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Internment Request Form
Funeral Home Information
Business Name
*
Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Internment Location
Cemetery Name
*
Manassas Cemetery
Rose Hill
Section #
Plot #
Is documentation of ownership available?
Yes
No
Upload documentation of ownership
Browse Files
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Choose a file
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of
Internment Service
Graveside Date and Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Existing Head Stone
*
Yes
No
I understand that the City of Manassas cost for full burial is $690 or for cremation is $360
*
Yes
No
I understand that a vault is required for burial, but not provided by the City of Manassas
*
Yes
No
Special Requests:
Deceased's Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Death
*
-
Month
-
Day
Year
Date
Next of Kin
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
By clicking I agree, I am acknowledging that everything on this form is correct to the best of my knowledge.
*
I agree
I do not agree
Please verify that you are human
*
Submit
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