Federal Trade Commission | Protecting America's Consumers



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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