APPLICATION FOR INTERMENT
ARIZONA VETERANS’ MEMORIAL CEMETERY SIERRA VISTA MARANA CAMP NAVAJO
PH: 520-458-7144 PH: 520-638-4869 PH: 928-214-3479
FAX: 520-458-7147 FAX: 520-638-4899 FAX: 928-214-3479
AVMC-SV@AZDVS.GOV AVMC-M@AZDVS.GOV AVMC-CN@AZDVS.GOV
DECEDENT NAME:
_________________________________________________________________
Legal name First middle last suffix
SSN#
____________________
Date of death
___________
Date of birth __________
Gender: M F Marital Status: Married Divorced Widowed Never Married Unknown
Relationship (to Veteran)
_________________
(Spouse and Dependants) A fee is required prior to service.
Place of residence ________________________________________________________________________________
Last known: City, State, Zip code, County of decedent
FUNERAL HOME
: __________________________
Contact
_________________ Phone
______________
Leave blank if family member is making arrangements
LEGAL NEXT OF KIN
____________________________________
Relationship
____________________
DOB:( spouse only) _____________________ SS#(spouse only) _________________________________________
Mailing Address_______________________________________________________________________
City ___________________________________ State __________________ Zip code ______________ Phone _______________
Email address: ___________________________
Is spouse a veteran _____ If yes Does surviving spouse want “a set aside grave?” _____ If yes, provide copy of discharge.
VETERAN
:
__________________________________________________
First middle last suffix
Service#
__________________________
SSN#
_________________________
VA Claim #
_____________________
Military Status: Veteran
Retired Military
Active Duty
Branch of Service: Army Air Force Navy Marine Corps Coast Guard Other _______________
Active Duty Dates: Entry ______________________ Discharge ______________________
Highest Rank______________
Entry ______________________ Discharge ______________________
Highest Rank______________
Display war periods on marker? Yes No If yes, which war period(s) ___________________ ________________________
Committal Shelter Veterans Chapel (Sierra Vista Only) None
Honors _________ Branch of service _____________ (Scheduled by funeral home or family.)
Desired emblem of belief (specify) _______________________
Casket Columbarium Cremation In-ground Cremation (Marana & Camp Navajo only)
Procession: Scheduled services w/ family____ Direct-to-witness ____ Direct (No witness) ____
Requested date and time for service: _____________________________________________________
Are there any previous interments under this veteran’s eligibility? Name________________________ Date of birth _______________
MONUMENTS MARKERS WILL BE ORDERED ON THE DAY OF INTERMENT.
Marker Additional Inscriptions such as “LOVING PARENTS” “IN LOVING MEMORY”: (Two lines- Columbarium niche -13
character spaces per line including spaces. Upright headstones 15 character spaces per line including spaces. Flat marker 2 lines
27 character spaces per line)
PLEASE FORWARD ALL AVAILABLE MILITARY DOCUMENTS
Military documentation (DD214 etc.) and marriage certificate and or death certificate is required to determine eligibility and for awards and
highest rank held. Information on this form will also be used to order the monument. Please insure that spelling and dates are accurate. I have
certified that the above information is correct.
SIGNATURE (NOK): ______________________________________ DATE: ______________________
(Next of Kin or Legal representative)
******************
FOR OFFICE USE ONLY
************************
SCHEDULING
:
Day _______________ Date_______________ Time _______________
Section ___________ Row __________ Site _________ Verified Docs_________ Verified by: _______
Revised
4/1/2016
Columbarium Niche Inscription
Upright headstone inscription
Flat Marker Inscription
928-214-3473
