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