DA Form 2122-1 "Statement of Compliance, Transfer of Custody, and Interment Checklist"

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What Is DA Form 2122-1?

This is a military form that was released by the U.S. Department of the Army (DA) on October 1, 2020. The form, often mistakenly referred to as the DD Form 2122-1, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

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Download DA Form 2122-1 "Statement of Compliance, Transfer of Custody, and Interment Checklist"

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STATEMENT OF COMPLIANCE, TRANSFER OF CUSTODY, AND INTERMENT CHECKLIST
For use of this form, see DA PAM 290-5; the proponent agency is OAC.
NAME OF DECEDENT (LAST, FIRST, MIDDLE)
DATE OF DEATH
NAME OF CEMETERY
I,
understand that the statuses listed below are in order of precedence and attest that there is no other
living person to my knowledge with a higher precedence than the one I indicated, and that I am the primary next-of-kin (PNOK) and/or person authorized to
direct disposition (PADD) for the above named decedent by virtue of being his/her:
PADD (DESIGNATED ON DD FORM 93 OR OTHER LEGAL DOCUMENT)
SPOUSE
ELDEST LIVING CHILD
ELDEST LIVING PARENT
COURT ORDERED LEGAL CUSTODIAN
ELDEST LIVING SIBLING
ELDEST LIVING GRANDPARENT
Other:
I acknowledge that I must provide proof of eligibility prior to the scheduling of services. Furthermore, to the best of my knowledge, the decedent was never
convicted or found to have committed a Federal or State capitol crime as referenced in 38 USC 2411(b).
I understand that interment in this cemetery implies my agreement to comply with all cemetery rules and regulations to include future eligibility for interment,
floral policy, and private monument restrictions.
If decedent is cremated, I further attest that 100% of the complete cremated remains (less an allowable 1 ounce removed for commemorative items) and only
the cremated remains of the above name decedent are being transferred to the cemetery representative with no intent to retain partial cremated remains for
scattering, interment/inurnment elsewhere, or retention for other purposes.
)
If I am the eligible service member or veteran, I agree to be interred in the same grave/niche (location:
upon my own death, and direct my PNOK/PADD to carry out this commitment. I further agree that, should I become ineligible for interment in the cemetery or
should I or my PNOK/PADD decide in the future that I will be interred elsewhere, my dependent's remains may be subject to removal at no expense to the
Government. I make the following declaration in accordance with 28 U.S.C. §1746. I am aware this declaration is the legal equivalent of a statement under
oath. I declare under penalty of perjury that I have carefully read this declaration, that the contents of this declaration are true and correct to the best of my
knowledge, and I have signed this declaration of my own voluntary act.
NAME OF PNOK/PADD
SIGNATURE
DATE
NAME OF WITNESS
SIGNATURE
DATE
NAME OF WITNESS
SIGNATURE
DATE
***************************
***************************
TO BE COMPLETED BY CEMETERY STAFF
TRANSFER OF POSSESSION OF REMAINS:
The person authorized to direct disposition or contractual funeral director thereof, hereby transfers possession
of the remains of the decedent named above to
Cemetery for final disposition.
Container Type:
Condition:
Director's License #:
RECEIVED FROM
RECEIVED BY
DISPOSITION
DATE/TIME
CONTAINER TAGGED
CONTAINER VERIFIED
CONTAINER & TAG PHOTOGRAPHED
DA FORM 2122-1, OCT 2020
APD AEM v1.00ES
PAGE 1 of 2
STATEMENT OF COMPLIANCE, TRANSFER OF CUSTODY, AND INTERMENT CHECKLIST
For use of this form, see DA PAM 290-5; the proponent agency is OAC.
NAME OF DECEDENT (LAST, FIRST, MIDDLE)
DATE OF DEATH
NAME OF CEMETERY
I,
understand that the statuses listed below are in order of precedence and attest that there is no other
living person to my knowledge with a higher precedence than the one I indicated, and that I am the primary next-of-kin (PNOK) and/or person authorized to
direct disposition (PADD) for the above named decedent by virtue of being his/her:
PADD (DESIGNATED ON DD FORM 93 OR OTHER LEGAL DOCUMENT)
SPOUSE
ELDEST LIVING CHILD
ELDEST LIVING PARENT
COURT ORDERED LEGAL CUSTODIAN
ELDEST LIVING SIBLING
ELDEST LIVING GRANDPARENT
Other:
I acknowledge that I must provide proof of eligibility prior to the scheduling of services. Furthermore, to the best of my knowledge, the decedent was never
convicted or found to have committed a Federal or State capitol crime as referenced in 38 USC 2411(b).
I understand that interment in this cemetery implies my agreement to comply with all cemetery rules and regulations to include future eligibility for interment,
floral policy, and private monument restrictions.
If decedent is cremated, I further attest that 100% of the complete cremated remains (less an allowable 1 ounce removed for commemorative items) and only
the cremated remains of the above name decedent are being transferred to the cemetery representative with no intent to retain partial cremated remains for
scattering, interment/inurnment elsewhere, or retention for other purposes.
)
If I am the eligible service member or veteran, I agree to be interred in the same grave/niche (location:
upon my own death, and direct my PNOK/PADD to carry out this commitment. I further agree that, should I become ineligible for interment in the cemetery or
should I or my PNOK/PADD decide in the future that I will be interred elsewhere, my dependent's remains may be subject to removal at no expense to the
Government. I make the following declaration in accordance with 28 U.S.C. §1746. I am aware this declaration is the legal equivalent of a statement under
oath. I declare under penalty of perjury that I have carefully read this declaration, that the contents of this declaration are true and correct to the best of my
knowledge, and I have signed this declaration of my own voluntary act.
NAME OF PNOK/PADD
SIGNATURE
DATE
NAME OF WITNESS
SIGNATURE
DATE
NAME OF WITNESS
SIGNATURE
DATE
***************************
***************************
TO BE COMPLETED BY CEMETERY STAFF
TRANSFER OF POSSESSION OF REMAINS:
The person authorized to direct disposition or contractual funeral director thereof, hereby transfers possession
of the remains of the decedent named above to
Cemetery for final disposition.
Container Type:
Condition:
Director's License #:
RECEIVED FROM
RECEIVED BY
DISPOSITION
DATE/TIME
CONTAINER TAGGED
CONTAINER VERIFIED
CONTAINER & TAG PHOTOGRAPHED
DA FORM 2122-1, OCT 2020
APD AEM v1.00ES
PAGE 1 of 2
* COMPLETE APPLICABLE SECTIONS ONLY PER YOUR RESPECTIVE CEMETERY AND SERVICE *
NAME OF DECEDENT (LAST, FIRST, MIDDLE)
SECTION
ROW
GRAVE
COURT
SECTION
COLUMN
NICHE
DATE/TIME OF INTERMENT
PRESERVICE CHECKS
1. BURIAL LOCATION SAME AS ON DAILY SCHEDULE & INTAKE SHEET
2. BURIAL LOCATION ON TAG SAME AS ON DAILY SCHEDULE & INTAKE SHEET
30 MINUTES PRIOR CHECKS
1. GRAVESITE/COLUMNBARIUM SET UP FOR SERVICE
2. TEMPORARY MARKER MATCHES SCHEDULE, TAG, GRAVE LINER & LID
NICHE OPEN (1ST INURNMENT ONLY
3. GRAVESITE EXCAVATED
NOT EXCAVATED
4. INDICATE TO MILITARY/ESCORT: ROUTE, TIME, AND ANY UNUSUAL ASPECTS OF FUNERAL
AFTER SERVICE CHECKS
1. TYPE OF CASKET: METAL
WOOD
CLOTH COVERED
OTHER
2. TYPE OF URN: METAL
WOOD
CERAMIC
MARBLE
PLASTIC
STONE
OTHER
3. URN DIMENSIONS: H
W
D
4. CASKET/URN TAGGED
5. WEATHER
6. CHAPLAIN'S NAME
7. AWAY FROM GRAVE SETUP
NOTIFIED FAMILY
SHOWED FAMILY PERMANENT GRAVE
8. CASKET/URN, LOCATION, & TAG PHOTOGRAPHED AND UPLOADED TO ACCOUNTABILITY SYSTEM
I do hereby attest that the information listed above is verified and true. Furthermore, I am transferring custody of the remains to the Cemetery Caretaker.
NAME OF CEMETERY REPRESENTATIVE
DATE
SIGNATURE
NAME OF CEMETERY CARETAKER
SIGNATURE
DATE
FUNERAL DISCREPANCIES/OBSERVATIONS:
APD AEM v1.00ES
DA FORM 2122-1, OCT 2020
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