(Marana & Camp Navajo only)
ARIZONA VETERANS’ MEMORIAL CEMETERY
SIERRA VISTA
PH:
FAX: 520-843-2329
AVMC-SV@AZDVS.GOV
CAMP NAVAJO
PH:
928-214-3474
FAX: 928- 752-2775
AVMC-CN@AZDVS.GOV
DECEDENT NAME: __________________ ___________________ ___________________________ ____
(Legal name) First last suffix
middle
Date of birth __________
Widowed
SSN# ____________________ Date of death ___________
Gender: M F Marital Status: Married Divorced
Never Married Unknown
Relationship Veteran (Non-Veteran Spouse or Eligible Dependents) A fee is required prior to service.
Place of residence: ________________________________________________________________________________
Place of residence at the time of death: City, State, Zip code, County of decedent
FUNERAL HOME (If applicable): __________________________ Contact _________________ Phone ______________
LEGAL NEXT OF KIN __________________________________________ Relationship _________________________
DOB:( spouse only) _____________________ SSN# (spouse only) __________________________________________
Mailing Address_________________________________________________________________________
City ___________________________________ State __________________
Zip code ______________
Phone _____________
Email address: _____________________________
Is the Legal Next of Kin (NOK) making the arrangements? Yes No If no, provide Name_________________ Phone _______________
Please provide power of attorney paperwork/Designation of representation, if other than Legal NOK.
Is the spouse a veteran (provide Discharge document(s)? Yes No If yes, does the surviving spouse want a separate gravesite? Yes No
VETERAN: _______________________________ ________________________ __________________________________________ _____
First middle last
SSN# ________________ Date of birth ____________
Do you have a copy of the military discharge(s)? Yes No (Must be legible and show Branch, Rank, Character of service, and Entry/Exit dates)
INTERMENT TYPE: Casket (In-Ground) Columbarium Wall/Niche (Cremains) In-Ground/Burial (Cremains)
Is the casket oversized? Yes No Material Type of Urn/ Casket? _________________________
Are there any previous interments? Yes No Name____________________________ Date of birth _______________
Request for Military honors? Yes No (Funeral Home is responsible for scheduling Military Honors and providing burial flag)
Requested date and time for service: ___________________________________________________
(Eligibility must be determined prior to scheduling. Services offered Monday- Friday excluding State and Federal Holidays)
PLEASE SEND COMPLETE 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 ensure that spelling and dates are accurate. I have certified that the above
information is correct and the decedent/veteran has not committed a capital crime or serious sex offense under Federal or State law.
SIGNATURE: ______________________________________ DATE: ______________________
(Next of Kin or Legal representative)
---------------------------------------For Cemetery Use Only (Do Not Complete)-----------------------------------------------
VETERAN: _______________________________ ________________________ __________________________________________ _____
First middle last
Service# __________________________ SSN# _________________________
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______________
Veterans Chapel (Sierra Vista Only)
SERVICE DETAILS: Committal Shelter
None
PROCESSION: Scheduled services w/ family____ Direct-to-witness ____ Direct (No witness) ____ 1
st
/ 2
nd
SCHEDULING: Day _______________ Date_______________ Time _______________
Section ___________ Row __________ Site _________ Verified Docs_________ Verified by: _______
APPLICATION OF INTERMENT
Revised
11/3/2021
MARANA
PH:
520-638-4869
FAX: 520-300-8403
AVMC-M@AZDVS.GOV
520-458-7144
click to sign
signature
click to edit
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