Dd Form 2063 - Record Of Preparation And Disposition Of Remains

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OMB No. 0704-0231
RECORD OF PREPARATION AND DISPOSITION OF REMAINS
OMB approval expires
(Within CONUS)
Jan 31, 2014
The public reporting burden for this collection of information is estimated to average 30 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. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0231). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply
with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE ADDRESS IN ITEM 1.
1. TO (Recipients and address authorized distribution)
2. NAME OF AUTHORITY ARRANGING PREPARATION
3. RECEIVING FUNERAL HOME
a. NAME
b. ADDRESS (Street, City, State and ZIP Code)
4. REMAINS OF
a. NAME (Last, First, Middle Initial)
b. GRADE/RANK
c. SSN
d. BRANCH OF SERVICE
e. ORGANIZATION
f. NAME OF PERSON DIRECTING DISPOSITION
g. ADDRESS OF PERSON DIRECTING DISPOSITION
OF REMAINS
h. RELATIONSHIP OF PERSON DIRECTING DISPOSITION
i. DATE OF DEATH (YYYYMMDD)
j. HOUR OF DEATH
k. CAUSE OF DEATH
l. PLACE OF DEATH
MORTUARY DATA
5
a. REMAINS RECEIVED AT MORTUARY
b. EMBALMING STARTED
c. EMBALMING COMPLETED
(1) DATE (YYYYMMDD)
(2) HOUR
(1) DATE (YYYYMMDD)
(2) HOUR
(1) DATE (YYYYMMDD)
(2) HOUR
e. RECOMMEND FAMILY BE ALLOWED TO
d. TYPE OF CASE
VIEW REMAINS (X one)
OTHER (Specify)
NOT AUTOPSIED
MUTILATED
NON-VIEWABLE
AUTOPSIED
VIEWABLE
VIEWING QUESTIONABLE
YES
NO
f. ARTERIES INJECTED
R
L
R
L
g. VEINS DRAINED
R
L
h. FLUID DILUTIONS
(1) CAROTID
(5) ILIAC
(1) JUGULAR
(1) INDEX OF CONCENTRATED ARTERIAL FLUID
(2) SUBCLAVIAN
(6) FEMORAL
(2) AXILLARY
(2) INDEX OF CONCENTRATED CAVITY FLUID
(3) AXILLARY
(7) RADIAL
(3) ILIAC
(3) PREINJECTION FLUID
Oz.
Gal.
(4) BRACHIAL
(8) ULNAR
(4) FEMORAL
(4) 1ST INJECTION
Oz.
Gal.
i. HARDENING COMPOUND USED (Lbs.)
j. DRAINAGE
(5) 2ND INJECTION
Oz.
Gal.
CONTINUOUS
RESTRICTED
(6) 3RD INJECTION
Oz.
Gal.
INTERMITTENT
(7) 4TH INJECTION
Oz.
Gal.
6. AREAS HYPODERMICALLY EMBALMED
k. TOTAL CONCENTRATED FLUID USED (Oz.)
(1) ARTERIAL
(4) HUMECTANT
7. PARTS RECEIVING POOR CIRCULATION AND HOW TREATED
(5) OTHER
(2) CAVITY
(3) PREINJECTION
8. RESTORATION TREATMENT
(Describe, state reason if features not restored)
9. EXPLAIN ANY DELAY IN RECOVERY, AUTOPSY, PREPARATION, INSPECTION OR SHIPMENT OF REMAINS
EXPENSE DATA
10a. EXPENSE AT PLACE OF DEATH: PREPARATION SERVICE OBTAINED BY (X one)
ANNUAL CONTRACT
ONE-TIME CONTRACT
$
(1) RECOVERY OF REMAINS
(7) TRANSPORTATION OF REMAINS
$
(a) SHIPPING
(2) METAL CASKET
$
$
0.00
(To include preparation of
(b) AIR
$
$
remains, hearse and related
STANDARD
(c) HEARSE
services)
$
OVERSIZED
(d) RAIL
(3) NAME OF CASKET MANUFACTURER
(8) TRANSPORTATION OF ESCORT
$
(a) AIR
$
$
0.00
(b) RAIL
$
$
(4) CLOTHING
(c) BUS
$
$
(5) FLAG
(d) PER DIEM
$
$
0.00
(6) CREMATION
(9) COMPLETE TOTAL
DD FORM 2063, MAR 2011
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional 8.0

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