Form N-644 - Application For Posthumous Citizenship Page 4
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4Part III. To Be Completed by the Department of Defense, Washington Headquarters Services, Directorate for
Information Operations and Reports
B. Unable to Certify
A. Certification
Based on the information received from the Department
Based on the information received from the Department
of Veterans Affairs concerning the death of the
of Veterans Affairs concerning the death of the
individual named on this form, I am unable to certify
individual named on this form, I certify that the
that the individual died as a result of injury or disease
individual died on:
incurred in or aggravated by service during a period of
hostilities specified by law.
Date (mm/dd/yyyy)
as a result of injury or disease incurred in or aggravated
Signature
Date
by service during a period of hostilities specified by
law.
Signature
Date
Title
Title
NOTE: Space below (Part IV) for use by U.S. Citizenship and Immigration Services Only
Part IV. To be Completed by U.S. Citizenship and Immigration Services
Applicant Authorized Next-of-Kin or Representative
Action Block
Positive Certification Military Service
Positive Certification Service Connected Death
Place of Enlistment Qualifies Under INA Section 329 (a)(1)
Decedent Admitted for Lawful Permanent Residence
Cert. #
Date Mailed
Initial Receipt
Resubmitted
Relocated
Completed
A #
Reg. Mail #
Rec'd
Sent
App'd
Denied
Ret'd
Form N-644 (09/15/11) Y Page 4
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