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BURIAL Expenses and/or HEADSTONE for a DECEASED SERVICE PERSON (VETERAN) Application

  1. BURIAL Expenses and/or HEADSTONE for a Deceased Service Person (VETERAN) Application

  2. Check what allowance for which you are applying:

  3. Veteran's Legal Residence at Time of Death

  4. Note: If the Veteran resided in a personal care unit of nursing home, provide the address and County in which Bona Fide residency was established upon admission.

  5. SERVICE INFORMATION

  6. DISPOSITION

  7. Cemetery

  8. Grave/Crypt

  9. APPLICANT CERTIFICATION

  10. I hereby certify that the information provided is true and correct to the best of my knowledge.

  11. OTHER

  12. AFFIDAVIT BY UNDERTAKER (If Applicable)

  13. I hereby certify that I buried the above-named Veteran and that the total expenses of this burial were correct as per the attached ITEMIZED bill and that the bill has been paid or annotated to indicate this allowance.

  14. Certification of Entitlement (to be completed by representative of County Commissioners)

    I certify that I have examined the proof of services of the deceased service person in this application, and the proof of relationship of the within named surviving spouse, and find that the statements made above are correct, and that the applicant is entitled to payment under Section 421 of the General County Code of 1929, as amended.

  15. Director __________________________________________, Montgomery County Registrar of Veterans Graves

  16. Leave This Blank:

  17. This field is not part of the form submission.