Medal Number (if applicable) ________________
Name of Confederate Veteran _______________________________________________
Name of Regiment ________________________________________________________
Enlistment Date (if known) _______________________________________
Discharge Date (if known) _______________________________________
Date of Bestowal (if known) ______________________________________
Name of UDC Chapter _________________________________ No. _______________
City ______________________________________________ State ______________
Who recieved the medal? __________________________________________________
(i.e, veteran, widow, son, daughter, grandson, granddaughter, etc.)Is Recipient's name engraved on the medal? Yes _____ No ______
Do you have a copy of the original Cross of Honor application ? Yes _____ No _____
If so, please include a copy with this form.Who currently owns this medal? _____________________________________________
Where is the medal currently located? ________________________________________
Was this medal donated to the UDC? Yes ______ No _______
If not, would they consider donating it to the UDC? Yes _____ No ______Is this Southern Cross of Honor Medal currently for sale? Yes _____ No ______
Was this found through an online auction like Ebay? Yes ______ No ________
If so, please give item number and final purchase price _________________ $_________
Give the name of the website and/or the URL ___________________________________** Please include a color photograph if possible.**
Name of person filling out this form ___________________________________________
UDC Chapter ____________________________________ Chapter No. ____________
City/Town _____________________________________________ State____________
Address: _______________________________________________________________
Email ______________________________________ Phone______ ________________******************************************
Mail this form to: Vanessa Burzynski 10933 Hwy 90 North, Bedias, Texas 77831-9325