Wilcox, Everett H.Jun 30 14 02:52p CYCADIA MONUMENT CO.
7277850856
p.1
Form approved, OMB No. 2900-0222
Respondent Burden: 15 minutes
IMPORTANT: Please read the General Information Sheet before completing this form. Type or
Department of Veterans Affairs
print clearly all information except for signatures. Illegible printing could result in an incorrect
1. FOR VA USE ONLY headstone or marker or delivery- Blocks outlined in bold are optional inscription items. Unless
indicated otherwise all other blocks must be completed. MILITARY DISCHARGE DOCUMENTS
OR RELATED SERVICE INFORMATION ARE REQUIRED.
2. NAME OF DECEASED TO BE INSCRIBED ON HEADSTONE OR MARKER (NO NICKNAMES OR TITLES PERMITTED)
3. GRAVE
.
IS:
CURRENTLYED
privatelyprMARKnrhased marker)
NOT MARKED
FIRST (Orinitiat)
:g li/F:...R Er-f�/
MIDDLE (Or/al I)
LAST
�^
��
SUFFIXRRENTLY
VETERANS SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
4. VETERAN'S SOCIAL SECURITY NO. OR SERVICE NO.
a`2 �yD Z
SSN: ✓ ! .� OR SVC. ND.:
PERIODS OF ACTIVE MILITARY DUTY (For additional space use Block 27)
6A. DATE(S) ENTERED
6B. DATE(S) SEPARATED
MONTH
DAY
YEAR
MONTH
DAY
YEAR
SA. DATE OF BIRTH
5B. DATE OF DEATH
�—
,J
/
! y 1/�
Pe c
/4
) Cy
1 ! 65"
MONTH
DAY
YEAR
MONTH
DAY
YEAR
�t�AJ
j 2 Co
/ ie
4
f
/L[
2 of
7. HIGHEST RANK ATTAINED (No pay grades)
M 4CORPS
B. BRANCH
A NAVY
OF
SERVICE (Check applicable bastes) - must be consistent ,.vith rank in Bar 7)
ART ARMY MERCHANT OTHER
CORPS GUARD AIR FORCE AIR FORCES MARINE (Spec)
9. VALOR OR PURPLE HEARTAWARD(S)
MEDAL OF DST SVC NAVY AIR
HONOR CROSS C: CROSS
(Doettneritatioe
FORCE SILVER
STAR
must beprovided)
BRONZE STAR PURPLE OTHER
MED (Sr')
19. WAR SERVICE
WOR
WA KOREA
(Check applicable box(es))
PERSIAN OTHER
VIETNAMGULF (Sprciy)
11. TYPE OF HEADSTONE OR MARKER REQUESTED (Che one;
FLAT,FLAT UPRIGHT FLAT BRONZE UPRIGHT
. - • E GRANITE MARBLE MARBLE NICHE GRANITE
!F B ED ❑ U F 0 0
12. DESIRED EMBL 110F BELIEF
EMBLEM NUMBER
NONE(SSpeLc[v)(Seereversesideofthisfornjoravailableemb-1
/ilbl!.(J)� 6/c
F APPLICANT
1 a INGADDRESS OfGkle
reef rty are nr ?lP C
itt
-14.
C_�J 13AXNO.(ot
U 1 't �o O f _ t F / � /
133. DAYTIME PHDNE NO. OF APPLICANT
1�7_7 4 `�c�i
E-MAIL ADDRESS (Optional)
FNO.
16. ARE YU:V11
)( NEXT OF XIN (Specijvrelationship) AUTHORIZED REPRESENTATIVE ON AUTHORIZED REPRESENTATIVE ON BEHALF OF
�nr^11 (/J BEHALF OF DECEDENT (IncludeWritten NEXT OF KIN (Include Written Authorization)
J�:� 6 r AretHALFtior.)
CERTIFICATION: By signing below 1 certify the headstone or marker will be installed in the cemetery listed in block 21 at no expense to the Government and all
information entered on this form is true and correct to the best of my knowledge. I also certify, to the best of my knowledge, that the decedent has never committed
a lLapital Crime or -was never�o �.etfof a sexual offense for which he or she was sentenced to a minimum of life imprisonment.
/
. SIC....-,— —
16. DATE N/DDJ 171:17 y.--
9 NAME AND UELwcrtY ADDRESS OF BUSINESS (CONSIGNEE) THAT WILL
1„ACCEPT PREPAID DELIVERY (No., Street, City, Slate, and ZIP Code); P.O. BOX
�/ IS NOTA ACCEPTABLE
CYCADIA MONUMENT GO
2500 JENNIFER TER.
PALM HARBOR, FL. 34685
20. DAYTIME PHONE NO.
(Include Area Coyle)
727-786-1551fI
21. NAME AND ADDRESS OF CEMETERY WHERE
GRAVE IS LOCATED (No., Street, City. Slate, r 1
ZIP Code)
C L42-4?" IA' 0 -it -r- GI ' C -
�f /�-�
CERTIFICATION: By signing below I agree to accept prepaid delive t e headstone or . :• ker.
22. PRINT + NAME AND SIGNATUR- 6 PERS• REPRESENTING BUSI •- s (C• SIG ) NAMED • r. • K 19
'/
3. DATE (11,11,03D
IfCERTIFICATION:
By signing t elow I certify the type of)feadstone or marker checked in block 1 permitted in the ceiyetery� n��4�m���ed i block 21.
, -24. PRINTED N E AND SIGNATURE OF CEMETERY"�OR OTHER RESPONSIBLE
OFFICIAL ii<lkiY(j 2Q CJ mak_ , ✓ A Clerk-
25. DAYTIME PHONE NO. (InciltdeAr )
727 -sem
26. 1),ATR I'M.WDDit+I'ri 4
oie_2 4) /'
27. REMARKS (Additional inscription .pace will vary In .size according to type of marker) �t l' t J i
28. CHECK BOX. BELOW IF REMAINS ARE NOT BURIED AND EXPLAIN IN BLOCK 27
(e.g., buried a1 sea, remains scattered, etc.) REMAINS NOT BURIED
29. SECTION/GRAVE NO. (State Cemetery Only)
VA FORM 40-1 330
MAY 2013
CLAIM FOR STANDARD GOVERNMENT HEADSTONE OR MARKER