Edit Form Name and Phone of Individual Reporting Death of Veteran?*? Name of Funeral Home Reporting*? AJ Holly & Sons Beil-Didier Funeral Home Cline Hanson Funeral Home (New London) Cline Hanson Dahlke Funeral Home (Manawa) Cline Hanson Dahlke Funeral Home (Weyauwega) Eberhardt Stevenson Funeral Home (Clintonville) Eberhardt Stevenson Funeral Home (Marion) Lewin Funeral Home Maple Crest Funeral Home Voie Funeral Home Other Would you like a copy of the DD214/Discharge Paperwork?*? Yes No Would you like us to send you a flag application?*? Yes No Is the Next of Kin Interested in a Government Marker?*? Yes No Veteran's Name (First MI Last)*? Veteran's Residence?*? Veteran's Date of Birth (mm/dd/yyyy)?*? Veteran's Social Security Number (xxx-xx-xxxx)*? Veteran's Place of Birth?*? Veteran's Date of Death (mm/dd/yyyy)?*? Veteran's Place of Death?*? Veteran's Date of Burial (mm/dd/yyyy)?? Veteran's Place of Burial (Name of Cemetery and City/Town Located - Include Plot Location (if possible)*? Name and Relationship of Next of Kin:*? Next Kin Address and Phone Number?*? You can upload the DD214/Discharge Paperwork Here? Additional Comments:?