Form 2 - Bucks County Veterans Benefits Form - Commissioners Of Bucks - Pennsylvania

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FORM #2
BUCKS COUNTY VETERANS BENEFITS
Application is hereby made for the following under Act of August 1955, P.L. 323
(
) Allowance of up to $50.00 toward base for federal marker or headstone.
1.
Full name of deceased veteran_______________________________________________________________
2.
(a) Place of Birth ______________________________(b) Date of Birth ______________________________
3.
Mark a cross (X) after branches of service in which he served. Army________Navy_____Marine Corps______
Coast Guard ______ Air Force ________
4.
Give the following information about his/her service:
ENLISTED:
Date__________________________________Place______________________________________
DISCHARGED Date_________________________________Place______________________________________
Veteran was a legal resident of the State of _____________________________at the time of enlistment.
RANK_________________________________Service Number_________________________________________
ORGANIZATIONS SERVED WITH: ________________________________________________________________
TYPE OF DISCHARGE: _________________________________________________________________________
Note: If he/she served under a name other than the one used in this application, give name under which he/she served:
____________________________________________________________
5.
Give the following information about his/her death and burial:
Death: Date _______________________Place_____________________________________________________
Burial: Date________________________Place_____________________________________________________
Mailing Address of Cemetery____________________________________________________________________
Location of Grave: Section ____________Range___________Lot_____________Grave ____________________
6.
Legal residence of veteran at the time of his/her death was at _________________________________Street
City of _____________________________________County of Bucks, Pennsylvania.
Decedent lived at that address for ________years, ______months immediately preceding death, and was a resident
Of Bucks County for a period of ________years immediately preceding death.
7.
Payment of this allowance shall be made to: ____________________________________________________
As all expenses of burial have/have not been paid. Note: Stike out word when same does not apply.
Sw orn and sub scribed before me this
_______________
Name________________________________________________
D
ay of
______________________________
20
________
Signature_____________________________________________
Address_______________________________________________
Nota ry P ublic
__________________________________
Phone #______________________Relationship______________
………………………………………………………………………………………………………………………………………………….
(To be returned by the contractor on the completion of the work)
CERTIFICATION OF ERECTION
To the Commissioners of Bucks
Doylestown, Pennsylvania:
I certify that I have erected a __foundation for a Government Marker on the grave of ________________________
at the cost of $______________, as per the Erection Authorization appearing on the reverse of this form.
Sworn and subscribed before me this ________
__________________________________
Day of _________________________20_____
(Name of Firm)
__________________________________
_______________________________________
Name
Title
(Notary Public)
Note : Payment of this account will not be made until this completed and notarized form is returned by the contractor.
If bill has already been paid, please designate party to be reimbursed.

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