Title: Section 78.2 - Format for statement of goods and services selected

78.2 Format for statement of goods and services selected. 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.

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

A. Alternative Services

1. Direct Cremation $_______

2. Direct Burial $_______

B. Transfer of remains to the funeral establishment,

including personnel, equipment and vehicle. $_______

C. Preparation of Remains

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 ar

rangements such as direct cremation or direct burial.

If we charge for embalming, we will explain why

below.

2. Other preparation (including use of preparation

room but excluding embalming)

a. Topical Disinfection $_______

b. Custodial Care $_______

c. Dressing/Casketing $_______

d. Cosmetology $_______

e. Restoration $_______

f. Other (specify) ______________________________ $_______

_______________________________________________

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.

E. Supervision (funeral director and staff) $_______

1. Supervision for visitation $_______

2. Supervision for funeral service $_______

3. Other supervision (specify) ___________________

________________________________________________

F. Use of the Facilities

Use of the facilties for visitation $_______

Use of facilities for funeral service $_______

Other use of facilities (specify) _______________ $_______

_________________________________________________

G. Livery

a. Hearse or $_______

b. Alternative vehicle $_______

(Specify type: ______________________________)

Flower vehicle $_______

Limousine(s) $_______

(Specify number:______ @ $_____ /limousine) $_______

Passenger car(s) $_______

(Specify number:______ @ $_____ /car)

H. Merchandise $_______

1. Casket or Alternative Container $_______

a. Supplier _____________________________________

b. Model name or number _________________________

c. Material: Species of wood ____________________

or kind of metal _____________________________

weight or gauge _____ or alternative container

(describe)____________________________________

d. Interior _____________________________________

2. Outer Interment Receptacle $_______

Supplier_____________________________________

Model name or number ________________________

Material ____________________________________

I. Additional Services and Merchandise Selected

(Describe and show price)

1. ________________________________________________ $_______

2. ________________________________________________ $_______

3. ________________________________________________ $_______

4. ________________________________________________ $_______

J. Limited Services

1. Forwarding remains to __________________________ $_______ 2. Receiving remains from _________________________ $_______

TOTAL OF FUNERAL HOME CHARGES $_______

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.)

1. ________________________________________________ $_______ 2. ________________________________________________ $_______ 3. ________________________________________________ $_______ 4. ________________________________________________ $_______ ESTIMATED TOTAL OF CASH ADVANCES $_______

III. SUMMARY OF CHARGES

1. Funeral Home Charges $_______

2. Cash Advances $_______

TOTAL FUNERAL CHARGES $_______

IV. EXPLANATION OF CHARGES

charges for embalming and for any items that are not required by law may be necessary because of cemetery requirements, crematory 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 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