Statement of Funeral Goods and Services Selected

Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use ay items, we will explain the reasons in writing below.

If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct cremation or immediate burial. If we charged for embalming, we will explain why below.

* Required

First Name *
Last Name *
Email Address *
No.
Deceased
Date of Death
Place of Death
Date of Statement

A. Charge for Services Selected
1. Professional Services:
Basic Services of Funeral Director & Staff
Embalming
Other preparation of body
Professional Services Sub-total

2. Facilities, Equipment & Staff:
Use of Facilities & Staff for Viewing-Visitation
Use of Facilities & Staff for Funeral Ceremony
Use of Facilities & Staff for Memorial Service
Use of Facilities & Staff for Graveside Service
Use of Facilities & Staff for Church Service
Facilities, Equipment & Staff Sub-Total

3. Transportation:
Transfer of Remains to Funeral Home
Hearse
Limousine
Sedan
Service - Utility Vehicle
Transportation Sub-Total

4. Other Services, Facilities, Equipment:



TOTAL OF SERVICES SELECTED $

B. Charge for Merchandise Selected
Casket (or other receptacle)
Name-No
Material
Color
Outer Burial Container
Name-No.
Material
Acknowledgement Cards
Register Book
Memory Folders - Prayer Cards
Clothing
Flowers
Cremation Urn
TOTAL OF MERCHANSISE SELECTED $

C. Special Charges
Forwarding remains to:
Receiving remains from:
Immediate Burial
Direct Cremation
Other
TOTAL OF SPECIAL CHARGES $
TOTAL FUNERAL HOME CHARGES $

Cash Advances
Certified Copies of Death Certificate
Burial Permits
Police Escorts
Clergy
Musician
Paid Newspaper Notice
Cemetery
Other
Other One
Other Two
Other Three
TOTAL CASH ADVANCES $

Summary
Total Funeral Home Charges
Local Sales Tax
State Sales Tax
Total Cash Advances
GRAND TOTAL
Less Credits and Payments
Total Credits
BALANCE DUE

Billing To

Disclosures