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2. Input on VA issues

   The board’s goal is to gather information for legislators and senators that shows them how citizens are being affected. We are seeking out individuals who are having issues related to being unable to obtain death certificates from the Veterans Affairs (VA) doctors upon the death of a military member in your family.

4. Reporting Party Information
6. First Name
7. Last Name
9. Email Address
10. I am
    -- Select One --family of decedenta funeral home providermedical examiner/coroner staff
14. Name of Decedent
15. Date of Death
17. Location of Death
19. Please explain the impacts delayed death certificates from the VA have had on you
21. I understand that by submitting this form I am volunteering my information to be shared with legislators. I recognize this is not an immediate remedy to the situation, but simply a way to give input on it. *

    1. I have read the above statement and agree.
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

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