DATE OF DEATH:
-2286000 U.S. ARMY MILITARY FUNERAL HONORS REQUESTConnecticut Army National GuardWaterbury OfficeOffice: (203) 568-1741Cell: (860) 883-6778Fax: (203) 568-1752PLEASE FAX REQUESTS WITH AT LEAST 48 HRS NOTICE. DISCHARGE PAPERWORK DOES NOT NEED TO ACCOMPANY THIS REQUEST, BUT IT MUST BE PROVIDED PRIOR TO CONDUCTING HONORS.DAY FORMCHECKBOX Monday FORMCHECKBOX Tuesday FORMCHECKBOX Wednesday FORMCHECKBOX Thursday FORMCHECKBOX Friday FORMCHECKBOX Saturday FORMCHECKBOX SundayMonth FORMTEXT ?????Date FORMTEXT ?????Year FORMTEXT ?????EXPECTED TIME OF FUNERAL HONORS FORMTEXT ?????: FORMTEXT ????? AM / PMTIME OF CHURCH/MEMORIAL SERVICE FORMTEXT ?????: FORMTEXT ????? AM / PMSELECT REQUESTED HONORS FORMCHECKBOX RIFLE SQUAD FORMCHECKBOX FLAG PRESENTATION FORMCHECKBOX TAPS FUNERAL HOME WILL PROVIDE FLAG? FORMCHECKBOX YES FORMCHECKBOX NO LAST NAME, FIRST, MIDDLE: FORMTEXT ?????REMAINS: FORMCHECKBOX CASKET FORMCHECKBOX URN FORMCHECKBOX OTHER (i.e., memorial service)SSN: FORMTEXT ?????DATE OF DEATH: FORMTEXT ?????WHERE WOULD YOU LIKE THE HONORS TO BE RENDERED? FORMCHECKBOX CEMETERY FORMCHECKBOX CHAPEL FORMCHECKBOX FUNERAL HOME FORMCHECKBOX OTHER (Specify) FORMTEXT ?????LOCATION NAME: FORMTEXT ?????PHONE: FORMTEXT ?????ADDRESS: FORMTEXT ?????PLOT NUMBER (IF KNOWN): FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP: FORMTEXT ?????NEXT OF KIN INFORMATIONNAME OF PERSON TO RECEIVE FLAG: FORMTEXT ?????RELATION TO DECEASED: FORMTEXT ????? FUNERAL HOME OR OTHER REQUESTOR INFORMATIONNAME: FORMTEXT ?????POINT OF CONTACT FOR CONFIRMATION: FORMTEXT ?????ADDRESS: FORMTEXT ?????PHONE: FORMTEXT ?????CELL PHONE: FORMTEXT ?????CITY: STATE: ZIP: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????COMMENTS: FORMTEXT ????? ................
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