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Get Dfa 67 A Form

Yes No If yes, have you made application for these benefits? Yes No PART II PERSON ARRANGING FOR BURIAL SERVICE Name: Address: PART III Phone Number: Relationship: LIST KNOWN LIVING RELATIVES OF DECEASED AND THEIR CURRENT LOCATION (Complete only if person arranging for burial service is a specified relative of the deceased. NAME RELATIONSHIP COUNTY STATE PART IV DESIGNATED RELATIVE S STATEMENT I hereby certify and swear that neither the estate of the deceased nor the above-listed re.

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