Dd Form 2063 – Fill Out and Use This PDF

The public reporting burden for this collection of information, 0704-0231, is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc- alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE ADDRESS IN BLOCK 1.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Sections 1481 through 1488; E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To record services performed by a licensed mortician in the reprocessing of remains and any expenses incurred.

ROUTINE USE(S): In addition to those disclosures generally permitted under Title 5 US Code Section 552a(b) of the Privacy Act of 1974, these records

contained therein may specifically be disclosed outside the DoD as a routine use pursuant to Title 5 US Code Section 552a(b)(3) as follows: Information from these records record services performed by a licensed mortician in the reprocessing of remains and any reimbursements received with the decedent. A licensed mortician will inspect remains to determine the degree of reprocessing needed. This information is vital for recording and cross checking services performed when reprocessing remains. Without the information, the government would not be able justify the incurred expenses and reimbursements received. The DoD Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and Accountability Act of 1996, applies to most such health information. DoD 6025.18-R may place additional procedural requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this system of records notice.

DISCLOSURE: Disclosure of information is mandatory IAW 10 U.S.C. Sections 1481 through 1488.

b. ADDRESS (Street, Apartment Number, City, State, ZIP Code)

4. DECEDENT DATA

a. NAME (Last, First, Middle Initial)

d. ORGANIZATION

e. BRANCH OF SERVICE

a. ARMY b. NAVY c. AIR FORCE

b. GRADE	c. SSN or DoD ID NUMBER	d. MARINE CORPS
		e. OTHER (Specify):
f. DATE OF DEATH (YYYYMMDD)		g. MEANS OF IDENTIFICATION

5. PERSON AUTHORIZED THE DISPOSITION OF THE REMAINS

b. RELATIONSHIP OF PERSON DIRECTING DISPOSITION

6. MORTUARY DATA

a. REMAINS RECEIVED AT MORTUARY		b. EMBALMING STARTED		c. EMBALMING ENDED
DATE (YYYYMMDD)	HOUR	DATE (YYYYMMDD) HOUR		DATE (YYYYMMDD)		HOUR
d. EXPLAIN ANY DELAY IN AUTOPSY, PREPARATION, INSPECTION			e. TYPE OF CASE
OR SHIPMENT OF REMAINS
			a. AUTOPSIED	b. NOT AUTOPSIED		c. VIEWABLE
			d. MUTILATED	e. NON-VIEWABLE
			f. VIEWABLE FOR IDENTIFICATION

g. OTHER (Specify):

AEM LiveCycle Designer

7. EMBALMING TREATMENT AND RESULTS

a. ARTERIES INJECTED R L

R

L

b. VEINS DRAINED R L

c. FLUID DILUTIONS

(1)

Carotid

(5)

Iliac

(1)

Jugular

(1)

Index of Concentrated Arterial Fluid

(2)

Subclavian

(6)

Femoral

(2)

Axillary

(2)

Index of Concentrated Cavity Fluid

(3)

Axillary

(7)

Radial

(3)

Iliac

(3)

Preinjection Fluid

Oz.

Gal.

(4)

Brachial

(8)

Ulnar

(4)

Femoral

(4)

1st Injection

Oz.

Gal.

d. HARDENING COMPOUND

e. DRAINAGE

(5)

2nd Injection

Oz.

Gal.

USED (lbs)

Gal.

(6)

3rd Injection

Oz.

Continuous

Restricted

Intermittent

Gal.

(7)

4th Injection

Oz.

8. ADDITIONAL PREPARATION REQUIRED

f. TOTAL CONCENTRATED FLUID USED

a. AREAS HYPODERMICALLY EMBALMED

(1) Arterial

Oz.

(2) Cavity

Oz.

(3) Preinjection

Oz.

(4) Humectant

Oz.

b. PARTS RECEIVING POOR CIRCULATION AND HOW TREATED

(5) Other

Oz.

c. RESTORATION TREATMENT (Describe and state reason if features are not restored)

d. PREPARING EMBALMER

(1) NAME

(2) LICENSE NUMBER

(3) STATE

(4) SIGNATURE

9. CASKET / URN

a. CASKET USED

b. NAME OF CASKET MANUFACTURER

c. URN USED

d. NAME OF URN MANUFACTURER

Metal

Cremation

Metal

Wood

Oversized

Wood

10. EXPENSE DATA

PREPARATION SERVICE OBTAINED BY:

Annual Contract

One-Time Contract

a. Recovery of Remains

g. Transportation of Remains

b. Casket

Method of Shipment

c. Mortuary Services

(1) Air

(2) Overland

(3) Water

h. Transportation of Escort

d. Clothing

(1) Air

(2) Rail

(3) Bus

e. Flag

(4) Ship/Boat

(5) Per Diem

f. Cremation

COMPLETE TOTAL

11. INTERMENT EXPENSES

a. PAYEE

b. AMOUNT PAID

12.INDICATE REASON(S), IF OVERSIZED CASKET USED

13.CONTRACTOR CERTIFICATION

I certify that the supplies and services furnished meet the terms and specifications of the contract, and the remains and supplies should be in a satisfactory condition at final destination.

AEM LiveCycle Designer

14. INSPECTION DATA (Remains, Casket and Shipping Container)				YES	NO	N/A
a. REMAINS (To be completed before remains are clothed)
(1)	Remains bathed to present a clean appearance
(2)	Face shaven; moustache, if any, and hairs protruding from nose and ears trimmed
(3)	Facial features and hands arranged to present a natural appearance
(4)	Fingernails clean and trimmed
(5)	Orifices
(6)	Abrasions, wounds and incisions sealed to prevent drainage and leakage	(Embalmer's Initial	)
(7)	Remains adequately preserved and disinfected	(Embalmer's Initial	)

b. REMAINS (To be completed during clothing and after casketing remains)

(1) Identification tags with remains

(2) Cosmetics applied to present a natural appearance of hands and face

(3) Eyelashes, eyebrows and hair free of cosmetics

(4) Hair styled (for female personnel)

(5) Restorative work appears natural

(6) Proper underclothing placed on remains

(7) Entire uniform clean, pressed and satisfactory in appearance and fit

(8) Epaulet ends under collar, tie in place, buttons and belt properly fastened and decorations correctly placed

(9) Remains present an appearance of repose in casket

(10) Clearance between head and end of casket adequate

(11) Non-viewable remains properly wrapped and secured in position

(12) Uniform placed over non-viewable wrapped remains

c. CASKET

(1) Casket meets specifications

(2) Interior and exterior of casket are clean and unmarred

(3) Casket properly closed and/or sealed

d. SHIPPING CONTAINER

(1) Shipping Container is properly marked

(2) Shipping Container is properly closed and/or sealed

c. INSTALLATION OR DEPARTMENT

d. REMARKS (Indicate item reference number, when applicable)

AEM LiveCycle Designer