STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED …



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619.280.0101 888.838.1730 FAX 619.280.0901

2840 Adams Ave. #104 7050 Eckstrom Ave.

San Diego, CA 92116 San Diego, CA 92111

FD1964 FD2017

STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED

Charges are only for those items that you selected or that are required. If SDFS is required bylaw or by a cemetery or

crematory to use any items, we explain the reason in writing below.

Deceased:     

Description of Services:     

|A. Professional Services | |C. Cash Advanced Items | |

|Service of funeral director and staff |$      |Disposition permit |$      |

|A Preparation of the body |$      |Death Certificate |$      |

|Cosmetics |$      |Flowers |$      |

|Dressing |$      |Music |$      |

|Casketing |$      |Honorarium |$      |

|Transfer of Remains |$      |Vocalists |$      |

|Use of Equipment and staff |$      |Obituaries |$      |

| | |Death Notice |$      |

|Packaging Pricing |$      |Shipping Container |$      |

|Forward of Remains to Another Funeral Home |$      |Limo |$      |

|Receiving Remains from Another Funeral Home |$      |Family Car |$      |

|Direct Cremation |$      |Van |$      |

|Immediate Burial |$      |Escort |$      |

|Traditional Services |$      |Cemetery Charges |$      |

|Graveside Service |$      |Grave opening/closing |$      |

|Memorial Service |$      |Memorial Card/Book |$      |

|SUBTOTAL |$      |Brochures |$      |

| | |Other |$      |

|B. Cremation & Funeral Related Merchandise | |Other |$      |

|Other Charges |$      |Other | |

|Casket/Urn |$      |SUBTOTAL |$      |

| | | | |

| | |A. Professional Services |$      |

|Combination Casket Airtray |$      |B. Cremation & Funeral Related | |

| | |Merchandise |$      |

|SUBTOTAL |$      |C. Cash Advanced Items |$      |

| | |Total Tax |$      |

| | |*GRAND TOTAL |$      |

*COST OF ARRANGEMENTS (including all

Services, merchandise, & cash advance items)

If any legal, cemetery, or crematory requirement has required the purchase of any of the items listed above, we will explain the requirement below. If you selected a funeral which requires embalming, such as a funeral with a viewing, you may have to pay for embalming. You do not have to pay for embalming if you did not approved selected arrangements such as direct cremation or immediate burial. If we charged for embalming, we will

explain the reason below.

Reason for Embalming:      

ACKNOWLEDGMENT AND AGREEMENT:

I hereby acknowledge that I have the legal right to arrange the final services for the deceased, and I authorize this funeral establishment to perfom1 services, furnish goods, and incur outside charges specified on this statement and I am eligible to receive a certified copy of the death record. I acknowledge that l have received, on this date, the General Price List, The Consumer Guide to Funeral and Cemetery Purchases Booklet and Casket Price List. I also acknowledge execution and receipt of a copy of the statement.

TERMS OF PAYMENT: THE BALANCE DUE IS PAYABLE PRIOR TO TIME OF SERVICES RENDERED.

Purchaser:      

Relationship to the deceased: _____________________________________________________________________

Signature

ACCEPTANCE: This funeral establishment agrees to provide all services, merchandise and cash advance indicated on the Statement.

BY ___________________________________________________________________________________________

FOR MORE INFORMATION ON FUNERAL, CEMETERY, AND CREMATION MATTERS, CONTACT: Department of Consumer Affairs, Cemetery and Funeral Bureau, 1625 North Market Blvd., Suite S-208, Sacramento, CA 95834; (916) 574-7870

Form #8

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