DD Form 2065 Disposition of Remains - Reimburseable Basis

OMB No. 0704-0030
OMB approval expires

DISPOSITION OF REMAINS - REIMBURSABLE BASIS
(Read Privacy Act Statement on back before completing form.)

The public reporting burden for this collection of information is estimated to average 20 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, Executive Services Directorate, Directives Division, 4800 Mark Center
Drive, Alexandria, VA 22350-3100 (0704-0030). 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 ITEM 1.
1. TO: (Recipients and address authorized distribution)

2. NAME OF DECEASED (Last, First, Middle Initial)

3. RELATIONSHIP TO SPONSOR
4. NAME OF SPONSOR (Individual, Agency or Firm)
6. GRADE OF SPONSOR

5. ADDRESS OF SPONSOR (Street, City, State and ZIP Code)

7. SSN OF SPONSOR

I, THE UNDERSIGNED, DESIRE THAT DISPOSITION OF REMAINS BE EFFECTED AS INDICATED BELOW: ;DSSOLFDEOHRSWLRQ
8. OPTION 1
a. Preparation of remains at the Government mortuary and return of remains to a continental United States port of entry in a transfer case.
. I have reimbursed the Government
The port mortuary will furnish the requested services and supplies at a cost of $
in this amount. It is requested that the remains be shipped to the following funeral home:

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DD FORM 2065, 20151214 DRAFT

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PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Sections 1481 through 1488; E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To record the sponsor’s instructions for the remains. To record cost for necessary
services and supplies. To record the name, address, and telephone number of a person in CONUS who may be
contacted concerning the remains, if necessary.
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 may be
disclosed to the Department of Veterans Affairs, and other Federal agencies in connection with eligibility,
notification and assistance in obtaining benefits due. If deceased has no spouse, children, representative of
minor children, or an executor or personal representative named in the deceased's will, then information from
these records may be released to the primary next of kin (PNOK) family member(s) of the injured or deceased
DoD personnel to aid in the settlement of the member's estate. The DoD Blanket Routine Uses at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx also apply to this system.
NOTE: This system of records contains individually identifiable health information. 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.

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DISCLOSURE: Voluntary; however, failure to furnish the requested information may delay processing and
shipment of remains to final destination.

DD FORM 2065 (BACK), 20151214 DRAFT