Full Name
Phone Number
Address
City, State, Zip
Occupation
Employer
Male
Female
Sex
Race
Hispanic Origin?
Yes
No
If yes, specify Cuban, Mexican, etc.
Date of Birth
Highest Level Education
Elem./High School Years
College Years
Place of Birth
State of Foreign County
Marital Status
If married or widowed, give Spouse's name
Next of Kin
Relationship
Their Street Address
Their City, State, Zip
Are you a Veteran?
Yes
No
Disposition of Cremated Remains
I request that the following dispostion of my cremated remains be made by the CPCS
Cremated remains may be buried at Indiantown Gap National Cemetery, Annville, PA.
Cremated remains can be interred in a columbarium at
Arlington National Cemetery, VA.
At this time, I am undecided as to the disposition of my cremated remains.
Cremated remains to be picked up at one of the Societies offices.
Cremated remains to be mailed to the following individual or cemetery listed below:
Individual or cemetery name if cremated remains are to be mailed
