Statement Of Funeral Goods And Services Form – Fill Out and Use This PDF

PART ONE OF -TWO PARTS

	4128 Westroads Drive, Suite 203	561-640-9009	Agreement No.
	West Palm Beach, FL 33407	Fax: 561-640-4411

www.edgleycremationservices.com

STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED/PURCHASE AGREEMENT

Date of Death
MO	DD	YR
Name of Deceased
Deceased's Last Address
		CITY	STATE	ZIP CODE
Charge to (Buyer) Name		Phone No. (	)
Buyer's Home Address
		CITY	STATE	ZIP CODE
Co-Buyer's Nome		Phone No. (	)
Co-Buyer's Address
		CITY	STATE	ZIP CODE

In this Agreement the words you and your refer to the Buyer and Co-Buyer, if any, signing this Agreement. The words we, us and our refer to the Funeral Provider or Seller whose name and address appear above. For good and valuable consideration, which each party acknowledges receiving, you agree to buy the goods and services described below. You authorize us to prepare and care for the body of the decedent named in this Agreement and to conduct the funeral and services and incur the charges listed in said Agreement. We have the right to called the total amounts due under this Agreement from any person who signs this Agreement as Buyer or Co-Buyer.

Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct cremation or immediate burial. If we charged for embalming, we will explain why below.

SECTION I: SERVICES AND MERCHANDISE			MERCHANDISE
FUNERAL DIRECTOR AND STAFF SERVICES			Casket/Cremation Casket
Professional Service Fee			Item No.
CARE OF PREPARATION OF REMAINS			Alternative container
Refrigeration			Outside enclosure
Other preparation		$ -	Item No.
TRANSPORTATION			Urns and vases
Transferring remains to crematory			Item No.
Additional Transportation:			TOTAL SECTION I
			SECTION II: CHARGES TO BE INCURRED BY US ON YOUR BEHALF
OTHER GOODS AND SERVICES			(Certain charges may be estimated - "e" means estimated)
1.	Prayer cards		❑ Cemetery
2.	Acknowledgement cards		❑ Crematory
3.	Register Book		❑ Flowers
A.	Memorial Package		❑ Obituary Notices
5.	Scattering at Sea		❑ Death Certificates
6.	Obituary Notices		❑ Vault Installation
7.	Forwarding of Cremains		❑ Clergy/Religious Facility
8.	Expediton of Death Certificate		❑ Outside Funeral Director's Expenses
9.	Flowers		❑ Medical Examiner's Fee

10.Shipping Container

11. Cemetery

12.Crematory

$

TOTAL SECTION II

TOTAL AMOUNT DUE

PART TWO OF TWO PARTS

Name of Deceased

Agreement No.

STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED/PURCHASE AGREEMENT

TOTAL CHARGES
Less cash received
Less assignment of,receivable from third party lender	($
Less assignment of	($
Unpaid balance due by:

PAYMENT TERMS: You understand that no extension of credit by us, subject to federal or state credit disclosure, installment sales, or other consumer credit statutes, is contemplated by this Agreement. You have no right to defer payment of any amount due under this Agreement. You agree that you are personally liable for payment of the applicable balance due shown on the Statement of Funeral Goods and Services Selected by the date indicated on the Statement. Such payment will be made to us at the address set forth in this Agreement. If you have not paid the principal balance in full within seven days after the date indicated, a one-time default charge of 10% of the unpaid portion of the principal balance will be imposed or the maximum amount allowed by law, if less.

Where the full amount due will not be paid prior to the performing of the services called for by this Agreement, you authorize us to inquire into your credit history.

IDENTIFICATION AND DESCRIPTION OF MANDATORY ITEMS AND EXPLANATION OF EMBALMING CHARGE: We have identified and described below any legal, cemetery or crematory requirements which compel the purchase of any items listed in Part One and we have explained why we charge for embalming. You acknowledge and agree that embalming andtor preparation of the remains may be performed at the facility of the above-referenced funeral home or at another facility that is duly licensed and equipped to provide such services.

You confirm that you have examined the service and merchandise items listed in Part One and found them to be correct and according to the arrangements selected and that prior to signing this Statement, you reviewed and approved a completed copy of this Statement. You also confirm that you have been informed of your right to select only such services and merchandise as you desire, and that you have the legel right to arrange the funeral services for the deceased named above.

ACKNOWLEDGEMENT OF DISCLOSURES/DISCLAIMER

The Federal Trade Commission Trade Regulation Rule on "Funeral Industry Practices" requires certain disclosures and prohibits misrepresentations. The following is a checklist we ask those we serve to read and sign to verify that the funeral arrangement conference was conducted in compliance with the Rule. You who made the arrangements for the funeral and final disposition of the above-named decedent do hereby attest to the following:

1.	You were given a General Price List effective on	prior to discussing funeral arrangements or the selection of any funeral goods or
	services.
2.	You were shown a Merchandise Price List effective on	prior to discussing caskets.
3.	You were shown an Outer Burial Container Price List effective	prior to discussing burial containers.

4.You were advised that the law does not require embalming except in certain special cases.

5.You were not advised that embalming is required for direct cremations, immediate burial, or a closed casket funeral without viewing or visitation if refrigeration is available, where state or local law does not require embalming in such cases.

6.You were not advised that any law requires a casket for direct cremation or that any container, other than an alternative container, is required for direct cremation.

7.You were advised that state law does not require the purchase of an outer burial container or any of the funeral goods or services you selected except as set forth on your Statement of Funeral Goods and Services Selected/Purchase Agreement.

8.No claims were made to you as the merchandise or services (embalming, casket, outer burial container) to the effect that embalming or the use of any merchandise available from us would delay the decomposition of the remains for a long term or indefinite time, or that any such merchandise would protect the body from gravesite substances. No representations or warranties were made to you about the protective features of caskets or outer buriel containers other than those made by the manufacturer. The only warranties were made to you about the protective features of caskets or outer burial containers other than those made by the manufacturer. The only warranties, expressed or implied, granted in connection with goods sold with the funeral service we arranged were the expressed written warranties. If any, extended by the manufacturers of such goods. No other warranties were extended to you.

9.You were advised that the funeral firm's cost for the items listed in Part One, Section II, may be different based on volume or cash discounts or other professional/trade customs where permitted by state or local law.

NOTICE TO BUYER/CO - BUYER

NOTICE: BY SIGNING THIS AGREEMENT, YOU ARE AGREEING THAT ANY CLAIM YOU MAY HAVE AGAINST THE SELLER SHALL BE RE- SOLVED BY ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A COURT OR JURY TRIAL AS WELL AS YOUR RIGHT OF APPEAL.