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Funeral Escort Request
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This form has been modified since it was saved. Please review all fields before submitting.
The Purcellville Police Department requires 48-hours advanced notice for any funeral escort. Once your online form is submitted, you will receive confirmation of receipt as well as escort availability.
Date of Request
*
Deceased Last Name:
*
Deceased First Name:
*
Requester Name:
*
Requester Email Address:
*
Funeral Home Phone Number:
*
Contact Cell Phone:
*
Funeral Home Name:
*
Funeral Home Address:
*
Date of Escort:
*
Time of Escort:
*
Location Name of Service:
*
Address of Service:
*
Location Name of Burial:
*
Address of Burial:
*
Number of Vehicles in Escort:
*
Email address:
*
The Purcellville Police Department will confirm reciept of this request through the above email address.
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