Contract

(Please fill out all fields highlighted in yellow only!)

N.Y.C. Funeral + Cremation Service Inc.

2203 Ave. Z, Brooklyn
NY 11235
800-969-6602

Name
Date of Death
Place of Death

ITEMIZATION OF FUNERAL SERVICE AND MERCHANDISE SELECTED

The following are the charges for the services, merchandise, and livery you have selected. You will not be charged for any items you do not choose unless it is necessary because of other selections you have made. Any such charges are explained below.

I. FUNERAL HOME CHARGES
(Indicate N/A for items of services and or merchandise that are not provided.)

A. Alternative Services

1. Direct Cremation
$
2. Direct Burial
..................................N/A

B. Transfer of remains to the funeral establishment
including personnel, equipment and vehicle

Removal from: hospital
$

C. Preparation of Remains ………………………………………………… N/A

1. Embalming (Including use of the preparation room) If you select a funeral for which this firm requires embalming such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you do not approve if you select arrangements such as direct cremation or direct burial. If we charge for embalming, we explain why below.

2. Other Preparation (Including us of preparation room but excluded from embalming)

a. Topical disinfection
..................N/A
b. Custodial care/ Cold Room
..................N/A
c. Dressing/ Casketing
..................N/A
d. Cosmetology
..................N/A
e. Restoration
..................N/A
f. Other (specify)
..................N/A

D. Arrangements .................N/A

Basic Arrangements: Including funeral director, other staff, equipment and facilities to respond to initial request for service, the arrangement conference, securing of necessary authorization and coordination of service plans with parties involved in the final disposition of the deceased.

E. Supervision (funeral director and staff)

1. Supervision for visitation
..................N/A
2. Supervision for the funeral service
..................N/A
3. Other supervision (Specify)
..................N/A

II. CASH ADVANCES

These are estimated charges for items to be paid to others. We will Charge you no more for these items than is actually paid to third parties. (Describe and show estimated charges)

F. Use of Facilities

1. Use of facilities for visitation
..........................N/A
2. Use of facilities for funeral service
..........................N/A
3. Other use of facilities (specify)
..........................N/A

G. Livery

1. a. Hearse
..........................N/A
b. Alternative vehicle
..........................N/A
2. Flower vehicle
..........................N/A
3. Limousine(s)
..........................N/A
4. Passenger Car(s)
..........................N/A

H. Merchandise

1. Casket or alternative container
..........................N/A
a. Supplier
..........................N/A
b. Model name or number
..........................N/A
c. Material: Species of wood
..........................N/A
Kind of metal
..........................N/A
Weight or gauge
..........................N/A
d. Interior
..........................N/A

2. Outer Interment Receptacle
..........................N/A
a. Supplier
..........................N/A
b. Model name or number
..........................N/A
c. Material:
..........................N/A

I. Additional Services and Merchandise Selected
(Describe and show price)

1. Acknowledgement Cards
..........................N/A
2. Prayer Cards
..........................N/A
3. Hairdressing
..........................N/A
4. Flowers
..........................N/A
5. Burial Garments
..........................N/A
6. Register Book
..........................N/A
7. Memorial Package
..........................N/A
8. Newspaper Notice(s)
..........................N/A
9. Inscription
..........................N/A
10. Monument
..........................N/A
12. Plastic Container
..........................N/A

J. Limited Services

1. Forwarding remains to
..........................N/A
2. Receiving remains from
..........................N/A

TOTAL OF FUNERAL HOME CHARGES
..........................$

STATEMENT OF GOODS AND SERVICES SELECTED

INVOICE TO

1. Cemetery or Rosemount Memorial Park Crematorium
$
2. Clergy Honoraria
..................................N/A
3. Death Certificate Transcripts(1)
..................................$
4. Permit Fee's
..................................$
5. DC Mailing Fee
..................................$
6. Cremation hand delivery
..................................$
7. Gratuities
..................................$
8. Tolls/Extra Mileage
..................................$
9. Safeguard Provision
..................................$
10. Other (Specify)
..................................$
11. Mailing via USPS Priority Mail with signature (all states)
..................................$

TOTAL FUNERAL CHARGES $

IV. EXPLANATION OF CHARGES

Explain charges for embalming and for any items that are not required by law but may be necessary because of cemetery requirements, crematory requirements or other selections made.

Combined charge for Facilities & Staff for Visitation
N/A
Combined charge for Facilities & Staff for funeral service
..................................N/A
Combined charge for other Facilities & Staff (explain)
..................................N/A

Signature of Licensed Funeral Director
Name of Licensed Funeral Director

ACKNOWLEDGEMENT OR RECEIPT

I have received this itemization for funeral services and merchandise selected

Next of Kin :
Signature

Date:

PUBLIC NOTICE

The New York State Department of Health is responsible for licensing and regulating New York State funeral directing under the Public Health Law.
You may contact the Department at: Bureau of Funeral Directing. New York State Department
875 Central Ave. Albany, New York 12206

EXCLUSION OF WARRANTY. The only warranties, express or implied, granted in connection with the goods sold with funeral services are the express written warranties, if any, extended by the manufacturers thereof. No other warranties an no warranties of merchantability or fitness for a particular purpose are extended by the funeral director.

The undersigned hereby authorizes the above funeral establishment or its representatives to obtain custody of the remains of:

Decedent name

Initial and state your relation to deceased

The undersigned hereby authorizes the above funeral establishment or its representatives :

to embalm not to embalm

Decedent name

Initial and state your relation to deceased

TOTAL FUNERAL CHARGES ....... $

Date:

The forgoing statement has been read to me by (to) me and I hereby acknowledge receipt of a copy of same and agree to pay the above funeral account and for such additional services and materials as are ordered by me, on or before the date of funeral services. In the event that this account is not paid in accordance with the terms of this agreement, the undersigned hereby agrees to pay any and all costs and attorney fee's incurred in connection with the collection of this account.

Prior to this discussion of these funeral arrangements, I was presented with a copy of this funeral firms "General Price List" for which I hereby acknowledge receipt, and have had an opportunity to review the firm's Casket Price List and Outer Interment Price List.

TERMS: This account becomes due on signing the contract. If the bill remains unpaid beyond the date of the funeral, a charge of 1% per month (annual rate 12%) may be added to the unpaid portion of the balance due.

The liability hereby assumed Is in addition to the liability imposed by law upon the estate and others, and shall not constitute a release thereof.

Name:

Signature

Relationship to deceased:

By (Funeral Director)

ADDITIONS OR ALTERATIONS OF SERVICES AND MERCHANDISE SELECTED. The following changes represent items of services and/or merchandise ordered or altered subsequent to the original funeral agreement.

Extra charges if Deceased is Morbidly Obese
Adjusted credits or discounts

BALANCE DUE .............. $

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