Form N-644 - Application For Posthumous Citizenship Page 3
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4B. Information About the Decedent (Continued)
Certificate of Applicant
E.
Living
Deceased
I certify, under penalty of perjury under the laws of the United States
of America, that the information in Part I is true and correct.
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
Date
Signature
F.
Living
Deceased
Name (Print or Type)
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
Address (Street Number and Name, City/Town, State/Province,
G.
Living
Deceased
Country, Zip-Postal Code
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
Part II. To Be Completed by the Applicable Executive Department
1.
No Active Duty Records Found for This Individual
6. Individual Entered Service Under the Lodge Act?
2.
No Casualty Records Found for This Individual
Yes
No
Unable to Determine
Record of Death Found
3.
Name of Decedent Correctly Shown
7.
(Complete a and b)
4.
Name of Decedent Different in Records
a. Date of Death (mm/dd/yyyy)
(List name shown in records)
b. Death resulted from injury or disease incurred in or
aggravated by active duty service during a period of
Active Duty Service Records Found
5.
military hostilities specified by law?
(Complete a through f)
Yes
No
Unable to Determine
a. Branch of Service
8. Certification
I certify the information given here concerning the
b. Date Entered Active Duty
(Check one or both, as appropriate)
Service
Death
c. Place Entered Active Duty Service (City/State/Country)
of the individual named on this form is correct according to
the records of the (name below).
(Specify Executive Department)
d. Service Number
e. Date Released From Service (mm/dd/yyyy)
Signature
Date
Phone number
Title
f. Honorable Service During a Period of Hostilities
(If no is checked, please provide an explanation)
Yes
No
E-mail address
Form N-644 (09/15/11) Y Page 3
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