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Sample 4ABC FUNERAL HOMESTATEMENT OF FUNERAL GOODS AND SERVICES SELECTEDCharges 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 any items, we will explain the reasons in writing below.Deceased: ________________________________________________________________________Purchaser: ________________________________________________________________________Address: _________________________________________________________________________Tel. No. ______________________________________________________________________________________________ ___________________Date of Death Date of ArrangementsBasic Services of Funeral Director and Staff and Overhead$__________Embalming$__________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.Other Preparation of the Body1. Cosmetic Work for Viewing$__________2. Washing and Disinfecting Unembalmed Remains$__________Transfer of Remains to the Funeral Home$__________Use of Facilities and Staff For Viewing$__________Use of Facilities and Staff For Funeral Ceremony$__________Use of Facilities and Staff For Memorial Service$__________Use of Equipment and Staff For Graveside Service$__________Hearse$__________Limousine$__________Casket$__________Outer Burial Container$__________Forwarding of Remains to Another Funeral Home$__________Receiving Remains from Another Funeral Home$__________Direct Cremation$__________Immediate Burial $__________CASH ADVANCE ITEMSWe charge you for our services in obtaining: [specify relevant cash advance items].Cemetery charges $__________Crematory charges$__________Flowers $__________Obituary notice$__________Death certificate$__________Music$__________ Total Cash Advance Items$__________TOTAL COST OF ARRANGEMENTS(including all services, merchandise, and cash advance items)$__________If any legal, cemetery, or crematory requirement has required the purchase of any of the items listed above, we will explain the requirement below:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Reason for Embalming:_________________________________________________________________________________ ................
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