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2. BURIAL Expenses and/or HEADSTONE for a Deceased Service Person (VETERAN) Application
4. Check what allowance for which you are applying:

   1. Allowance of $100.00 toward the burial expenses of a deceased service person [16 P. S. 5109], AND/OR
   2. Allowance up to $100.00 towards a County Approved Headstone OR Lettering for a deceased service person [16 P. S. 5113], OR
   3. Allowance up to $100.00 toward base for a Federal Marker or Headstone for a deceased service person
6. Veteran's First Name*
7. Veteran's Last Name*
9. Date of Birth*
   Date of Birth
10. Date of Death*
    Date of Death
11. Social Security Number*
13. Widow/Widower's First Name
14. Widow/Widower's Last Name
16. Veteran's Legal Residence at Time of Death
18. Street Address*
20. City*
21. State*
22. Zip*
24. County*
26. 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.
28. SERVICE INFORMATION
30. Active Duty Branch of Service*
    -- Select One --Air ForceArmyCoast GuardMarine CorpsNavyOther
31. War Era Served*
    -- Select One --World War II 12/7/1941 - 12/31/1946Korean Conflict 6/27/1950 - 1/31/1955Vietnam Era 8/5/1964 - 5/7/1975Persian Gulf War 8/2/1990 - PresentOther
33. Enlistment Date*
    Enlistment Date
34. Discharge Date*
    Discharge Date
35. Units/Organizations
37. Type of Discharge*
    -- Select One --HonorableGeneralOther than Honorable ConditionsBad ConductDishonorable
38. Service Number (prior to 1970)
40. Was a service-connected disability or injury/illness from service a cause/factor in the Veteran’s death? *
    -- Select One --YesNoUnsure
42. DISPOSITION
44. Cemetery
46. Cemetery Name*
48. Street Address*
50. City*
51. State*
52. Zip*
54. Municipality*
56. Grave/Crypt
58. Section/Mausoleum*
59. Grave Range*
61. Lot Number
62. Grave/Crypt Number
64. APPLICANT CERTIFICATION
66. I hereby certify that the information provided is true and correct to the best of my knowledge.
68. Applicant's First Name*
69. Applicant's Last Name*
71. Address*
73. City*
74. State*
75. Zip*
77. Relationship*
    -- Select One --FatherMotherBrotherSisterSpouse/PartnerFriendNeighborOther
78. Email*
80. Phone Number*
82. Payment shall be made to:*
84. OTHER
86. DD-214 or Military Discharge Record*
88. Death Certificate*
90. Funeral Bill Paid in Full OR Annotated to account for a $100 burial allowance*
92. AFFIDAVIT BY UNDERTAKER (If Applicable)
94. 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.
96. Name of Firm and Applicant
98. Address
100. City
101. State
102. Zip
104. 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.
106. Director __________________________________________, Montgomery County Registrar of Veterans Graves
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108. 1. Receive an email copy of this form.
109. Email address

     This field is not part of the form submission.

110. Submit Submit and Print

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