D9182 Claim for compensation of Funeral Expenses and ...

SECTION ADeceased’s Personal Details1 DVA File No. (if known)Where known, please providethe DVA file number for allclaims made to DVA inrelation to the conditionsregarded as the deceased’scause of death.2 Full nameTitle Mr Mrs Miss Ms OtherSurnameGiven name(s)Previous name(if applicable)3 Date of birth4 Gender Male FemaleService Details5 Service Number/PMKeysNumber6 Service Arm Army Navy RAAFDate of enlistmentDate of dischargeDetails of Death7 Has death liability alreadybeen determined by DVA?NoDate of deathTime of deathPlease briefly describe the events that led to the (ex)member’s death.In the case of a claim that involved death from disease please explain why youbelieve employment with the Military caused or materially contributed to thedisease.Please attach a copy of the death certificateYesPlease provide DVA File Number and go directly to Section BD9182 11/13 P4 of 12