Form V40-4962 Verification of Eligibility for Burial in a National Cem

OMB Approved No. 2900-0232
Respondent Burden:15 Minutes
Expiration Date: Aug. 31, 2026
NUMBER

VERIFICATION OF ELIGIBILITY FOR
BURIAL IN A NATIONAL CEMETERY
NOTE: Orally summarize the below Privacy Act Notice and provide a copy of this form before collecting information from a person.

PRIVACY ACT NOTICE: The information is solicited under Chapter 24, Title 38, United States Code, and will be used in determining the eligibility of the deceased for burial in a national
cemetery, in making a preliminary determination concerning the monument inscription, and in making burial arrangements. Disclosure is voluntary. However, if the information is not furnished, burial
may be delayed. The information may be disclosed outside the VA as permitted by law, or as stated in the "Notices of Systems of VA Records," identified as (42VA41), Veterans and Dependents
National Cemetery Interment Records-VA and (41VA41), Veterans and Dependents National Cemetery Gravesite Reservation Records, which have been published in the Federal Register in
accordance with the Privacy Act of 1974.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
The OMB control number for this project is 2900-0232, and it expires 08/31/2026. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per year,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at
VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0232 in any correspondence. Do not send your completed VA Form 40-4962 to this email address.

SECTION I - FUNERAL HOME INFORMATION
NAME OF FUNERAL HOME CONTACT
DATE CALL RECEIVED (MM/DD/YYYY)

NAME AND ADDRESS OF FUNERAL HOME
A.M.

TIME

P.M.

SECTION II - DECEDENT
LAST NAME, FIRST NAME, MIDDLE INITIAL

DATE OF BIRTH (MM/DD/YYYY)

HOME OF RECORD AT TIME OF DEATH (City, County, and State)

DECEDENT
SON

DAUGHTER

DATE OF DEATH (MM/DD/YYYY)

SPOUSE

VETERAN

OTHER

SECTION III - VETERAN
LAST NAME, FIRST NAME, MIDDLE INITIAL

MARITAL STATUS

SEX (Optional. Information will be used for statistical purposes only)

FEMALE

SERVICE NUMBER OR SSN

VA CLAIM NUMBER

MALE

WHAT IS YOUR RACE AND/OR ETHNICITY? (Select all that apply and enter additional details in the spaces below. Information will be used for statistical purposes only)
AMERICAN INDIAN OR ALASKA NATIVE - Provide details below.
Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian
Reservation of Montana, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, Aztec, Maya, etc.
ASIAN - Provide details below.
Chinese

Asian Indian

Filipino

Vietnamese

Korean

Japanese

Haitian

Nigerian

Ethiopian

Somali

Iranian

Egyptian

Syrian

Iraqi

Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

Native Hawaiian

Samoan

Chamorro

Tongan

Fijian

Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

BLACK OR AFRICAN AMERICAN - Provide details below.
Jamaican

Lebanese

NATIVE HAWAIIAN OR PACIFIC ISLANDER - Provide details below.

Enter, for example, Pakistani, Hmong, Afghan, etc.

African American

MIDDLE EASTERN OR NORTH AFRICAN - Provide details below.

WHITE - Provide details below.

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

English

German

Irish

Italian

Polish

Scottish

Enter, for example, French, Swedish, Norwegian, etc.

HISPANIC OR LATINO - Provide details below.
Mexican

Puerto Rican

Salvadoran

Cuban

Dominican

Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

MILITARY STATUS
ON ACTIVE DUTY
RETIRED
IN RESERVE

PERIOD OF SERVICE
WWI

WWII

KOREAN

VIETNAM

ACTIVE DUTY DATES (MM/DD/YYYY)
ENTERED

RELEASED

OTHER SERVICE DATES (MM/DD/YYYY)
ENTERED

RELEASED

OTHER (Specify)

VETERAN

HIGHEST GRADE, RATE OR RANK, AND BRANCH OF SERVICE IN WHICH HELD

SECTION IV - NEXT OF KIN
NAME AND ADDRESS OF NEXT OF KIN

RELATIONSHIP
DATE OF BIRTH OF WIDOW(ER) (If next

NAME OF MOTHER (If next of kin)

of kin) (MM/DD/YYYY)

VA FORM
MAR 2025

40-4962

Page 1

SECTION V - INTERMENT DATA
INTERMENT
TENTATIVE DATE

TIME

GRAVE/LOCATION
TIME

ACTUAL DATE

(MM/DD/YYYY)

SECTION

(MM/DD/YYYY)

A.M.

A.M.

P.M.
GRAVE POSITION

3 FT.

7 FT.

5 FT.

9 FT.

P.M.

OUTSIDE CONTAINER

CL

LH

VAULT

LL

RH

GOVT. GRAVELINER

WOOD

METAL

CONCRETE

PLASTIC/FIBERGLASS

NO CONTAINER

WAS THERE A
PREVIOUS INTERMENT?
YES

TYPE OF RESERVATION
RESERVATION

NO

REOPENER

INFORMATION REGARDING PREVIOUSLY INTERRED FAMILY MEMBER(S)
DATE(S) OF DEATH (MM/DD/YYYY)
DATE(S) OF INTERMENT (MM/DD/YYYY)

NAME(S) OF FAMILY MEMBER(S)
DISTANCE (MILES) FROM
DECEDENT'S RESIDENCE

DEPTH OF GRAVE

NUMBER

CREMAINS

HAS FOREMAN BEEN NOTIFIED
OF RESERVED GRAVE?
YES

NO

BURIAL PERMIT

URN

ON FILE

OTHER (Specify)

NOT REQUIRED

NOT FURNISHED FOR RECORD
SIGNED AND RETURNED

SECTION VI - RELIGIOUS DATA
DENOMINATION OF DECEDENT
CATHOLIC

RELIGIOUS EMBLEM

NAME AND ADDRESS OF OFFICIATING CLERGY

COMMITTAL SERVICES DESIRED?

JEWISH

PROTESTANT

YES

OTHER (Specify)

NO

SECTION VII - ELIGIBILITY VERIFICATION

(For persons who served honorably with a special guerrilla unit or irregular forces operating from a base
in Laos in support of the Armed Forces during the period February 28, 1962 and May 7, 1975)

AT TIME OF DEATH

WAS A CITIZEN OF THE UNITED STATES OR AN ALIEN LAWFULLY ADMITTED FOR PERMANENT RESIDENCE IN THE U.S.

YES

NO

RESIDED IN UNITED STATES

YES

NO

DIED ON OR AFTER MARCH 23, 2018

YES

NO

EVIDENCE OF SERVICE
ORIGINAL DOCUMENTATION ISSUED BY A GOVERNMENT AGENCY OFFICIALLY DOCUMENTING THE SERVICE TYPE, LOCATION AND DATES SERVED;
AN AFFIDAVIT OF THE DECEDENT'S SUPERIOR OFFICER ATTESTING TO THE TYPE OF SERVICE, LOCATION, AND DATES SERVED;
TWO AFFIDAVITS FROM OTHER INDIVIDUALS WHO WERE ALSO SERVIING WITH SUCH A SPECIAL GUERILLA UNIT OR IRREGULAR FORCES AND WHO
PERSONALLY KNEW OF THE DECEDENT'S SERVICE; OR
OTHER APPROPRIATE EVIDENCE THAT FACTUALLY DOCUMENTS THE SERVICE, LOCATION AND DATES SERVED.
DATE MESSAGE SENT

TIME

(MM/DD/YYYY)

DATE REPLY RECEIVED

A.M.

TIME

(MM/DD/YYYY)

P.M.

WAS DISCHARGE CERTIFICATE FURNISHED?
A.M.
P.M.

YES

NO

SECTION VIII - MISCELLANEOUS DATA
ARE PALLBEARERS SERVICES REQUIRED?
YES

INITIALS

NO

DATE (MM/DD/YYYY)

ARE CLERGY SERVICES REQUIRED?
YES

NO

WILL THERE BE MILITARY HONORS?
YES

NO

SECTION IX - FOR VA USE ONLY (Initial if required and give date when completed)
ITEM
INITIALS DATE (MM/DD/YYYY)

ITEM

VA FORM 40-4956, RECORD OF INTERMENT

VA FORM 40-4956, RECORD OF INTERMENT
FOR NEXT OF KIN

VA FORM 40-4960, REMPORARY GRAVE
MARKER

VA FORM 40-4982, INTERMENT REGISTER

VA FORM 40-4961, STATEMENT OF MARITAL
STATUS

VA FORM 40-4987, AGREEMENT FOR BURIAL
OF CREMATED REMAINS

VA FORM 40-4964, CERTIFICATION OF
MONUMENT DATA

PROOF OF SERVICE

REMARKS

VA FORM 40-4962, MAR 2025

Page 2