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
Arizona State Veteran Cemetery
Check list
Call in to tentative schedule a service date and time.
Interment application completely filled out and signed.
Attached legible copy military discharge paper work (Generally this will be the
DD214 form, Honorable Separation from Active duty, Veteran Affairs certificate of
service etc.)
If married, attach copy of marriage license, certificate of marriage or death
certificate (This document will automatically verify the spouses eligibility for burial
in a veterans cemetery)
If spouse is a military veteran, copy of their military discharge paper work.
Send application of interment and supporting documents. Call to verify receipt of
documents. (See Application of Interment for contact information.)
Military honors scheduled and verified by funeral home. (In the case of the
funeral home not being involved contact AVMC staff.)
Burial interment US Flag has been giving to the family. If not, contact your local
post office and they will provide a burial flag free of cost.
Interment $____ fee has been paid by check or money order made out to AVMC
and in memo section write the name of the dependent decedent (Dependent
interments only)
Links: Funeral Directors Resources
http://www.cem.va.gov/cem/funeraldirector.asp
Funeral Directors and NOK are responsible for scheduling of any clergy, honor
guards and bagpipers that will be part of the Committal Service. Cemetery
personnel can assist NOK with contact information for service if requested.
MARKER INSCRIPTION WORKSHEET
LAST NAME: ________________________________________________________
FIRST NAME & INITIAL: ________________________________________________________
(include suffix, ie. Jr., Sr., II, III)
RANK: __________________________ BRANCH: ______________________________
WAR TIME: ________________________________________________________
BIRTH DATE: __________________________ DEATH DATE: __________________________
Optional Additional Inscription for Columbarium Wall:
Optional Additional Inscription for Upright Granite:
In-ground Cremated Remains Marker
No Optional Additional Inscription available when spouse’s name added
PLEASE NOTE IF DOCUMENTATION PROVIDED FOR MEDAL RECIPEINTS, ONE LINE OF OPTIONAL
INSCRIPTION WOULD NEED TO BE REMOVED FOR ALL OF THE ABOVE MARKER TYPES.
Signature of next of kin: _______________________________________ Date: __________________
EMBLEM OF BELIEF: _____________________________________ MAJOR AWARDS: ____________
(Purple Heart, Bronze Star, Silver Star ect.)
____________
U.S. Department of Veterans Affairs
National Cemetery Administration
AVAILABLE EMBLEMS OF BELIEF FOR PLACEMENT
ON GOVERNMENT HEADSTONES AND MARKERS
(1) LATIN
(CHRISTIAN)
CROSS
(2) BUDDHIST
(3) JUDAISM
(Star of David)
(4) PRESBYTERIAN
CROSS
(5) RUSSIAN
ORTHODOX CROSS
(6) LUTHERAN
CROSS
(7) EPISCOPAL
CROSS
(8) UNITARIAN
(Flaming Chalice)
(9) UNITED
METHODIST
(10) AARONIC
ORDER
CHURCH
(11) MORMON
(Angel Moroni)
(12) NATIVE AMERICAN
CHURCH OF NORTH
AMERICA
(13) SERBIAN
ORTHODOX
(14) GREEK CROSS
(15) BAHAI
(9-Pointed Star)
(16) ATHEIST
(17) MUSLIM
(Crescent and Star)
(18) HINDU
(19) KONKO-KYO
FAITH
(20) COMMUNITY
OF CHRIST
(21) SUFISM
REORIENTED
(22) TENRIKYO
CHURCH
(23) SEICHO-NO-IE
(24) THE CHURCH
OF WORLD
MESSIANITY
(25) UNITED CHURCH
OF RELIGIOUS
SCIENCE
(26) CHRISTIAN
REFORMED
CHURCH
(27) UNITED
MORAVIAN
CHURCH
(28) ECKANKAR
(29) CHRISTIAN
CHURCH
(30) CHRISTIAN
& MISSIONARY
ALLIANCE
(31) UNITED
CHURCH OF
CHRIST
(32) HUMANIST
EMBLEM OF
SPIRIT
(33)
PRESBYTERIAN
CHURCH (USA)
(34) IZUMO
TAISHAKYO
MISSION OF HAWAII
(35) SOKA GAKKAI
INTERNATIONAL
(USA)
(36) SIKH
(KHANDA)
(37) WICCA
(Pentacle)
Page 1 of 2
AVAILABLE EMBLEMS OF BELIEF (CONTINUED)
(38) LUTHERAN
CHURCH
MISSOURI SYNOD
(39) NEW
APOSTOLIC
(40)
SEVENTH DAY
ADVENTIST CHURCH
(41) CELTIC
CROSS
(42) ARMENIAN
CROSS
(43) FAROHAR
(44) MESSIANIC
JEWISH
(45) KOHEN HANDS
(46) CATHOLIC
CELTIC CROSS
(47) FIRST CHURCH OF
CHRIST, SCIENTIST
(Cross & Crown)
(48) MEDICINE
WHEEL
(49) INFINITY (51) LUTHER
ROSE
(52) LANDING
EAGLE
(53) FOUR
DIRECTIONS
(54) CHURCH
OF NAZARENE
(55) HAMMER
OF THOR
(56) UNIFICATION
CHURCH
(57) SANDHILL
CRANE
(58) CHURCH OF
GOD
(59) POMEGRANATE
(60) MESSIANIC (61) Shinto
Emblem (98) MUSLIM (Islamic 5-Pointed Star) is not shown due to copyright.
February 2015