{"id":5824,"date":"2025-06-11T11:39:55","date_gmt":"2025-06-11T16:39:55","guid":{"rendered":"https:\/\/vetaffairs.la.gov\/?page_id=5824"},"modified":"2025-06-30T16:54:55","modified_gmt":"2025-06-30T21:54:55","slug":"demande-de-prevoyance-funeraire","status":"publish","type":"page","link":"https:\/\/vetaffairs.la.gov\/fr\/pre-need-burial-request-application","title":{"rendered":"Demande de pr\u00e9voyance fun\u00e9raire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5824\" class=\"elementor elementor-5824\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-04f07ed e-flex e-con-boxed e-con e-parent\" data-id=\"04f07ed\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-88c4289 elementor-widget elementor-widget-heading\" data-id=\"88c4289\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Pre-Need (Before Death)<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-45d78e4 li-styling elementor-widget elementor-widget-text-editor\" data-id=\"45d78e4\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>If you are using this form prior to a loved one passing away, you will select the Pre-Need button. This will allow you to only fill out the parts of the application needed to determine eligibility. This is not a requirement for burial in our cemetery but you can do this in advance of passing if you are unsure of your eligibility for burial in a Louisiana state veterans cemetery.<\/p><ul><li><strong>Veteran and Military Service Information<\/strong> \u2013 This is information about the veteran only. You do not have to be retired from military service to be eligible but the question helps us to verify we have all of the information we need about the veteran\u2019s service. There is a place to mark any additional information you think we may need in order to determine eligibility.<\/li><li><strong>Required Fields<\/strong> \u2013 Certain information about the veteran is required to submit this form. If the field is outlined in RED it is required.<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1463b50 elementor-widget elementor-widget-heading\" data-id=\"1463b50\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Burial (After Death)<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-751739f li-styling elementor-widget elementor-widget-text-editor\" data-id=\"751739f\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>If someone has passed away and they have been or are in the process of being cremated, the person arranging the burial would complete this form by selecting the Burial button. The first section is all about the person who has passed away. If they are the veteran, when you select the veteran button their basic information will copy to the veteran information section. If the person who passed away is the dependent then you will need to complete the veteran section in full.<\/p><ul><li><strong>Veteran and Military Service Information<\/strong> \u2013 This is information about the veteran only. You do not have to be retired from military service to be eligible but the question helps us verify we have all of the information we need about the veteran\u2019s service. There is a place to mark any additional information you think we may need in order to determine eligibility.<\/li><li><strong>Contact Information<\/strong> \u2013 We only need Funeral Home information if they are involved in the burial. We do need the family member who is making arrangements listed as the Family Contact, if this person is the not the legal next of kin we will need contact information for the legal next of kin in this order: Legally Married Spouse, Biological or Adopted Children, Parents, Siblings, Extended Family.<\/li><li><strong>Interment\/Service Information<\/strong> \u2013 You will select your cremation location based on the area of your choice (subject to availability at that cemetery). Please read over the choices for services requested before you choose. Our cemeteries use these choices when scheduling services to ensure the best employee coverage and setup for your service choice.<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ff6065e elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-heading\" data-id=\"ff6065e\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Apply here:<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7d683d0 elementor-widget elementor-widget-shortcode\" data-id=\"7d683d0\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><div class=\"gf-logic-announcer sr-only\" aria-live=\"polite\">placeholder<\/div><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_7' id='gform_7' class='pre-need-burial-form' action='\/fr\/wp-json\/wp\/v2\/pages\/5824#gf_7' data-formid='7' novalidate>\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"42\" \/>\n\t\t\t\t\t\t<script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n\n\t\t\t\t\t<\/div><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LfaguwrAAAAAD1Ru0fYnu0M-b2rk9WNME9ICeAJ' data-tabindex='0'><input id=\"input_cd9dd5320020fefeee61b975273695e9\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_cd9dd5320020fefeee61b975273695e9\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_59\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Apply here:<\/h2><\/div><fieldset id=\"field_7_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full form-choice-buttons gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What are you requesting for?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_3'>\n\t\t\t<div class='gchoice gchoice_7_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Pre-Need (Before Death)'  id='choice_7_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_3_0' id='label_7_3_0' class='gform-field-label gform-field-label--type-inline'>Pre-Need (Before Death)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Burial (After Death)'  id='choice_7_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_3_1' id='label_7_3_1' class='gform-field-label gform-field-label--type-inline'>Burial (After Death)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full cemetery-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please select your preferred cemetery:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_60'>\n\t\t\t<div class='gchoice gchoice_7_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Central Louisiana Veterans Cemetery'  id='choice_7_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_60_0' id='label_7_60_0' class='gform-field-label gform-field-label--type-inline'>Central Louisiana Veterans Cemetery<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Northeast Louisiana Veterans Cemetery'  id='choice_7_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_60_1' id='label_7_60_1' class='gform-field-label gform-field-label--type-inline'>Northeast Louisiana Veterans Cemetery<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Northwest Louisiana Veterans Cemetery'  id='choice_7_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_60_2' id='label_7_60_2' class='gform-field-label gform-field-label--type-inline'>Northwest Louisiana Veterans Cemetery<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_60_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Southeast Louisiana Veterans Cemetery'  id='choice_7_60_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_60_3' id='label_7_60_3' class='gform-field-label gform-field-label--type-inline'>Southeast Louisiana Veterans Cemetery<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_60_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Southwest Louisiana Veterans Cemetery'  id='choice_7_60_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_60_4' id='label_7_60_4' class='gform-field-label gform-field-label--type-inline'>Southwest Louisiana Veterans Cemetery<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_4\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Decedent Information<\/h2><\/div><fieldset id=\"field_7_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_7_1'>\n                            \n                            <span id='input_7_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_7_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_7_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_7_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_7_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_7_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_7_1_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.8' id='input_7_1_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_1_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_7_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_7'>Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_7_7' type='text' value='' class='large'  aria-describedby=\"gfield_description_7_7\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_7'>Format: 123-45-6789<\/div><\/div><div id=\"field_7_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_8'>Date of Death<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_7_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_7_8_date_format gfield_description_7_8\" aria-invalid=\"false\" \/>\n                            <span id='input_7_8_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_8' class='gform_hidden' value='https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_7_8'>Format: mm\/dd\/yyyy<\/div><\/div><div id=\"field_7_9\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_9'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_7_9' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_7_9_date_format gfield_description_7_9\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_9_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_9' class='gform_hidden' value='https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_7_9'>Format: mm\/dd\/yyyy<\/div><\/div><fieldset id=\"field_7_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half male-female-buttons field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Male or Female<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_10'>\n\t\t\t<div class='gchoice gchoice_7_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Male'  id='choice_7_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_0' id='label_7_10_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Female'  id='choice_7_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_1' id='label_7_10_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half vet-dep-buttons gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Veteran or a dependent? If this is a dependent, there may be a fee due on the day of burial.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_11'>\n\t\t\t<div class='gchoice gchoice_7_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Veteran'  id='choice_7_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_0' id='label_7_11_0' class='gform-field-label gform-field-label--type-inline'>Veteran<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Dependent'  id='choice_7_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_1' id='label_7_11_1' class='gform-field-label gform-field-label--type-inline'>Dependent<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half marriage-status-buttons gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_13'>\n\t\t\t<div class='gchoice gchoice_7_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Never Married'  id='choice_7_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_13_0' id='label_7_13_0' class='gform-field-label gform-field-label--type-inline'>Never Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Married'  id='choice_7_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_13_1' id='label_7_13_1' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Divorced'  id='choice_7_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_13_2' id='label_7_13_2' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Widowed'  id='choice_7_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_13_3' id='label_7_13_3' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half if-married-buttons gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If married, is surviving spouse a veteran? If yes, return discharge documents with this form.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_14'>\n\t\t\t<div class='gchoice gchoice_7_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_7_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_14_0' id='label_7_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_7_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_14_1' id='label_7_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_51\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full sub-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Home of record at time of death<\/p><\/div><div id=\"field_7_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_52'>Zipcode<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_7_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_53'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_7_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_54'>Parish\/County<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_7_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_55'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_7_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half buried-buttons gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is a spouse or dependent already buried in this cemetery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_57'>\n\t\t\t<div class='gchoice gchoice_7_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_7_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_57_0' id='label_7_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_7_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_57_1' id='label_7_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_58'>If yes, please enter name<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_7_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_15\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Veteran and Military Service Information<\/h2><\/div><fieldset id=\"field_7_16\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Veteran&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_7_16'>\n                            \n                            <span id='input_7_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.3' id='input_7_16_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_16_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_7_16_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.4' id='input_7_16_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_16_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_7_16_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.6' id='input_7_16_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_16_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_7_16_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.8' id='input_7_16_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_16_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_7_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_17'>Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_7_17' type='text' value='' class='large'  aria-describedby=\"gfield_description_7_17\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_17'>Format: 123-45-6789<\/div><\/div><fieldset id=\"field_7_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third male-female-buttons field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Male or Female<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_56'>\n\t\t\t<div class='gchoice gchoice_7_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Male'  id='choice_7_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_56_0' id='label_7_56_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Female'  id='choice_7_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_56_1' id='label_7_56_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_18\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_18'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_7_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_7_18_date_format gfield_description_7_18\" aria-invalid=\"false\" \/>\n                            <span id='input_7_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_18' class='gform_hidden' value='https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_7_18'>Format: mm\/dd\/yyyy<\/div><\/div><div id=\"field_7_19\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_19'>Branch of Service<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_7_19' class='large gfield_select'     aria-invalid=\"false\" ><option value='Army' >Army<\/option><option value='Marine Corps' >Marine Corps<\/option><option value='Navy' >Navy<\/option><option value='Air Force' >Air Force<\/option><option value='Space Force' >Space Force<\/option><option value='Coast Guard' >Coast Guard<\/option><option value='National Guard\/Reserve' >National Guard\/Reserve<\/option><\/select><\/div><\/div><div id=\"field_7_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_20'>Highest Rank Held<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_7_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_61'>Year Entered Service<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_7_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_62'>Year Exited Service<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_7_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full retired-buttons gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Retired from Service (More than 20 Years)? Discharge documents must match this info.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_23'>\n\t\t\t<div class='gchoice gchoice_7_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_7_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_0' id='label_7_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_7_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_1' id='label_7_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_25\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_25'>Any other information the cemetery should know about the veteran&#039;s service?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_7_25' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_7_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half crime-buttons gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has the deceased or veteran ever been convicted of a state or federal crime which the punishment could be life imprisonment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_26'>\n\t\t\t<div class='gchoice gchoice_7_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_7_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_26_0' id='label_7_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_7_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_26_1' id='label_7_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_27\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Contact Information for Scheduling (Must be funeral home if a casket burial)<\/h2><\/div><div id=\"field_7_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_28'>Funeral Home (Required if Casket)<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_7_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_29'>Contact Person<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_7_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_30\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_30'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_7_30' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_7_30\"  \/><\/div><div class='gfield_description' id='gfield_description_7_30'>Format: (123) 456-7890<\/div><\/div><div id=\"field_7_31\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_31'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_31' id='input_7_31' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_7_31\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_7_31'>Format: sample@domain.com<\/div><\/div><div id=\"field_7_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_32'>Family Contact Name<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_7_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_33\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_33'>Relationship<\/label><div class='ginput_container ginput_container_select'><select name='input_33' id='input_7_33' class='large gfield_select'     aria-invalid=\"false\" ><option value='Spouse' >Spouse<\/option><option value='Son' >Son<\/option><option value='Daughter' >Daughter<\/option><option value='Mother' >Mother<\/option><option value='Father' >Father<\/option><option value='Sibling' >Sibling<\/option><option value='Next of Kin' >Next of Kin<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_7_34\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_34'>Family Contact Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_34' id='input_7_34' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_7_34\" autocomplete=\"tel\" \/><\/div><div class='gfield_description' id='gfield_description_7_34'>Format: (123) 456-7890<\/div><\/div><div id=\"field_7_35\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_35'>Family Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_35' id='input_7_35' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_7_35\" autocomplete=\"email\"\/>\n                        <\/div><div class='gfield_description' id='gfield_description_7_35'>Format: sample@domain.com<\/div><\/div><div id=\"field_7_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_36'>Legal next of kin name (If different from above)<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_7_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_37\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_37'>Relationship<\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_7_37' class='large gfield_select'     aria-invalid=\"false\" ><option value='Spouse' >Spouse<\/option><option value='Son' >Son<\/option><option value='Daughter' >Daughter<\/option><option value='Mother' >Mother<\/option><option value='Father' >Father<\/option><option value='Sibling' >Sibling<\/option><option value='Next of Kin' >Next of Kin<\/option><\/select><\/div><\/div><div id=\"field_7_48\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_48'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_48' id='input_7_48' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_7_48\"  \/><\/div><div class='gfield_description' id='gfield_description_7_48'>Format: (123) 456-7890<\/div><\/div><fieldset id=\"field_7_38\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_38' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_38_1_container' >\n                                        <input type='text' name='input_38.1' id='input_7_38_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_7_38_1' id='input_7_38_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_38_3_container' >\n                                    <input type='text' name='input_38.3' id='input_7_38_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_7_38_3' id='input_7_38_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_38_4_container' >\n                                        <select name='input_38.4' id='input_7_38_4'     aria-required='true'   autocomplete=\"address-level1\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' selected='selected'>Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_38_4' id='input_7_38_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_38_5_container' >\n                                    <input type='text' name='input_38.5' id='input_7_38_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_7_38_5' id='input_7_38_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_38.6' id='input_7_38_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_7_39\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Interment\/Service Information<\/h2><\/div><fieldset id=\"field_7_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half interment-types-checkboxes field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Interment Types (Select One)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_40'><div class='gchoice gchoice_7_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Casket (In ground)'  id='choice_7_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_1' id='label_7_40_1' class='gform-field-label gform-field-label--type-inline'>Casket (In ground)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Columbarium Wall (Niche\/Cremains)'  id='choice_7_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_2' id='label_7_40_2' class='gform-field-label gform-field-label--type-inline'>Columbarium Wall (Niche\/Cremains)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='In-Ground Burial (Cremains)'  id='choice_7_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_3' id='label_7_40_3' class='gform-field-label gform-field-label--type-inline'>In-Ground Burial (Cremains)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Scatter Garden (Memorial Wall)'  id='choice_7_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_4' id='label_7_40_4' class='gform-field-label gform-field-label--type-inline'>Scatter Garden (Memorial Wall)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_42'>If casket is over 28&quot; wide, insert measurements<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_7_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half spouse-burial-buttons field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will a spouse be buried with decedent in the future?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_44'>\n\t\t\t<div class='gchoice gchoice_7_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_7_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_44_0' id='label_7_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_7_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_44_1' id='label_7_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half spouse-burial-yes-buttons field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If yes, will subsequent spouse be<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_45'>\n\t\t\t<div class='gchoice gchoice_7_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Casketed'  id='choice_7_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_45_0' id='label_7_45_0' class='gform-field-label gform-field-label--type-inline'>Casketed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Cremated'  id='choice_7_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_45_1' id='label_7_45_1' class='gform-field-label gform-field-label--type-inline'>Cremated<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_45_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Undecided'  id='choice_7_45_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_45_2' id='label_7_45_2' class='gform-field-label gform-field-label--type-inline'>Undecided<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full services-requested-checkboxes field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Services Requested at Cemetery (No funerals are held at cemetery)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_46'><div class='gchoice gchoice_7_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Very brief committal service with honors at committal shelter'  id='choice_7_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_46_1' id='label_7_46_1' class='gform-field-label gform-field-label--type-inline'>Very brief committal service with honors at committal shelter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='Brief committal service only (No honors)'  id='choice_7_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_46_2' id='label_7_46_2' class='gform-field-label gform-field-label--type-inline'>Brief committal service only (No honors)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_46_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.3' type='checkbox'  value='Honors only (Veteran)'  id='choice_7_46_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_46_3' id='label_7_46_3' class='gform-field-label gform-field-label--type-inline'>Honors only (Veteran)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_46_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.4' type='checkbox'  value='Direct burial (Not using shelter)'  id='choice_7_46_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_46_4' id='label_7_46_4' class='gform-field-label gform-field-label--type-inline'>Direct burial (Not using shelter)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_63\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_7_63'>Discharge Documents (DD-214, Retirement ID Card, etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_7_63' 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class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_7_63' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_7_63 gfield_description_7_63\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_7_63'>Accepted file types: pdf, jpg, Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_7_63'><\/ul> <div id='gform_preview_7_63' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_7_63'>Any information we will need to determine eligibility<\/div><\/div><div id=\"field_7_47\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bulleted-list gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><ul>\n<li>Funeral home is responsible for requesting military honors and providing the burial flag<\/li>\n<li>A burial transit permit must accompany all casketed remains<\/li>\n<li>By submitting this form I accept and agree with all va regulations for burial<\/li>\n<li>Funeral home is responsible for verifying marriage documents to ensure the eligibility of spouses<\/li>\n<\/ul><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_7' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' 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