RAC-MOAA Death Notification Form

Your E-Mail Address: (E-mail address required to send data)

Decedent Information

Rank: Lastname: First: MI: Suffix:
Date of Death: (DD-MMM-YY) Spouse name: Deceased (Y/N):
Has family notified Casualty Assistance Office from deceased's military service (Y/N):
Burial Arranged (Y/N): Military Honors (Y/N): Retired Pay Stopped (Y/N):
Survivor Benefit Plan (SBP) Payments Started (Y/N): VA Headstone Requested (Y/N):
Casket flag requested from VA (Y/N): (Note: Flag normally arranged by funeral director)

Funeral Information

Viewing Location:
Viewing Hours: From to Dates:
Memorial Service:
Date (DD-MMM-YY): Time: Public: Private: (Mark with 'X')
Burial Location:
Date (DD-MMM-YY): Time: Public: Private: (Mark with 'X')

Survivor Information

Survivor Name:
Street Address:
City: State: Zipcode: Phone:
Contact Phone: Contact Person: