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APPLICATION FOR BURIAL EXPENSES FOR DECEASED SERVICE PERSON The County Code of 1955 as Amended; Article XIX-A(b) Affidavit Supporting Burial Claim Part I: To be executed by Personal Representative, Next of Kin, Individual, or Veterans Organization I (We) hereby make application for the Burial Expenses of a Deceased Service Person in the amount of and hereby certify that the facts set forth below are true and correct to the best of my (our) knowledge and belief. Service Person: Last Name First Name Middle Initial Place of Birth Date of Birth Branch(es) of Service in which service person served: Army Marine Corps Navy Air Force Coast Guard Name served under (if same as above write “same”) Enlistment / Commission: Date Discharged: Date Type of Discharge Rank Service Number Units served with State of legal residence at the time of Enlistment / Commissioning Death and burial information: Death: Date Place Burial: Date Place Name and Location of Cemetery: Location of Grave: Section Range Lot Grave Legal residence of the service person at the time of his/her death: , County, Payment of this allowance shall be made to: as all expenses of burial have have not been paid. By signing this application, the applicant certifies that the information provided is true and correct to the best of my knowledge, information and belief. The law provides severe penalties including fines and imprisonment for making false statements on official forms such as this Application for Burial Benefits. I understand that this verification is made subject to the penalties of 18 Pa C.S.A. § 4904 pertaining to unsworn falsification to authorities. this day of ,20 Signature (Personal Representative, Next of Kin, Veterans Group) (Address) Part II-Affidavit by Undertaker. I hereby certify that I buried the above-named service person, as herein before stated, and that these expenses of $ have have not been paid. Name of Firm Signature of Undertaker Address Part III: To be completed by representative of the County Commissioners I have examined the proof of the service of the within named service person, and find that the statements made above are correct, and that such service during the War and residence at the time of death entitled the applicant to the benefits of The County Code of 1955, as amended Article XIX-A Director of Veterans Affairs Part IV- Authorization for Payment. We have satisfied ourselves that the within named deceased service person had legal residence in the County of and that payment of Allowance should be made to Commissioner Part V-Warrant Order. Warrant No. should be drawn in payment of this account, to the order of Controller/ Treasurer Act 154 of 2018 SIGN SIGN