• Statement of Goods and Services form

  • Statement of Goods and Services

    "*" indicates required fields

    MM slash DD slash YYYY
    MM slash DD slash YYYY
    DIRECT CREMATION SERVICE
    ADDITIONAL SERVICES AND MERCHANDISE

    Call for assistance with this (727) 223-5911

  • Certified Copies of Death Certificate…….With cause of death ($10 ea):
  • Certified Copies of Death Certificate…….Without cause of death ($10 ea):
  • Urn
  • TOTAL DUE (at time of family conference/meeting)
  • ACKNOWLEDGEMENT AND AGREEMENT: I hereby acknowledge that I have the legal right to arrange the final disposition for the deceased and I authorize this establishment to perform the direct cremation services and other services and merchandise specified on this statement. By my signature below, I acknowledge that I have received, on this date, the General Price List and copy of this statement.

    TERMS OF PAYMENT: I agree to pay and/or guarantee payment of the charges listed on this statement. In the event of default of payment, I agree to pay reasonable attorney’s fees and court costs. I agree that the liability is being personally assumed by me and is in addition to the liability imposed by law upon the estate, and this agreement does not constitute a release of liability. By my signature below, acknowledgment and agreement of the above are hereby made.

    MM slash DD slash YYYY
    Address*
    State*

    ACCEPTANCE: This establishment agrees to provide all services and merchandise specified on this statement.

    Hidden
    Hidden
    MM slash DD slash YYYY
    Hidden