Name and Phone of Individual Reporting Death of Veteran
*
Name of Funeral Home Reporting
*
AJ Holly & Sons
Beil-Didier Funeral Home
Cline Hanson Funeral Home (New London)
Cline Hanson Dahlke Funeral Home (Manawa)
Cline Hanson Dahlke Funeral Home (Weyauwega)
Eberhardt Stevenson Funeral Home (Clintonville)
Eberhardt Stevenson Funeral Home (Marion)
Lewin Funeral Home
Maple Crest Funeral Home
Voie Funeral Home
Other
Would you like a copy of the DD214/Discharge Paperwork?
*
Yes
No
Would you like us to send you a flag application?
*
Yes
No
Is the Next of Kin Interested in a Government Marker?
*
Yes
No
Veteran's Name (First MI Last)
*
Veteran's Residence?
*
Veteran's Date of Birth (mm/dd/yyyy)?
*
Veteran's Social Security Number (xxx-xx-xxxx)
*
Veteran's Place of Birth?
*
Veteran's Date of Death (mm/dd/yyyy)?
*
Veteran's Place of Death?
*
Veteran's Date of Burial (mm/dd/yyyy)?
Veteran's Place of Burial (Name of Cemetery and City/Town Located - Include Plot Location (if possible)
*
Name and Relationship of Next of Kin:
*
Next of Kin Address and Phone Number?
*
You can upload the DD214/Discharge Paperwork Here
Additional Comments: