36C78619Q0004-017.pdf

APPENDIX B - TRANSFER OF BLANK GOVERNMENT-FURNISHED HEADSTONES,

MARKERS, OR NICHE COVERS

I certify that the blank headstones, markers, or niche covers specified below were transferred to the VA contractor listed at the bottom of the form.

Printed Name of Cemetery Personnel: ________________________________

Signature:_________________________________________Date:___________

Check the appropriate box and insert the quantity for the type of headstone, marker or niche cover being transferred to the on-site contractor.

(A1) Blank Marble Memorial Wall Marker Quantity: ______

(C1) Blank Granite Memorial Wall Marker Quantity: ______

(H1) Blank Granite Niche Cover Quantity: ______

(I1) Blank Marble Niche Cover Quantity: ______

(J1) Blank Granite Marker, Thin Flat 3” Quantity: ______

(L1) Blank Granite Marker, Small Flat 3” Quantity: ______

(U1) Blank Marble Upright Headstone Quantity: ______

(W1) Blank Granite Upright Headstone Quantity: ______

List any rejects below, include type and quantity:

I certify that the headstones, markers, or niche covers specified above were received by me and the quantity of items has been verified.

Printed Name of VA Contractor:__________________________________

Signature:_________________________________________Date:___________