1. I. FUNERAL HOME CHARGES (Indicate N/A for items of service and/or merchandise that are not provided.)
2. A. Alternative Services
3. 1. Direct Cremation $ __
4. 2. Direct Burial $ __

5. B. Transfer of remains to the funeral establishment, including

   personnel, equipment and vehicle. $ __

6. C. Preparation of Remains

7. 1. Embalming (including use of 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 will explain why below.

8. 2. Other preparation (including use of preparation room but excluding embalming)
9. a. Topical Disinfection $ __
10. b. Custodial Care $ __
11. c. Dressing/Casketing $ __
12. d. Cosmetology $ __
13. e. Restoration $ __

14. f. Other (specify) _________ $ __

    ______________

15. D. Arrangements $ __

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

16. E. Supervision (funeral director and staff)
17. 1. Supervision for visitation $ __
18. 2. Supervision for funeral service $ __

19. 3. Other supervision (specify) _________ $ __

    _________________

20. F. Use of the Facilities
21. 1. Use of the facilities for visitation $ __
22. 2. Use of facilities for funeral service $ __

23. 3. Other use of facilities (specify) _________ $ __

    ___________________

24. G. Livery
25. 1. a. Hearse or $ __

26. b. Alternative vehicle $ __

    (Specify type: _________ )

27. 2. Flower vehicle $ __

28. 3. Limousine(s) $ __

    (Specify number: __@ $__/limousine)

29. 4. Passenger car(s) $ __

    (Specify number: __@$__/car)

30. H. Merchandise $ __
31. 1. Casket or Alternative Container $ __
32. a. Supplier
33. b. Model name or number

34. c. Material: Species of wood or kind of metal weight or

    gauge __ or alternative container (describe)

35. d. Interior

36. 2. Outer Interment Receptacle $ __

    Supplier

    Model name or number

    Material

37. I. Additional Services and Merchandise Selected

    (Describe and show price)

38. 1. ______________ $ __
39. 2. ______________ $ __
40. 3. ______________ $ __
41. 4. ______________ $ __
42. J. Limited Services
43. 1. Forwarding remains to __________ $ __

44. 2. Receiving remains from _________ $ __

    TOTAL OF FUNERAL HOME CHARGES $ __

45. 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 the third parties. (Describe and show estimated charges.)

46. 1. ______________ $ __
47. 2. ______________ $ __
48. 3. ______________ $ __

49. 4. ______________ $ __

    ESTIMATED TOTAL OF CASH ADVANCES $ __

50. III. SUMMARY OF CHARGES
51. 1. Funeral Home Charges $ __

52. 2. Cash Advances $ __

    TOTAL FUNERAL CHARGES $ __

53. 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.

    Signature of Licensed Funeral Director Date

    Printed or Typed Name of Funeral Director

    ACKNOWLEDGMENT OF RECEIPT

    I have received this itemization of funeral services

    and merchandise selected.

    Signature of Licensed Funeral Director 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 of Health

    Corning Tower, Empire State Plaza

    Albany, NY 12237

The statement of goods and services selected shall be in the following format:

ITEMIZATION OF FUNERAL SERVICES AND MERCHANDISE SELECTED

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