Burial Assistance Application

Name of deceased Ounalashka Corporation Shareholder:__________________________

Most recent address:_______________________________________________________

________________________________________________________________________

Social Security Number:____________________________________________________

Date of Birth:____________________  Date of Death:____________________________

Funeral Home address:_____________________________________________________

________________________________________________________________________

Phone:____________________________  Fax:_________________________________

Applicant name:__________________________________________________________

Relationship to the deceased:________________________________________________

Applicant’s address:_______________________________________________________

________________________________________________________________________

Phone:____________________________  Fax:_________________________________

Email address:____________________________________________________________

Signature:_______________________________________________________________

A death certificate must be received before this application can be processed. If payment is not made directly to a funeral home, the applicant can be reimbursed for up to $1000.00 for funeral expenses upon receipt or invoice of those expenses.