` 

 

VA Office of Inspector General

OFFICE OF AUDITS AND EVALUATIONS

National Cemetery 

Administration 

Audit of 

Internal Gravesite 

Review of Headstone 

and Marker Placement 

February 7, 2013 

12-02223-98 
 

ACRONYMS AND ABBREVIATIONS 

BOSS Burial Operations Support System 

MSN Memorial Service Network 

NCA National Cemetery Administration 

OIG Office of Inspector General 

VA Veterans Affairs 

To Report Suspected Wrongdoing in VA Programs and Operations: 

Telephone: 1-800-488-8244 

Email: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
 

Report Highlights: Audit of NCA’s 

Internal Gravesite Review of 

Headstone and Marker Placement 

Why We Did This Audit

The National Cemetery Administration 

(NCA) mission is to honor veterans with 

final resting places in National shrines with 

lasting tributes commemorating their service 

to our Nation. In October 2011, the Deputy 

Under Secretary for Field Programs directed 

each Memorial Service Network to conduct 

gravesite reviews of headstone and marker 

placements at VA National cemeteries. At 

the request of the Chairman of the House 

Committee on Veterans’ Affairs, we 

conducted this audit to determine if NCA 

adequately identified and addressed issues 

found during its Phase One internal 

gravesite review. 

What We Found 

NCA’s Phase One review procedures did not 

identify and report all misplaced headstones 

and unmarked gravesites. At four of 12 

National cemeteries, we identified seven 

misplaced headstones or unmarked 

gravesites, as well as outdated and illegible 

maps. This occurred because NCA did not 

have an impartial and independent review 

procedure to accurately identify and report 

misplaced headstones and unmarked 

gravesites. Further, NCA did not provide 

sufficient time and resources needed to 

conduct a review of this magnitude, and 

Memorial Service Networks did not provide 

cemetery directors with updated and 

accurate gravesite layout maps. 

As a result, on July 5, 2012, we issued a 

Management Advisory Memorandum to the 

Under Secretary for Memorial Affairs 

recommending NCA revise its procedures 

for completing internal gravesite reviews. 

After revising its procedures, NCA 

conducted its Phase One follow up and 

identified 146 additional errors at four of 

12 cemeteries we reviewed. 

What We Recommended 

We recommended the Under Secretary for 

Memorial Affairs ensure implementation of 

the recommendations in the Management 

Advisory Memorandum; take corrective 

actions for the additional errors identified in 

this report, implement procedures to assess 

cemetery size and director responsibility 

before conducting additional reviews, and 

implement controls to ensure gravesite 

layout maps are current and accurate. 

Agency Comments 

The Under Secretary for Memorial Affairs 

agreed with our recommendations and 

provided an appropriate action plan. We 

will follow up on the implementation of 

corrective actions. 

LINDA A. HALLIDAY 

Assistant Inspector General 

for Audits and Evaluations 

VA Office of Inspector General i 
TABLE OF CONTENTS 

Introduction .....................................................................................................................................1
 

Results and recommendations .........................................................................................................2
 

Finding NCA’s Internal Gravesite Review Procedures Need Strengthening .................. 2
 

Recommendations ............................................................................................. 8
 

Appendix A Background ..................................................................................................... 10
 

Appendix B Scope and Methodology .................................................................................. 12
 

Appendix C Statistical Sampling Methodology .................................................................. 14
 

Appendix D OIG Management Advisory Memorandum, July 5, 2012 ............................... 15
 

Appendix E NCA’s Response to OIG’s Management Advisory Memo, July 25, 2012 ...... 18
 

Appendix F Under Secretary for Memorial Affairs Comments .......................................... 20
 

Appendix G Office of Inspector General Contact and Staff Acknowledgments .................. 26
 

Appendix H Report Distribution ......................................................................................... 27
 

VA Office of Inspector General ii 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Objective 

Organizational 

Overview 

NCA’s Internal 

Gravesite 

Reviews 

INTRODUCTION 

At the request of the Chairman of the House Committee on Veterans’ 

Affairs, we conducted this audit to determine whether the National Cemetery 

Administration (NCA) adequately identified and addressed issues found 

during NCA’s Phase One internal gravesite review. 

NCA’s mission is to honor veterans and their families with final resting 

places in National shrines and with lasting tributes that commemorate their 

service to our Nation. In FY 2011, NCA conducted approximately 

117,000 interments and processed 373,000 applications for headstones and 

markers for placement in cemeteries. Memorial Service Networks (MSNs) 

provide direction, operational oversight, and engineering assistance to the 

cemeteries located in their geographic areas. 

In October 2011, NCA directed MSN and cemetery directors to conduct a 

system-wide review of all gravesites within the National cemetery system 

that had undergone projects to raise and realign headstones and markers. 

NCA conducted the review in two phases. Phase One verified headstone and 

marker placements in all cemetery burial sections where “raise and realign” 

projects had been completed. In March 2012, the Under Secretary for 

Memorial Affairs provided a statement to the House Committee on Veterans’ 

Affairs concerning the progress of NCA’s system-wide internal review of 

gravesites within the National cemetery system. According to his statement, 

NCA conducts raise and realign projects to ensure headstones and markers 

are maintained at proper height and alignment. In addition, he stated that 

these major renovation projects are critical to NCA’s ability to meet 

veterans’ expectations and its National shrine standards. When a headstone 

or marker is set on an incorrect gravesite, it is considered misplaced. When 

there is no headstone or marker on a gravesite, it is considered unmarked. 

NCA reviewed nearly 1.6 million of 3.1 million gravesites at 93 National 

cemeteries during its Phase One review. Phase Two verified headstone and 

marker placements in the remaining cemetery burial sections where raise and 

realign projects were not completed. NCA completed the Phase Two 

gravesite review in June 2012, and expected to finalize and report the results 

by December 31, 2012. 

Appendix A provides additional background information. Appendix B 

provides information about the audit scope and methodology, and 

Appendix C provides the statistical sampling methodology used in the audit. 

VA Office of Inspector General 1 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Finding 

NCA’s Review 

Guidance 

MSN Review 

Responsibilities 

RESULTS AND RECOMMENDATIONS 

NCA’s Internal Gravesite Review Procedures Need 

Strengthening 

NCA’s Phase One review procedures did not identify and report all 

misplaced headstones and unmarked gravesites. At 4 of 12 National 

cemeteries, we identified seven misplaced headstones or unmarked 

gravesites, as well as outdated and illegible maps. However, the cemetery 

directors at two of the four cemeteries where we identified errors certified 

the accurate placement of all headstones and did not report any 

discrepancies. These errors occurred because of the following: 

	 NCA procedures lacked sufficient controls to ensure an impartial and 

independent review to accurately identify and report misplaced 

headstones and unmarked gravesites. 

	 NCA did not provide sufficient time and resources needed to conduct a 

review of this magnitude. 

	 MSNs did not provide cemetery directors with updated and accurate 

gravesite layout maps. 

As a result, on July 5, 2012, we issued a Management Advisory 

Memorandum recommending NCA revise its procedures for completing 

internal gravesite reviews. (For more information and details of these 

recommendations, see Appendix D.) NCA tested the new procedures at 

9 of 12 cemeteries that we visited. At the completion of Phase One, NCA 

had identified 251 errors after reviewing nearly 1.6 million gravesites at 

93 National cemeteries. After NCA revised its review procedures and 

conducted follow-up reviews of gravesites that were part of the Phase One 

review, NCA identified 146 additional gravesite errors at four of the 

nine cemeteries that were part of our sample. 

NCA issued Policy Memorandum NCA-41A-2012-01 on October 14, 2011, 

instructing cemetery directors or acting cemetery directors to complete the 

Phase One review by December 31, 2011. The memorandum provided 

guidance and responsibilities to the MSN and cemetery directors for 

completing their Phase One review. 

The responsibilities assigned to MSN officials follow: 

	 Coordinate with each cemetery to identify sections that were raised and 

realigned. 

	 Review the gravesite layout maps, confirm they are the correct maps for 

the review, and if necessary, update the maps. 

VA Office of Inspector General 2 
 

 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Cemetery 

Director Review 

Responsibilities 

Errors 

Reported by 

NCA for Phase 

One Review 

Management 

Advisory 

Memorandum 

	 Provide the cemetery director with correct, updated gravesite layout 

maps. 

	 Maintain a record of all discrepancies and report the location of the errors 

to the Deputy Under Secretary for Field Programs. 

The responsibilities assigned to the cemetery directors follow: 

	 Use the gravesite layout maps provided by the MSN to conduct the 

review for the raised and realigned sections identified. 

	 Review and verify that the realigned sections match the gravesite layout 

map. 

	 Verify that each headstone or marker in the entire section matches the 

gravesite layout map. 

	 Record and report any headstone or marker discrepancies to the MSN. 

	 Record and report all unidentifiable headstones or markers to the MSN. 

Before revising its review procedures, NCA identified 251 discrepancies at 

13 of 93 National cemeteries at the completion of the Phase One review. 

NCA classified the errors as 218 misplaced headstones, 25 unmarked 

gravesites, and eight misplaced veteran remains. According to 

congressional testimony provided by the Under Secretary in March 2012, 

NCA notified congressional committees, contacted next of kin where 

possible, and implemented corrective action plans once MSN staff verified 

the accuracy of the errors. 

In July 2012, we issued a Management Advisory Memorandum to the Under 

Secretary for Memorial Affairs because of our concerns that NCA’s Phase 

One internal gravesite review procedures were inadequate. After completing 

reviews at 6 of 12 National cemeteries, we identified 4 misplaced headstones 

and two unmarked gravesites, as well as outdated and illegible maps. A 

description of the gravesite errors follows: 

	 Winchester National Cemetery, Winchester, VA, is located in the 

MSN 1 area of responsibility. The cemetery director certified the 

accurate placement of all headstones and did not report any discrepancies 

to the MSN. Using NCA’s review procedures, we matched the headstone 

numbers to the gravesite map and identified two misplaced headstones 

and one unmarked gravesite. The cemetery director did not know why 

staff did not identify the errors during the initial Phase One review. 

	 Wood National Cemetery, Milwaukee, WI, is located in the MSN 4 area 

of responsibility. The cemetery director certified the accurate placement 

*

 We found a seventh gravesite error after we issued the advisory memorandum. The results 

of all 12 sample sites are at Appendix B. 

VA Office of Inspector General 3 
 

 

 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Table 1 

Reasons 

Review 

Procedures 

Needed 

Modification 

of all headstones and did not report any discrepancies to the MSN. 

However, we identified two misplaced headstones by following NCA 

procedures and using the gravesite layout maps. The cemetery director 

did not know why staff did not identify the errors during the initial Phase 

One review. 

	 Philadelphia National Cemetery, Philadelphia, PA, is located in the 

MSN 1 area of responsibility. While reviewing our sample using the 

gravesite layout maps, we identified one unmarked gravesite. The 

cemetery director did not know why the error was not identified during 

the initial Phase One review. 

The following table shows the number of gravesites reviewed by NCA, the 

errors NCA identified during its Phase One review, and the errors we 

identified at the same cemeteries prior to issuing the Management Advisory 

Memorandum. We reviewed 200 gravesites at each National cemetery. 

Gravesite Errors Identified 

Prior to Issuing the Management Advisory Memorandum 

MSN National Cemetery 

Gravesites 

Reviewed 

by NCA 

Errors 

Identified 

by NCA 

Errors 

Identified 

by OIG 

1 Philadelphia (PA) 11,041 13 1 

1 Winchester (VA) 5,097 0 3 

2 Bay Pines (FL) 27,304 0 0 

2 Marietta (GA) 16,960 0 0 

4 Jefferson Barracks (MO) 123,851 0 0 

4 Wood (WI) 25,531 0 2 

Total 209,784 13 6 

Source: NCA Phase One and VA OIG results as of June 8, 2012. 

We found NCA’s procedures lacked controls to ensure independence and did 

not provide adequate time and resources to conduct a review of this 

magnitude. In addition, MSN staff did not provide updated gravesite layout 

maps to cemetery directors. During our audit work, we recommended the 

Under Secretary for Memorial Affairs revise the internal gravesite review 

procedures, complete follow-up reviews of all Phase One and Phase Two 

National cemeteries, determine the reasons directors’ certifications did not 

disclose the errors we identified, and take appropriate administrative actions. 

NCA requested and we provided additional suggestions concerning revisions 

to its review procedures. This included consideration for the appropriate 

number of resources needed when reviewing cemeteries that differ in size, 

complexity, and age. 

VA Office of Inspector General 4 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Review 

Procedures 

Lacked 

Independence 

Adequate Time 

and Resources 

Needed To 

Conduct 

Reviews 

Phase Two began in April 2012, and NCA used the same procedures as the 

Phase One review. NCA cannot reasonably ensure that all misplaced 

headstones or unmarked gravesites were identified during the Phase Two 

review until follow-up reviews are completed using the revised procedures. 

Appendices D and E provides more information on the Management 

Advisory Memorandum and NCA’s response to the advisory. 

NCA’s policy memorandum limited the review process to the cemetery or 

the acting cemetery director. The memorandum stated the cemetery director 

could request exceptions through the MSN office and forward them to the 

Deputy Under Secretary for Field Programs for approval. 

Auditing principles and best practices state that review procedures have an 

independent element of checks and balances. Independent reviews increase 

objectivity and provide impartial judgment associated with conducting and 

reporting results. Assigning cemetery and MSN staff who are not directly 

associated with the cemetery to conduct reviews is an effective control to 

better identify gravesite errors and improve the accuracy and reliability of the 

review results. 

NCA planned the reviews without considering the variables among 

cemeteries, such as size, complexity, and age. Cemetery directors reviewed 

a range of 2,700 to nearly 124,000 gravesites for the 12 cemeteries we 

visited. NCA’s October 2011 policy memorandum instructed each cemetery 

director or acting cemetery director to complete the review and certify the 

accuracy of the results by December 31, 2011, without considering cemetery 

size. 

For the sites we visited, only two cemetery directors requested additional 

assistance in conducting the review by the completion date. During the week 

following the issuance of the policy memorandum, a cemetery director, who 

was responsible for reviewing over 123,000 gravesites at a large cemetery, 

requested and received approval for assistance to complete the review. 

According to the request, the director needed assistance due to the size of the 

cemetery and the geographical distance between the satellite locations 

assigned to him. Although the director at the second cemetery did not 

specify a reason, NCA granted approval for additional assistance in 

conducting the review of over 32,000 gravesites. 

Cemetery staff at nearly every site told us that completing the review in 

78 days (from October 14, 2011, through December 31, 2011), as well as 

continuing standard cemetery operations proved challenging. Considering 

the additional errors found by our auditors replicating NCA’s review 

procedures, we determined that cemetery directors were overwhelmed and 

felt pressure to complete the review by the target date. As a result, the 

necessary due diligence was not applied to identify all errors. In addition, 

VA Office of Inspector General 5 
 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Gravesite Maps 

Needed 

Updating 

Results of 

NCA FollowUp Reviews 

some directors were responsible for reviewing not only a large cemetery but 

the smaller satellite cemeteries assigned to them as well. 

NCA’s policy memorandum required MSN offices to review gravesite layout 

maps, make any necessary updates, and provide each cemetery director with 

the most current map to conduct the Phase One review. However, NCA did 

not ensure that the MSNs provided the cemetery directors with updated and 

accurate gravesite layout maps. 

Gravesite layout maps used to conduct the review at 4 of 12 cemeteries we 

visited were not accurate. We found the following types of map 

discrepancies: 

	 Maps showed reserved gravesites when the burial space was occupied. 

	 Maps showed an obstructed gravesite when the burial space was 

occupied. 

	 Maps showed duplicate gravesites. 

	 Maps did not include all gravesites. 

Cemetery directors’ responsibilities include ensuring gravesite layout maps 

are maintained and updated daily. The maps reflect interment usage of 

gravesites and memorial sites. NCA guidance requires cemetery directors to 

transmit updated map information to the appropriate MSN staff at least once 

every 6 months. The guidance also states that MSN staff will return updated 

maps to the cemetery semi-annually. 

At one cemetery, the gravesite layout maps were illegible and were not 

updated since 1970. At another cemetery, we observed four rows of 

headstones that were not included on the map used by the cemetery director 

to conduct the review. In addition, a cemetery director told us that the 

updated maps received from the MSN do not always include all the updates 

provided by the cemetery, which resulted in the continued use and reliance 

on inaccurate maps. 

In response to our Management Advisory Memorandum, NCA revised its 

procedures for completing internal gravesite reviews and tested its new 

procedures at 9 of 12 cemeteries that we visited or planned to visit during our 

audit. At the completion of Phase One, NCA identified 251 errors after 

reviewing nearly 1.6 million gravesites at 93 National cemeteries. After 

NCA revised its review procedures and conducted follow-up reviews of 

gravesites that were part of the Phase One review, NCA identified 

146 additional gravesite errors at four of the nine cemeteries that were part of 

our sample. NCA used independent teams to conduct follow-up reviews 

instead of relying solely on the cemetery director. 

VA Office of Inspector General 6 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

	 At Winchester National Cemetery, NCA identified 60 errors while 

conducting a 100 percent review of all gravesites. The MSN director 

advised us that the review team found 35 of 60 headstones using a probe 

because the headstones had sunk below ground level. Sunken headstones 

occur when ground conditions change and deteriorate over an extended 

period. In addition, two sets of markers were inadvertently switched and 

caused 4 of the 60 errors. The MSN director could not explain why the 

errors were not identified during the initial Phase One review. 

	 At Riverside National Cemetery, the MSN reviewed a sample of 

400 gravesites and identified 52 gravesite errors. These errors occurred 

because one headstone was misplaced during a raise and realign project 

that caused 49 adjacent headstones to be offset. This resulted in placing 

two spousal remains in incorrect gravesites during subsequent 

interments. The cemetery director could not explain why the errors were 

not identified during the initial Phase One review. 

	 At Wood National Cemetery, the MSN identified 32 misplaced 

headstones while conducting a second review of all gravesites previously 

reviewed in Phase One. NCA told us the misplaced headstones were 

placed by mistake on the incorrect gravesites during raise and realign 

projects. The cemetery director could not explain why the errors were 

not identified during the initial Phase One review. 

	 At Philadelphia National Cemetery, the MSN identified two errors (one 

unmarked and one misplaced headstone) while conducting a 100 percent 

review of all gravesites. The cemetery director could not explain why the 

errors were not identified during the initial Phase One review. 

Table 2 shows the number of gravesites reviewed and errors identified during 

NCA’s subsequent reviews using the revised procedures. 

Table 2 

Results of Subsequent Additional Errors Identified by NCA 

MSN National Cemetery MSN Gravesites 

Reviewed 

Errors Identified 

by MSN 

1 Winchester (VA) 5,097 60 

5 Riverside (CA) 400 52 

4 Wood (WI) 25,531 32 

1 Philadelphia (PA) 11,041 2 

TOTAL 42,069 146

 Source: NCA’s MSN data. 

NCA’s internal gravesite review procedures were not adequate to identify all 

errors, which affected the validity and accuracy of the review. 

Consequently, NCA reported unreliable and understated results to Congress 

Conclusion 

VA Office of Inspector General 7 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Management 

Comments 

and OIG 

Response 

following the completion of NCA’s Phase One review. Because NCA used 

similar procedures during segments of the Phase Two Review, the results of 

that review may also be unreliable and understated. Identifying all gravesite 

errors and taking corrective actions will ensure VA properly honors veterans 

and their families with final resting places that commemorate their service to 

our Nation. 

Recommendations 

1)	 We recommended the Under Secretary for Memorial Affairs ensure 

implementation of the three recommendations in the July 5, 2012, 

Management Advisory Memorandum. 

2)	 We recommended the Under Secretary for Memorial Affairs ensure 

management take corrective actions regarding the additional 153 errors 

identified in this report, including the notification of congressional 

committees and contacting families when possible. 

3)	 We recommended the Under Secretary for Memorial Affairs implement 

procedures to assess cemetery size and cemetery director responsibility to 

ensure adequate time and resources are available before conducting 

future gravesite reviews. 

4)	 We recommended the Under Secretary for Memorial Affairs implement 

controls, including a certification, to ensure gravesite layout maps are 

routinely updated, accurate, and provided to the cemeteries. 

The Under Secretary for Memorial Affairs agreed with our recommendations 

and provided an appropriate action plan. NCA will ensure implementation 

of the recommendations in our Management Advisory Memorandum. The 

Phase Two review was completed in December 2012, using a more 

independent review process and improved procedures. MSN leadership also 

conducted independent gravesite reviews at every National cemetery and 

soldiers’ lot administered by VA. NCA will research the reasons that errors 

occurred and take the appropriate administrative action. 

In addition, NCA will assess cemetery size, staffing, and operational needs to 

ensure adequate time and resources before conducting future reviews. NCA 

will establish a certification procedure and reporting process to ensure 

gravesite layout maps are routinely updated, accurate, and provided to 

cemeteries. In the future, NCA plans to replace the legacy Burial 

Operational Support System (BOSS) with newer technology. 

NCA will take corrective actions for all gravesite errors identified in the 

report. In the written comments to the draft report, NCA provided us with an 

explanation for two of the errors we identified. Although we appreciate 

NCA’s diligence and timely efforts to address the findings, we believe the 

errors are valid and require additional research to ensure all deficiencies are 

VA Office of Inspector General 8 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

appropriately addressed to meet NCA’s standards for accuracy. NCA plans 

to inform Congress, contact families and other stakeholders about the errors, 

and complete all corrective actions by the end of February 2013. 

We consider those corrective actions that are completed or in process to be 

acceptable. We acknowledge that conducting a self-initiated review 

demonstrates NCA’s commitment to ensuring VA-administered National 

cemeteries and soldier’s lots continue to operate under the highest standards. 

The Under Secretary for Memorial Affairs comments and NCA’s action plan 

can be found in Appendix F. 

VA Office of Inspector General 9 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Appendix A 

Role of NCA 

Organizational 

Structure 

NCA’s Phase 

One Internal 

Gravesite 

Review 

Background 

In 1973, Congress passed Public Law 93-43, the National Cemeteries Act, 

which ordered the transfer of 82 National cemeteries from the Department of 

the Army to the then-Veterans Administration. Additionally, VA received 

jurisdiction over 32 soldiers’ lots and transferred the procurement and supply 

of Government headstones and markers. During the Under Secretary’s 

March 2012 congressional testimony, he stated NCA is currently 

experiencing the largest expansion of the National cemetery system since the 

Civil War. NCA has built 18 new National cemeteries from 1992 through 

2010. NCA is in the land-acquisition and planning phase for five additional 

cemeteries. 

NCA’s mission is to honor veterans and their families with final resting 

places in National shrines and with lasting tributes that commemorate their 

service to our Nation. NCA’s responsibilities include maintaining 

approximately 3.1 million gravesites at 131 National cemeteries in 39 states 

and Puerto Rico and 33 soldiers’ lots and monuments. In addition, NCA 

furnishes headstones, markers, and medallions for the graves of veterans 

around the world; administers both the Presidential Memorial Certificate 

program and First Notice of Death program; and oversees the Federal grants 

program for the construction of state and tribal veteran cemeteries. In 

FY 2011, NCA conducted approximately 117,000 interments and processed 

373,000 applications for headstones and markers for placement in 

cemeteries. Additionally, NCA provided over 7,000 headstone medallions 

and issued nearly 780,000 Presidential Memorial Certificates. 

NCA’s field structure is geographically organized into five MSNs with 

offices located in Philadelphia, PA; Atlanta, GA; Denver, CO; Indianapolis, 

IN; and Oakland, CA. 

In October 2011, NCA issued Policy Memorandum NCA-41A-2012-01 to 

direct MSN and cemetery directors to conduct a review to verify headstone 

and marker placement in all burial sections where raise and realign projects 

had been completed by contractors and/or NCA employees. According to 

the Under Secretary for Memorial Affairs statement given in March 2012, 

the review was to confirm that all headstones and markers in raised and 

realigned burial sections were in the proper location. NCA initiated the 

review following the discovery of 47 markers offset by one gravesite in a 

burial section at Fort Sam Houston National Cemetery. This resulted in 

placing the remains of four decedents in the wrong gravesites. 

In March 2012, during the House Committee on Veterans’ Affairs hearing on 

Disability Assistance and Memorial Affairs, the Under Secretary for 

Memorial Affairs provided a statement on the progress of NCA’s 

system-wide internal review of gravesites within the National cemetery 

system. The review was conducted in two phases: Phase One included 

VA Office of Inspector General 10 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Raise and 

Realign 

Projects 

burial sections where raise and realign projects were completed and Phase 

Two verified headstone and marker placements in the remaining cemetery 

burial sections where raise and realign projects were not completed. 

During the Under Secretary’s March 2012 congressional testimony, he stated 

NCA conducts raise and realign projects to ensure headstones and markers 

are maintained at proper height and alignment. These major renovation 

projects are critical to NCA’s ability to meet its National Shrine standards 

and, more importantly, to honor veterans. NCA uses contractors and NCA 

employees to conduct raise and realign projects. 

VA Office of Inspector General 11 
 

 

 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Appendix B Scope and Methodology 

Scope We conducted our audit work from May through November 2012. The 

scope of the audit included a review of NCA Phase One review procedures 

performed from October 14 through December 31, 2011 and finalized the 

results on April 3, 2012. The universe of National cemeteries included 

93 National cemeteries with nearly 1.6 million gravesites. We visited 

12 National cemeteries from June through July 2012. 

The following is a list of the 12 sample cemeteries, the number of gravesite 

errors identified by NCA during its Phase One review, and the number of 

gravesite errors identified by the OIG during this audit. 

Table 3 

Methodology 

Gravesite Errors Identified by NCA and OIG 

MSN National Cemetery 

Gravesites 

Reviewed 

by NCA 

Errors 

Identified 

by NCA 

Errors 

Identified 

by OIG 

1 Philadelphia (PA) 11,041 13 1 

1 Winchester (VA) 5,097 - 3 

2 Bay Pines (FL) 27,304 - -

2 Beaufort (SC) 17,410 4 -

2 Marietta (GA) 16,960 - -

3 Fort Logan (CO) 62,741 - -

3 Santa Fe (NM) 32,322 13 -

4 Jefferson Barracks (MO) 123,851 - -

4 Wood (WI) 25,531 - 2 

4 Zachary Taylor (KY) 10,655 - -

5 Riverside (CA) 37,711 1 1 

5 Roseburg (OR) 2,723 - -

Total 373,346 31 7 

Source: NCA Phase One and VA OIG results. 

We interviewed NCA management and staff to obtain an understanding of 

NCA’s Phase One review procedures. We selected a statistical sample of 

12 National cemeteries to assess the quality of NCA’s review procedures by 

performing the following steps at each location: 

	 Reviewing the Statements of Compliance and the Results of NCA’s 

review. 

VA Office of Inspector General 12 
 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Data Reliability 

Government 

Standards 

	 Interviewing the cemetery director to obtain an understanding of the 

Phase One review and results. 

	 Conducting an inventory of 200 gravesites using gravesite layout maps to 

ensure headstones were accurately placed. 

	 Comparing interment records with the inscriptions on the headstones to 

verify the proper location of headstones and markers. 

	 Identifying misplaced headstones and markers and unmarked gravesites 

during our physical observations of cemetery grounds. 

	 Verifying correction of previously reported misplaced headstones and 

markers and unmarked gravesites. 

We tested the reliability of computer-processed data by comparing the BOSS 

data with Records of Interment. We also compared BOSS data with 

gravesite layout maps and headstones and markers during our audit. If a 

gravesite in our sample did not match the gravesite layout map, we obtained 

BOSS data along with the Record of Interment to verify the accuracy of the 

information. We concluded the BOSS and the Records of Interment data 

were sufficiently reliable for this audit. 

Our assessment of internal controls focused on those controls relating to our 

audit objective. We conducted this performance audit in accordance with 

generally accepted government auditing standards. These standards require 

that we plan and perform the audit to obtain sufficient, appropriate evidence 

to provide a reasonable basis for our findings and conclusions based on our 

audit objective. We believe that the evidence obtained provides a reasonable 

basis for our conclusions based on our audit objective. 

VA Office of Inspector General 13 
 

 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Appendix C 

Population 

Sampling 

Design 

Projections 

and Margins of 

Error 

Statistical Sampling Methodology 

We selected a stratified random sample of gravesites to determine whether 

NCA adequately identified and addressed issues found during NCA’s Phase 

One internal gravesite review. 

The audit universe included 1,588,372 gravesites, which encompassed 

93 National cemeteries within the National cemetery system. We used 

BOSS data provided by NCA to identify the audit universe. The records 

included the burial sections and gravesites reviewed during Phase One of 

NCA’s internal gravesite review during the period October 14, 2011, through 

December 31, 2011. From the universe of gravesites, we identified a sample 

of 12 National cemeteries and 2,400 gravesites for review. 

We used a two-stage sampling approach. For the first stage, we stratified the 

universe of cemeteries into four groups based on the errors identified and the 

number of gravesites reviewed during NCA’s Phase One review. We 

grouped cemeteries that identified errors during NCA’s gravesite review into 

one stratum. 

We stratified the remaining cemeteries into three groups by cumulating the 

sum of the square roots of the number of gravesites then splitting the 

cumulative value into three equal-sized groups. The second stratum included 

cemeteries with 141,908 to 22,299 gravesites reviewed and the third stratum 

included cemeteries with 22,298 to 7,428 gravesites. The fourth stratum 

included cemeteries with 7,427 to 1 gravesites reviewed. We computed the 

allocation based on an optimal Neyman allocation. 

We needed a minimum of two sample units (cemeteries) per stratum. As a 

result, we selected four sites each for strata one and two, and two sites each 

for strata three and four for a total of 12. We randomly selected the sample 

cemeteries from the four groups. 

For the second stage, we used the random sample of 12 National cemeteries 

from Stage 1 to select a random sample of gravesites and applied a discovery 

sampling method. We applied a 90 percent confidence interval and a 

3 percent error rate to arrive at a required sample size of 200 gravesites per 

cemetery. We selected the sample gravesites in simple random order. 

We reviewed 2,400 gravesites from 12 cemeteries nationwide and 

determined there were 7 unreported errors at 4 National cemeteries from 

NCA’s Phase One review. NCA identified 146 additional errors. As a 

result, we determined the Phase One results were understated and NCA’s 

review procedures were inadequate. Given the potential for a large margin 

of error, a meaningful projection was not possible for the gravesites in our 

universe. As a result, we did not project the errors in our sample. 

VA Office of Inspector General 14 
 

 

 

 

 

 

 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Appendix D OIG Management Advisory Memorandum, July 5, 2012 

Department of 

Veterans Affairs Memorandum

Date:	 July 5, 2012 

From:	 Assistant Inspector General for Audits and Evaluations (52) 

Subj:	 Management Advisory—Significant Issues Identified During Audit of National 

Cemetery Administration’s Internal Gravesite Review 

To:	 Under Secretary for Memorial Affairs (41) 

1.	 We are providing this management advisory for your immediate action to address 

issues regarding National Cemetery Administration’s (NCA) Phase One internal 

gravesite review procedures and reported results. Although we have only 

completed reviews of 6 of 12 selected national cemetery sites, we found 3 of the 6 

cemeteries visited did not identify all misplaced and missing headstones and that 

results of NCA’s reviews were inaccurately reported. We identified these errors 

during our audit of NCA’s internal gravesite review. We are assessing whether 

NCA adequately identified and addressed issues found during their Phase One 

review. In the upcoming months, we will provide a draft report outlining our 

results and recommendations based upon reviews at all 12 national cemeteries 

selected as sample sites. 

2.	 NCA completed their Phase One review in March 2012 and reported identifying 

249 errors, consisting mostly of misplaced headstones and markers. NCA is 

currently conducting Phase Two, which is expected to be completed by the end of 

this year. The purpose of these internal gravesite reviews are to ensure that all 

headstones and markers in burial sections that were raised and realigned are 

properly located. The identification and reporting errors made by the three national 

cemeteries are described below: 

 Winchester National Cemetery. Winchester National Cemetery, Winchester, 

VA, is located in Memorial Service Network (MSN) 1 area of responsibility. The 

Director of the cemetery certified that all headstones were accurately placed on the 

correct gravesites and reported no discrepancies to MSN 1. We identified two 

gravesites marked with incorrect headstones and one unmarked gravesite. The 

three gravesites were identified as occupied on the gravesite map. We also 

observed other gravesites that were not part of our review without headstones or 

markers which were noted as occupied on the gravesite map. The cemetery director 

said it was likely these headstones had sunk and that further investigation was 

needed. 

VA Office of Inspector General 15 
 

 

 

 

 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Page 2 

 Philadelphia National Cemetery. Philadelphia National Cemetery, 

Philadelphia, PA, is located in the MSN 1 area of responsibility. We observed a 

gravesite that was not part of our review without a headstone, which should have 

been reported during the Phase One review. 

3.	 We are concerned that NCA will continue to lack reasonable assurance of its 

accountability for gravesites if cemetery directors cannot demonstrate due diligence 

in fulfilling their responsibilities for ensuring the accuracy of marking of gravesites 

and reporting the results of their reviews. NCA’s internal gravesite review 

procedures instructed the cemetery director or acting cemetery director to 

accomplish the review. NCA also required MSN offices review gravesite maps; 

confirm that maps were correct, update if necessary; and provide each cemetery 

director with the gravesite map to conduct the review. NCA should that considers 

the variables among cemeteries, such as size, complexity, and age. By performing 

a more independent review, NCA can obtain better assurance regarding the 

accuracy of its reported results. Increased oversight of the review process would 

reduce the risk of not identifying mismarked gravesites and inaccurate reporting of 

results. 

4.	 We also found that MSN 1 did not confirm that Winchester and Philadelphia 

National Cemeteries’ gravesite maps were updated and correct. Winchester 

National Cemetery’s map had not been updated since 1956 with approximately 10 

percent of new burials at the cemetery occurring after 1956. In addition, portions of 

the map were illegible. The Director of Philadelphia National Cemetery determined 

that their gravesite map had been updated locally in 2008. However, the MSN had 

not provided an updated map to the cemetery since 2005. 

5.	 We recommend that the Under Secretary for Memorial Affairs take the following 

actions: 

a) Revise current internal gravesite review procedures to ensure the accuracy of 

gravesite reviews and reporting of results. 

b) Plan and complete another review of all Phase One and Two National 

Cemeteries using revised procedures. 

c) Research the reasons the Directors’ certifications did not disclose the same 

conditions we identified and take administrative action as deemed appropriate. 

VA Office of Inspector General 16 
 

 

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Page 3 

6.	 Please provide your written comments to this Management Advisory by July 25, 

2012. Your comments should provide an implementation plan and target 

completion dates for addressing the recommendations. If you have questions or 

wish to discuss the issues in this Management Advisory, please contact Gary Abe, 

Deputy Assistant Inspector General for Audits and Evaluations, or myself at (202) 

461-4725. We appreciate the cooperation your staff extended to us during this 

audit. 

LINDA A. HALLIDAY 

VA Office of Inspector General 17 
       

         

                     

       

             

                           

                   

       

                           

                         

                  

                         

                                

                       

                         

                          

                         

                          

                         

                                 

                          

                           

                       

                         

                       

                       

                           

                               

                      

                         

                           

                             

                    

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Appendix E NCA’s Response to OIG’s Management Advisory 

Memo, July 25, 2012 

Department of 

Veterans Affairs Memorandum

Date:	 July 25, 2012

From:	 Under Secretary for Memorial Affairs (40)

Subj:	 Response to Management Advisory – Significant Issues Identified During Audit of National

Cemetery Administration’s Internal Gravesite Review

To: Assistant Inspector General for Audits and Evaluations (52)

1.	 The purpose of this memorandum is to respond to your management advisory of July 5,

2012, entitled, “Significant Issues Identified During Audit of National Cemetery

Administration’s Internal Gravesite Review”.

2.	 I share the concerns expressed, and NCA has taken steps to establish a more independent

review process and improved procedures in order to enhance the reasonable assurance for

the accuracy of the gravesites at our national cemeteries. The recommended independent

review process has enabled NCA to revisit the cemeteries where your office discovered

errors, as well as the cemeteries you visited the week of July 16‐20, 2012. These initial

actions are providing information and insights for use in developing improved gravesite

review procedures, and these procedures will become part of a detailed and deliberate

plan supporting another review of all our cemeteries by December 2012. I would

appreciate receiving any additional information gathered by your team during visits on July

16‐20, 2012, which could further inform development of our revised procedures. My staff

will be requesting this information from your office in the very near future.

3.	 I anticipate having a revised plan in place by August 17, 2012, with the goal of providing

reasonable assurance of accountability of gravesites by the end of the calendar year. Key

elements of the new procedures will include the conduct of independent reviews to include

improved sampling procedures and oversight by senior leadership at the Memorial Service

Network level. In addition, by mid‐fall 2012, the Deputy Under Secretary for Field

Programs will have completed the necessary training for, and the establishment of,

specialized review teams to provide an additional and higher level of review.

4.	 NCA is currently in the process of validating all discrepancies including those reported by

cemetery directors during Phase II of the audit, those found by your team, and those found

by the NCA independent reviews. Once this very thorough validation process is complete,

we will report all discrepancies to families and Congress. As recommended, NCA will

research the reasons for the discrepancies among the findings of the Cemetery directors, as

certified by the initial audit, the findings of your auditors, and the findings of the

independent review. Appropriate administrative action will be taken against employees in

VA Office of Inspector General 18 
   

                        

           

                          

                   

       

                                   

                      

                       

                    

                         

                               

     

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

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Subject: Response to Management Advisory – Significant Issues Identified During Audit of

National Cemetery Administration’s Internal Gravesite Review

cases where our research indicates it is warranted. This validation period, to include

external communications and the initiation of administrative actions, should be complete

by August 31, 2012.

5.	 We in NCA believe we are the keepers of a Sacred Trust and are the guardians of the

country’s National Shrines. These unique and special responsibilities were the underlying

motivations for the self‐initiated review of gravesites—the first in the 150‐year‐history of

national cemeteries. We are committed to providing reasonable assurance regarding the

accuracy of our reported audit results and to maintaining a high level of accountability,

today and in the future. We appreciate your assistance in helping us meet this goal.

Steve L. Muro

VA Office of Inspector General 19 
       

         

                       

     

             

                             

                       

  

                             

                     

                           

                        

                       

                        

                          

                          

                           

         

                       

                       

                         

                          

                        

                         

                           

                 

       

                      

                         

                               

                      

                          

                               

   

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Appendix F Under Secretary for Memorial Affairs Comments 

Department of 

Veterans Affairs Memorandum

Date: January 15, 2013

From:	 Under Secretary for Memorial Affairs (40)

Subj:	 Draft Report, Audit of NCA’s Internal Gravesite Review of Headstone and Marker

Placements (Project Number 2012‐02223‐R4‐0135)

To: Assistant Inspector General for Audits and Evaluations (52)

I appreciate the opportunity to respond to the recommendations in the VA Office of

Inspector General report, “Audit of Internal Gravesite Review of Headstone and Marker

Placements.”

For the first time in the 150‐year history of national cemeteries, the National Cemetery

Administration (NCA) conducted a comprehensive review of all 3.2 million gravesites

within the 131 national cemeteries and 33 soldier’s lots maintained by the Department of

Veterans Affairs (VA). NCA conducted this self‐initiated review to confirm that all

headstones and markers are set at the proper location, and to ensure VA‐administered

national cemeteries continue to operate under the highest standards as national shrines.

NCA leaders administered the review in two phases. Phase I included burial sections

where “raise and realign” projects were conducted, and concluded on April 3, 2012.

Phase II, which reviewed burial sections that comprise the rest of the NCA inventory,

concluded on December 31, 2012.

NCA’s review included 84 national cemeteries that were transferred from the

Department of the Army to the Veterans Administration (now the Department of

Veterans Affairs) in 1973, approximately 110 years after establishment of the first national

cemeteries. Although Congress mandated the transfer of records to VA, Congress did not

require any retroactive review of the transferred cemetery records. Accordingly, the audit

which NCA conducted from October 2011 to December 2012 was self‐initiated and the

first complete review to verify the correct placement of remains and accurate marking of

gravesites in the history of the national cemetery system.

OIG Finding and NCA response

 The OIG found that NCA’s Internal gravesite review procedures need strengthening.

This finding emanates from the IG’s discovery of 7 misplaced headstones or unmarked

gravesites at 4 of the 12 cemeteries that the OIG audited (issues that should have been

identified by the cemetery directors during NCA’s review). Additionally, the OIG

describes that there were outdated and illegible maps at these cemeteries. NCA offers

the following responses in detail to the finding and the OIG’s analysis of the reasons for

the finding:

VA Office of Inspector General 20 
   

                     

                         

                          

                        

                           

                        

                             

                          

                     

                         

                         

                          

                 

                      

                       

                         

            

                         

                       

                          

                             

                      

                        

                     

                          

                            

                      

                       

                           

                             

                           

                            

                        

                             

                       

                            

                   

                    

                   

                          

                    

           

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

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 NCA’s Internal Gravesite Review Procedures needs strengthening because at 4 of

12 national cemeteries the IG found 7 misplaced headstones or unmarked gravesites in

addition to outdated and illegible maps. NCA concurs that our review procedures need

strengthening. The review procedures NCA used for this self‐initiated review of 164

sites was limited in scope and designed to quickly determine the prevalence of a

particular error that we had encountered and self‐reported. While the overall results

show a low error rate after reviewing all 3.2 million gravesites, NCA’s standard is that

there should be no errors at all. This self‐initiated first‐ever review informed NCA that

future reviews need to be comprehensive and must leverage information technology

and NCA’s robust historical records of interment to offer automated checks of the

match between a gravesite, its marker, the record(s) of interment for that gravesite

and the overall gravesite layout plan for that cemetery. This philosophy will be

incorporated in the legacy replacement system, Memorial Applications Redesign

(MAR). The MAR “Mapping” solution will include a Geo‐Spatial Information System

(GIS) interface that will layer the interment data, burial maps, and cemetery

engineering drawings into a single view allowing a real time comprehensive review and

analysis of the interment workflow process.

 The IG discovered 7 misplaced headstones or unmarked gravesites at 4 of the

12 audited cemeteries (issues that should have been identified by the cemetery

directors during NCA’s review). While NCA concurs with this finding in principal, NCA

can only concur that there were 5 misplaced headstones or unmarked graves at 3 of

the 12 audited cemeteries. At Winchester National Cemetery, NCA resolved one

discrepancy that OIG identified as a mismarked grave. Although the inscribed gravesite

number was not correct, the historic headstone accurately depicted the decedent’s

name. Based on the reporting instructions for the headstone and marker review, NCA

did not include this finding as a mismarked grave. Additionally, the IG reported a

headstone missing from a gravesite at Philadelphia National Cemetery. After an

historical review and analysis, NCA determined this gravesite never existed. I will

describe this situation in detail later in this response because it offers an instructive

lesson on the scope of managing the 150 year old system that NCA manages today.

 At 4 of 12 cemeteries there were outdated and illegible maps. NCA concurs in

principal that gravesite layout plans were not updated to NCA standards in all cases.

NCA Gravesite Layout Plans are required to be updated semi‐annually. NCA learned

through this review that the focus on updating gravesite layout plans at most of our

cemeteries was on burial sections with current interments and that older sections

were not updated or periodically certified. As noted later in this response, NCA will

establish a certification procedure and reporting process ensuring gravesite layout

maps are routinely updated, accurate, and provided to the cemeteries. NCA

innovators have been developing improved processes to handle gravesite layout

changes before this review occurred. One such tool, the Gravesite Burial Status and

Accounting Tool (GBSAT) has been particularly effective. GBSAT utilizes Excel

spreadsheets to track and generate gravesite usage

VA Office of Inspector General 21 
   

                            

                       

                          

                            

                             

           

     

                     

                        

               

                   

           

                         

                      

                   

                         

               

                          

                     

                   

                         

   

                     

                          

                     

                               

                    

                          

                             

                          

                       

           

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

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data, which is then used to maintain full‐size gravesite layout maps. The MSN that

created GBSAT showed among the least problems with errors during this gravesite

review. All the other MSNs are currently incorporating the GBSAT into their operations

and GBSAT is being used as a leverage point for the Memorial Applications Redesign.

The MSN with the most difficult map issues has hired a new engineering technician to

support improvements in the gravesite layout plans.

OIG Recommendations and NCA Responses

1) “We recommend the Under Secretary for Memorial Affairs ensure implementation of

the three recommendations in the July 5, 2012, Management Advisory Memorandum.”

NCA concurs and implemented the recommendations as follows:

a) “Revise current internal gravesite review procedures to ensure accuracy of

gravesite reviews and reporting of results.”

NCA revised the Phase II gravesite review procedural directive based on experience in

implementing the Phase I gravesite review. Additionally, NCA directed that memorial

service network executive leaders conduct independent gravesite reviews at every

national cemetery and soldiers’ lot administered by VA after the cemetery directors had

completed their reviews. These leader‐conducted independent reviews were designed

to increase assurance in the accuracy of the overall results. MSN senior leadership

conducted these reviews through scientific random sampling of gravesites or complete

“re‐audits” at every VA national cemetery and soldiers lot.

b) “Plan and complete another review of all Phase One and Two National Cemeteries

using revised procedures.”

As previously noted, NCA conducted independent gravesite reviews at every national

cemetery and soldiers’ lot administered by VA. From August to November 2012, MSN

senior leaders conducted statistically‐valid sampling or full re‐audits of each national

cemetery to increase assurance in the accuracy of the data reported in the Phase I and

Phase II reviews. MSN leaders then researched and validated all discrepancies

identified during these additional reviews. NCA will include the findings of the sample

reviews with the Phase II results which will be reported to Congress, and will inform

next‐of‐kin and other stakeholders about the errors. NCA plans to inform Congress and

other stakeholders in January / February 2013, and complete all corrective actions by

the end of February 2013.

VA Office of Inspector General 22 
   

                     

                 

                       

                                 

                    

  

                     

                       

                     

                         

                      

                          

  

                 

                       

                    

                          

                           

                          

                     

                        

                     

                   

                      

                     

                    

                       

                       

                               

                       

                        

                       

                        

                   

                         

                    

                 

                        

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

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c) “Research the reasons the Director’s certifications did not disclose the same

conditions we identified and take administrative action as deemed appropriate.”

NCA is researching the reasons for the discrepancies that Cemetery Directors identified

during the Phase I and Phase II reviews; as well as the findings that OIG auditors and

MSN leadership discovered during the independent reviews. NCA supervisors will take

appropriate administrative action.

2) “We recommend the Under Secretary for Memorial Affairs ensure management take

corrective actions regarding the additional 153 errors identified in this report, including

the notification of congressional committees and contacting families when possible.”

Except for the specific findings noted below, NCA concurs and will implement this

recommendation. NCA plans to inform Congress and other stakeholders in January/

February 2013, and complete all corrective actions by the end of February 2013. The

exceptions are:

a)	 At Winchester National Cemetery, Virginia, NCA employees researched and

physically located 36 “Unknown Soldier” markers for Civil War era gravesites that

NCA initially identified as unmarked. NCA employees discovered these historic

markers had sunk beneath the turf, probably over a period of many decades.

The markers were cleaned and raised to correctly mark the graves of the unknown

Civil War soldiers. As the markers were found and corrected during the MSN

validation process, these 36 gravesites were not included in NCA’s report

as unmarked graves. (NCA originally reported to OIG that employees located 35

markers. Subsequently, one additional marker was found.) Also, as previously

noted, NCA resolved one other discrepancy at Winchester National Cemetery

that was originally reported as a mismarked grave. Although the inscribed

gravesite number was not correct, the historic headstone accurately depicted the

decedent’s name. Based on the reporting instructions for the headstone and

marker review, NCA did not include this finding as a mismarked grave.

b)	 At Philadelphia National Cemetery, NCA concluded that the OIG’s finding of an

unmarked grave is not correct – there is no gravesite # B280 despite its listing in

NCA’s Burial Operations Support System (BOSS). All NCA records will be annotated

to ensure future employees know this gravesite does not exist. NCA’s research

concluded that the cemetery’s gravesite layout plan correctly indicates there is no

gravesite between gravesites # B279 and B281. In 1885, the United States

purchased approximately 13 acres to concentrate the scattered remains of Civil

War soldiers from multiple cemeteries in the Philadelphia area into one location at

a new Philadelphia National Cemetery. NCA’s research indicates that when

remains from Glenwood National Cemetery were moved to the

Philadelphia National Cemetery, the plan was to move the entire cemetery intact,

VA Office of Inspector General 23 
   

                     

                       

                   

                         

                     

                       

                           

                       

                     

                       

                      

                     

                          

                           

                    

                     

                       

               

                       

                               

                       

                            

                         

                     

                           

                         

   

                   

                       

       

                      

                     

                      

                    

                      

                         

                               

                       

              

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

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with remains and markers retaining the same numbering system and order.

Historic records indicate that the remains of the soldier originally interred in

gravesite 280 at Glenwood were not reinterred at Philadelphia National

Cemetery; it is possible that the soldier’s remains were claimed by family upon

disinterment from the defunct cemetery. The layout map of Philadelphia National

Cemetery “skipped” gravesite B‐280 (as well as gravesite numbers of other soldiers

originally interred at Glenwood who are known to have not been re‐interred in the

new section at Philadelphia National Cemetery.) During the 1950’s, while creating

a new recordkeeping system on typewritten cards, a burial record was

inadvertently created for the Civil War soldier based on the handwritten ledger

that documented the original interment at the defunct cemetery. This error was

“re‐transcribed” in 1994 when NCA created its electronic Burial Operations Support

System (BOSS.) The cemetery director did not find this error that the IG reported,

because the scope of NCA’s review did not mandate a records review if the

headstones matched the gravesite layout plan, which it correctly did.

3) “We recommend the Under Secretary for Memorial Affairs implement procedures to

assess cemetery size and cemetery director responsibility to ensure adequate time and

resources are available before conducting future gravesite reviews.”

NCA concurs. NCA always assesses cemetery size, staffing and operational tempo when

issuing operational tasks and will continue to do so in the future. NCA was aware that

this review would challenge our leaders while they continued to operate their

cemeteries to the high standards we demand of them. It was necessary, however to

implement a demanding schedule in order to obtain the information we needed to

advise stakeholders of the status of our cemeteries. Despite the challenge, most

cemeteries, including some of the largest and busiest, were able to submit results that

we have reasonable assurance are correct based on post review audits and scientific

random sampling.

4) “We recommend the Under Secretary for Memorial Affairs implement controls,

including a certification to ensure gravesite layout maps are routinely updated, accurate,

and provided to the cemeteries.”

NCA concurs with the recommendation. NCA will establish a certification procedure

and reporting process ensuring gravesite layout maps are routinely updated, accurate,

and provided to the cemeteries. Memorial Service Network (MSN) Directors will

update, publish and forward open cemetery gravesite layout maps semi‐annually. MSN

Directors will update and publish closed cemetery gravesite layout plans annually. If

there are no gravesite activity changes to specific burial sections, then these sections

will be reviewed, and a new date affixed to the gravesite layout map. Each MSN will

certify semiannually when these steps are completed. The first certifications will be due

on March 31 and September 30, 2013.

VA Office of Inspector General 24 
   

                            

                             

                               

                             

                       

                           

                       

                             

                        

                           

                         

                         

   

                             

                     

                             

                       

                             

                             

                                 

                           

                         

                     

                               

                           

                         

                           

                             

                           

                               

  

     

Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

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NCA appreciates the feedback the OIG has provided throughout this audit process. It has

informed the reviews we have recently conducted and it will inform the future reviews we

must complete in order to uphold our sacred trust as caretakers of the final resting places

of Veterans and their families. NCA is pleased that the OIG found that our Burial

Operations Support System (BOSS) and our Records of Interment were sufficiently reliable

for this audit. Our experience with our own gravesite review was similar; when mismarked

or unmarked graves were discovered, we were able to determine what corrections

needed to be made by examining our records of interment and comparing them to our

gravesite layout plans. NCA employees created the BOSS system “in‐house” in 1994

reflecting an NCA characteristic of being innovative in response to the needs of Veterans.

We consider ourselves fortunate to have predecessors who were innovative for we have

seen other organizations struggle when they didn’t take advantage of technology at the

right time.

Looking to the future, NCA, with the support of VA’s Office of Information and

Technology, is implementing its Memorial Applications Redesign (MAR), which will replace

the legacy Burial Operations Support System. The MAR is the next step in the innovation

cycle to ensure mission accomplishment and it will be the system that electronically

integrates over 150 years of records of interment with our gravesite layout plans. NCA will

ensure accuracy of these records and interment layout plans as MAR is brought on board.

This will not be easy, as we will need to conduct more gravesite and record reviews in

order to accomplish this, but it will be done. NCA’s formidable recordkeeping will assist

current and future VA employees in fulfilling our responsibilities to account for remains

and provide perpetual care for those interred in VA national cemeteries.

NCA is a proud organization that finds itself at the pinnacle of all organizations inside

and outside the government in the areas of customer service and in operations and

maintenance of facilities. While the number of errors discovered during our review was

relatively small, any error in this area is unacceptable. NCA will use technology, training

and the experience gained over the last year to create a new gravesite accounting system

that will continue NCA’s leadership as a world class organization, and help NCA maintain

its status as a model of excellence for burial and memorials for our Nation’s Veterans and

their families.

Sincerely,

Steve L. Muro

VA Office of Inspector General 25 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Appendix G Office of Inspector General Contact and Staff 

Acknowledgments 

OIG Contact For more information about this report, please 

contact the Office of Inspector General at 

(202) 461-4720. 

Acknowledgments	 Cherie Palmer, Director 

Alicia Castillo-Flores 

Joseph DeAntonis 

Kevin Gibbons 

Lee Giesbrecht 

Cynnde Nielsen 

Maria Stone 

Nelvy Viguera Butler 

Ora Young 

VA Office of Inspector General 26 
Audit of NCA’s Internal Gravesite Review of Headstone and Marker Placement 

Appendix H Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Health Administration
 

Veterans Benefits Administration 

National Cemetery Administration
 

Assistant Secretaries
 

Office of General Counsel 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report will be available in the near future on the OIG’s Web site at 

www.va.gov/oig. This report will remain on the OIG Web site for at least 2 

fiscal years. 

VA Office of Inspector General 27