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2. 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.
4. Date of Request*
6. Deceased Last Name:*
7. Deceased First Name:*
9. Requester Name:*
10. Requester Email Address:*
12. Funeral Home Phone Number:*
13. Contact Cell Phone:*
15. Funeral Home Name:*
16. Funeral Home Address:*
18. Date of Escort:*
19. Time of Escort:*
21. Location Name of Service:*
22. Address of Service:*
24. Location Name of Burial:*
25. Address of Burial:*
27. Number of Vehicles in Escort:*
29. Email address:*
    The Purcellville Police Department will confirm reciept of this request through the above email address.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field