STATEMENT OF GOODS & SERVICES FAMILY OWNED AND OPERATED SINCE 1954 Name Email Address No Deceased Date of Death Place of Death Date of Statement Basic Services of Funeral Director & Staff Embalming Other preparation of body Professional Services Sub-total 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 Transfer of Remains to Funeral Home Hearse Limousine Sedan Service - Utility Vehicle Transportation Sub-Total Other Services, Facilities, Equipment: TOTAL OF SERVICES 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 $ Forwarding remains to: Receiving remains from: Immediate Burial Direct Cremation Other 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 $ 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 7 + 2 = Submit
