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Application for Burial expenses of a Deceased Service Persons Widow / Widower Under Subdivision of Article 19 of “The County Code” of 1955 As Amended APPLICATION - County of PART I – Affidavit supporting Burial Claim, to be executed by Personal Representative, Next of Kin, Individual, or Veterans’ Organization I (We) hereby make application for the Burial Expenses of a Widow/ Widower of a Deceased Service Person, as provided by Subdivision Article 19 of “The County Code” of 1955, as amended 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: 1. Full name of deceased widow/ widower___ Date of Death Place of Death__ Legal residence at time of death was (Street and Number) County of _ , Pa. (City, Borough, Town or Township) She / He resided at this address for_ years and months immediately prior to his / her death. Date of Burial_ Place of Burial 2. Name of deceased Veteran_ The veteran served during the War. Rank Co. Regiment _ Division Serial Number _ Date of Enlistment _ Date of Discharge or Separation Date of Death Place of Burial _ Did decedent remarry after his / her spouse’s death_ Veteran was a legal resident of the State of at time of enlistment. 3. Payment of this allowance shall be made to__ as all expenses of burial Have Have Not been paid. 4. In witness whereof I have placed my hand this day of , 20__ _ (Personal Representative, Next of Kin, Individual, or Veterans’ organization) (Address) Part II - Affidavit by Undertaker. I hereby certify that I buried the above named widow / Widower of a deceased service person, as hereinbefore stated, and that these expenses Have Have Not been paid. (Name of Firm) Sworn by me this By___ Day of , 20 (Name) (Title) (undertaker) (Address) (NOTE: *Strike out word not when same does not apply) Part III – Certification of Entitlement. (To be completed by representative of the County Commissioners) I certify that I have examined the proof of service of the deceased service person named in this application and the proof of relationship of the within named widow / widower, and find that the statements made above are correct, and that the applicant is entitled to payment under subdivision Article 19 of “The County Code” of 1955, as amended. (Title: Director of Veterans’ Affairs)