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IMPORTANT: Read the instruction sheet before c<? leting this form. Type or print in caps (excejit siq
Bit fJu.
2. HIGHEST RANK;
\. NAME OF DECEASED EXACTLY AS IT IS TO AP? . _^R ON HEADSTONE OR MARKER (See Item 1 of Instructions regarding options)
AND BRANCH OF SERVICE IN WHICH HELD
Mitt Mir*/** Ms.
3. WAS'THE DECEASED AWAJrtJEO THE *? WARS DURING WHICH DEC
MEDAL OF HONOR?
? VES fflLo
I DECEASED
kMjJUSLZ
*3 ).
^ orm Approved
OMU No. 76-110668
13. APPLICANT'S NAME AND AODRv city, and State)
*No. and street,
c5/^ A# / S/	*
14. ARE/CODE AND PHONE NO.
15. RELATIONSHIP TO DECEASEO
I accept responsibility Tor placement of me headstone 01 marker at iro expense
[ accept responsibility lor placement ot (lie headstone <JT marker at rtti expense ;o the Government. 1 certify that all statements made are true and correct to the best of my knowledge.
5. YEAR OF BIRTH
7.TYPE OF HEADSTONE OR MARKER REQUESTEO (Check one;
? UPRIGHT	__ FLAT	~	FLAT	___
MARBLE	n MARBLE	PH GRANITE	rH
HEADSTONE	I 1 MARKER	I 1 MARKER	LJ
6. YEAR OF DEATH
/?? -3/- /3S~S
16. SIGNATURE OF APPLICANT
FLAT
BRONZE
MARKER
6. RELIGIOUS EMBLEM DESIRED (Check one)
? LATIN	____ STAR OF	OTHER	fSpaei/v
CROSS.	I j DAVID	I I in i(am 25 on
(Chrtattan)	LJ (Jewiah)	L?J t
J reverse)
9. NAME OECEASED USED DURING SERVICE (Firat, middle, Iasi)
? 2 t /flZ
J NOHRECOVERABLE
10.SOCIAL SECURITY NO.
<T /JLA 7&J7-
ibTship to-. consigneetSname ANO AOORESS (No. and street, city, and Slate)
Ss
e/Jr, s/e-JA/ ft. '%'**"
0*0-,
I /. UM I C.
ZIP CODE
1 have agreed to take the headstone or marker to the cemetery.
19. AREA CODE AND PHONE NO
(&&/J
12. PLACE OF BURIAL (Name oi cemetery, city, and Stale) &(/*/> &S-/
20. SIGNATURE OF CONSIGNER
(VWCT
FOR USE OF VETERANS ADMINISTRATION
INSCRIPTION OATA
A headstone or marker of tlie type checked in Item 7 will be permitted at the grave or memorial ploU
22. SIGNATURE AND TITLE OF OFFICIAL IN CHARGE Of <
VA FORM
DEC 1974 40-1330
APPLICATION FOR HEADSTONE OR MARKER
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