Appendix B. Statement of Funeral Goods and Services Selected

STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED

The charges are only for those items that are used. If we are required by law to use any items, we will explain the reasons in writing.

FUNERAL OF                                                                                         FORWARDING OF REMAINS TO ANOTHER FUNERAL HOME                                                                                                                      $                                                                                      

This charge includes removal of body, services of staff, necessary authorizations, embalming, and local transportation (but not shipping charges.)

RECEIVING OF REMAINS FROM ANOTHER FUNERAL HOME                                                                                                $                   

This charge includes services of staff, care of remains, and transportation to cemetery or crematory.

DIRECT CREMATION (As selected)                                                                                                                                               $                   

This charge includes removal of body, necessary authorizations, services of staff, transportation to crematory, and cremation of body.

TRANSFER OF REMAINS TO FUNERAL HOME (                 miles transported)                                                                           $                   

IMMEDIATE BURIAL (As selected)                                                                                                                                                $                   

This charge includes removal of body, services of staff, necessary authorizations, and local transportation to cemetery.

FUNERAL ARRANGEMENTS (Indicated services and facilities selected)                                                                                          $                     Funeral Director and Staff Services                                

Embalming

Other preparation of body                                             

Use of facilities for viewing                                          

Use of facilities for funeral                                              Other use of facilities

AUTOMOTIVE EQUIPMENT (Indicated items selected)                                                                                                                 $                     Hearse

Limousine

Other automobiles

ACKNOWLEDGMENT CARDS                                                                                                                                                       $                   

CASKET SELECTED                                                                                                                                                                        $                   

VAULT OR LINER                                                                                                                                                                           $                   

OTHER ITEMS (describe)_                                                                                                                                                              $                   

$                   

CASH ADVANCE ITEMS

Organist and/or other music	$_
Hairdresser or barber	$_
Flowers	$_
Pallbearers	$_
Motorcycle escorts	$_
Clergy Honoraria	$_
Obituary Notice	$_
Death Certificate(s)	$_
Gratuities	$_
Other (describe)	$_
Total		$_

TOTAL COST FOR ARRANGEMENTS SELECTED                                                                                                                       $                   

FOR FUNERAL HOME                                                                              

Date                                                                   

Arranged by

Date_

NOTICE TO PURCHASER

You may choose to purchase a casket or container for the funeral services and final disposition. However, except under certain public health circum- stances pursuant to A.R.S. § 36-136, state law does not require the purchase or use of caskets or containers.

METHOD OF PAYMENT AND INTEREST CHARGES [describe the method of payment required by the funeral establishment for the funeral services and any interest charges.