DECEASED NAME: RANK: SSN: STATUS/RACE
MILITARY FUNERAL HONORS REQUEST FORM
DECEASED NAME: RANK: RETIREE OR VETERAN/RACE
_______________________________________________________________________________________________
POC: _______________________________PHONE#_______________________FAX#______________________
EMAIL ADDRESS: _________________________________________ County of Burial______________________
FUNERAL HOME NAME/ADDRESS
_______________________________________________________________________________________________
_______________________________________________________________________________________________
HONORS REQUESTED: ____ TAPS _____PALL BEARERS ____FIRING SQUAD ____BUGLER _____CHAP _____2 MAN REP
FUNERAL SERVICE:
TIME: EST/CST DATE: __________ PLACE: _____________________________________________
BURIAL SERVICE:
TIME EST/CST DATE: __________ PLACE: ____________________________________________
DETAIL REPORT:
TIME EST/CST DATE: __________ PLACE: ____________________________________________
*Does the Funeral Home have a Flag? ______YES _________ NO
Person receiving Flag ______________________________ Relationship ________________
If Retired:
Place of Birth ________________________ Date of Retirement_____________________
Date/Time of Death: ____________________________ Place of Death __________________________________
City/State of Death ____________________________ Circumstances ___________________________________
PLEASE FAX THIS REQUEST TO 706-545-7132 AND CALL FOR VERIFICATION OF RECEIPT. ADDITIONAL INFORMATION WILL BE REQUIRED.
PHONE NUMBERS 706-545-4606/706-545-4116/706-545-6346/706-545-1917/706-545-2710/706-545-4026/706-545-7116.
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