Va Form 40-1330 - Claim For Standard Government Headstone Or Marker

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Form, approved, OMB No. 2900-0222
Expiration Date: Feb 18, 2017
Respondent Burden: 15 minutes
IMPORTANT:
Please read the General Information Sheet before completing this form. Type or print
Department of Veterans Affairs
clearly all information except for signatures.
Illegible printing could result in an incorrect headstone or
marker or delivery. Blocks outlined in bold are optional inscription items. Unless indicated otherwise all
1. FOR VA USE ONLY
MILITARY DISCHARGE DOCUMENTS OR RELATED
other blocks must be completed.
SERVICE INFORMATION IS REQUIRED.
2. NAME OF DECEASED TO BE INSCRIBED ON HEADSTONE OR MARKER (NO NICKNAMES OR TITLES PERMITTED)
3. GRAVE IS:
FIRST (Or Initial)
MIDDLE (Or Initial)
LAST
SUFFIX
CURENTLY MARKED
(with privately purchased marker)
Sam
Cafferty
X
NOT MARKED
VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
4. VETERAN''S SOCIAL SECURITY NO. OR SERVICE NO.
PERIODS OF ACTIVE MILITARY DUTY (For additional space use Block 27)
6A. DATE(S) ENTERED
6B. DATE(S) SEPARATED
SSN:
OR SVC. NO.:
MONTH
DAY
YEAR
MONTH
DAY
YEAR
5A. DATE OF BIRTH
5B. DATE OF DEATH
MONTH
DAY
YEAR
MONTH
DAY
YEAR
03
03
1933
08
09
2012
8. BRANCH OF SERVICE (Check box(es) - must be consistent with rank (Box 7))
7. HIGHEST RANK ATTAINED (No pay grades)
MERCHANT
MARINE
COAST
ARMY
OTHER
ARMY
NAVY
CORPS
GUARD
AIR FORCE
AIR FORCES
MARINE
(Specify)
9. VALOR OR PURPLE HEART AWARD(S) (Documentation must be provided)
10. WAR SERVICE (Check applicable box(es))
BRONZE
OTHER
MEDAL OF
DST SVC
NAVY
AIR FORCE
SILVER
PURPLE
OTHER
WORLD
PERSIAN
STAR
(Specify)
KOREA
VIETNAM
(Specify)
HONOR
CROSS
CROSS
CROSS
STAR
MEDAL
WAR II
GULF
HEART
11. TYPE OF HEADSTONE OR MARKER REQUESTED (Check one)
12. DESIRED EMBLEM OF BELIEF
FLAT
FLAT
UPRIGHT
FLAT
BRONZE
UPRIGHT
EMBLEM NUMBER
BRONZE
GRANITE
MARBLE
MARBLE
NICHE
GRANITE
NONE
(Specify)(See reverse of ths form for available emblems)
B
G
U
F
Z
V
13A. NAME AND MAILING ADDRESS OF APPLICANT
(222) 222-2222
13B. DAYTIME PHONE NO. OF APPLICANT
(No., street, city, State, andZip Code)
Vickie Cafferty
14. E-MAIL ADDRESS (Optional)
2222 Wire Way
15. FAX NO. (Optional)
Funkytown, PA 222222
16. ARE YOU:
AUTHORIZED REPRESENTATIVE ON BEHALF
AUTHORIZED REPRESENTATIVE ON BEHALF OF
NEXT OF KIN (Specify relationship)
OF DECEDENT (Include Written Authorization)
NEXT OF KIN (Include Written Authorization)
CERTIFICATION: By signing below I certify the headstone or marker will be installed in the cemetery listed in block 21 at no expense to the
Government and all information entered on this form is true and correct to the best of my knowledge. I also certify, to the best of my knowledge, that
the decedent has never committed a serious crime, such as murder or other offense that could have resulted in imprisonment for life, has never been
convicted of a serious crime, and has never been convicted of a sexual offense for which he or she was sentenced to a minimum of life
imprisonment.
PENALTY: The law provides severe penalties, which include fine or imprisonment, or both, for the willful submission of any statement or evidence
of a material fact, knowing it to be false or for the fraudulent acceptance of any benefit to which you are not entitled.
17. SIGNATURE OF APPLICANT
18. DATE (MM/DD/YYYY)
08/25/16
19. NAME AND DELIVERY ADDRESS OF BUSINESS (CONSIGNEE) THAT WILL
20. DAYTIME TELEPHONE NO.
21. NAME AND LOCATION OF CEMETERY WHERE
(Include Area Code)
ACCEPT PREPAID DELIVERY (No. and street, city, State and ZIP Code); P.O. Box
GRAVE IS LOCATED (No., Street, City, State and
ZIP Code)
IS NOT ACCEPTABLE
CERTIFICATION: By signing below I agree to accept prepaid delivery of the headstone or marker.
22. PRINTED NAME AND SIGNATURE OF PERSON REPRESENTING BUSINESS (CONSIGNEE) NAMED IN BLOCK 19
23. DATE (MM/DD/YYYY)
08/25/16
CERTIFICATION: By signing below I certify the type of headstone or marker checked in block 11 is permitted in the cemetery named in block 21.
25. DAYTIME PHONE NO.
24. PRINTED NAME AND SIGNATURE OF CEMETERY OR OTHER RESPONSIBLE
26. DATE (MM/DD/YYYY)
(Include Area Code
OFFICIAL
27. REMARKS (Additional inscription space will vary in size according to the type of marker)
28. CHECK BOX BELOW IF REMAINS ARE NOT BURIED AND EXPLAIN IN BLOCK 27
29. SECTION/GRAVE NO. (State Cemetery Only)
(e.g., burried at sea, remains scattered, etc.)
REMAINS NOT BURIED
VA FORM
40-1330
CLAIM FOR STANDARD GOVERNMENT HEADSTONE OR MARKER
FEB 2014
ALL PREVIOUS VERSIONS OF THIS FORM WILL BE OBSOLETE ON OCTOBER 1, 2014

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