Form 10-2065 FUNERAL ARRANGEMENTS

OMB Number: 2900-0080
Estimated burden: 5 minutes

FUNERAL ARRANGEMENTS
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals
who must complete this form will average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts
and fill out the form. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing
the burden, may be addressed by calling the Health Benefits Contact Center at 1-877-222-8387.
PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Chapter 23 and 24, Title 38,
United States Code, "Veterans' Benefits", and will be used to initiate, authorize and document funeral arrangements. This information
may be disclosed when consistent with a "routine use" of this system of records 24VA136, "patient Medical Record-VA" as set forth in
the Compilation of Privacy Act Issuances. Disclosure is voluntary. However, failure to furnish the information may result in a delay in
burial. Failure to furnish this information will have no adverse effect on any other benefit to which you or the deceased may be entitled.
NAME OF DECEASED (Last, First, Middle Initial) (This is a mandatory field.)

CLAIM NUMBER

PLACE OF DEATH

SOCIAL SECURITY NUMBER (mandatory)
DATE OF DEATH (mm/dd/yyyy)

MILITARY SERVICE VERIFIED
YES

NO

NAME AND ADDRESS OF FUNERAL DIRECTOR TO WHOM REMAINS ARE TO BE RELEASED

PART I - COMPLETE WHEN GOVERNMENT TRANSPORTATION IS REQUESTED
METHOD OF SHIPMENT
HEARSE/VAN

FROM

TO

COST

AIR FREIGHT/AIR CARGO

U.S. POSTAL SERVICE (CREMATED REMAINS)
NAME, ADDRESS AND RELATIONSHIP OF ESCORT

NAME AND ADDRESS OF CONSIGNEE

PART II - COMPLETE WHEN BURIAL IS DESIRED IN NATIONAL CEMETERY
DATE BURIAL DESIRED
(mm/dd/yyyy)

WILL ATTEND GRAVE-SIDE
SERVICES

NUMBER IN
FUNERAL PARTY

MILITARY HONORS
DESIRED
YES

NO

MILITARY CHAPLAIN
DESIRED
YES

NO

GRAVESITE DESIRED BY
SPOUSE
YES

NO

REMARKS

The monetary amounts awarded for funeral arrangements are regulated by 38 U.S.C. Chapter 23 and may change periodically.
In light of this, please refer to the link below where the most current information concerning VA burial and plot internment allowances can be obtained.
http://www.benefits.va.gov/BENEFITS/factsheets/burials/Burial.pdf
I have read and understand the foregoing statements. Arrangements made for disposition of the remains of the deceased are consistent
with my wishes.
SIGNATURE OF NEAREST RELATIVE (or Acting Authority) AND RELATIONSHIP

ADDRESS

SIGNATURE OF EMPLOYEE (Witness)

TITLE

VA FORM
DEC 2015 (R)

10-2065

DATE (mm/dd/yyyy)