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2. APPLICATION FOR RENSSELAER COUNTY HONOR-A-DECEASED VETERAN

   Please elaborate on all information concerning the Veteran so that we may have a full biography for our pamphlet and ceremony. 

   Please complete all fields on application, please DO NOT write “See Obit”.  All fields are required, use "N/A" if needed.

   Submitted applications must be accompanied by a copy of Veteran’s Report of Separation/DD-214 or Report of Casualty and a copy of Veteran’s obituary.

   For questions, please call the Rensselaer County Veterans Service Agency (518)270-2760.

4. VETERAN INFORMATION (please complete all fields)

6. Name (Include maiden name if applicable)*
8. Date of Birth*
   Date of Birth
9. Date and Place of Enlistment*
11. Significant Military Assignments, Accomplishments, and Awards*
13. Date of Separation*
    Date of Separation
14. Date of Death*
    Date of Death
15. Place of Burial*
17. Please attach a copy of the Veteran’s Report of Separation/DD-214 or Report of Casualty*
19. Please attach a copy of the Veteran’s obituary*
21. Employment (Please list all jobs with years)*
22. Schools Attended and Years*
24. Parents' Names (Please include mother’s maiden name)*
25. Brothers and Sisters*
27. Spouse (please include maiden name)*
28. Date and Place of Marriage*
30. Children's Names*
31. Grandchildren:*
33. Where did the Veteran grow up and later reside?*
35. Did the Veteran retire from an occupation or an organization?*
37. What were the Veteran's hobbies and/or special interest?*
39. In what community activities did the Veteran take part?*
41. Did the Veteran belong to any special organizations?*
43. FAMILY CONTACT INFORMATION (please complete all fields)
45. Name*
46. Relationship*
48. Address*
49. Phone*
50. Email*
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field