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
Volume
VOLUME A-1a (Title 10)