. Retired From Military?
19. Military Rank at Time of
Discharge
B.
Living
Deceased
Yes
No
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
21. VA Claim Number (If any)
22. Total Number of Children (If none, write "None")
C.
Living
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
23. Complete the Following for Each Child
A.
D.
Living
Deceased
Living
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
Form N-644 (09/15/11) Y Page 2