DIRECT CREMATION ...... $1,175.00 DISCLOSURE/DISCLAIMER

Includes medical examiner fee for approval of cremation, removal and shelter Tri-State Funeral Services, Inc. of remains, basic services of staff, authorization, 1 certified copies of death Name of Deceased ______certificate, container for cremation. Date of Death ______

Date of Final Disposition of Body ______(Storage Fees) “Worthy Of Your Trust” Storage fee will be applied after five days at $25.00 a day. The Federal Trade Regulation Rule for “Funeral Industry Practices” requires certain disclosures and prohibits misrepresentations. This Disclosure/Disclaimer CREMATION WITH FUNERL VIEWING, RENTAL CASKET. $2895.00 Form is a check list we ask those we serve to read and sign if during the arrangements for the funeral of the aforementioned decedent our funeral home did VI. OUR PAYMENT POLICY or did not do the following. General Price List 1. Cash advances (monies paid to third parties on your behalf to help facilitate the I/We who made the arrangements for the funeral and final disposition of the funeral) represents an interest-free cash outlay on the part of the funeral home; remains of the aforementioned decedent do hereby attest to the following: therefore all cash advances must be paid at the time of the arrangements. 2. Payment policy – Total Funeral Bill – We are a small business providing • I/We hereby acknowledge that I/we have the legal right to arrange the funeral services and merchandise and are totally dependent upon our clients for prompt services for the deceased and authorize the Tri-State Funeral Services, Inc., to payment. Our payment terms are: perform the services, provide funeral goods and incur outside charges.

• I/We were given a General Price List effective January 1, 2019 prior to a. Payment via valid insurance claims is accepted along with a standard discussing prices, service and merchandise. processing fee. • I/We were shown a Casket Price List effective January 1, 2019 prior to b. All other payments for funeral expenses must be paid 48 hours prior to the discussing prices of caskets. funeral date by certified check, cashier’s check, money order, bank or • I/We were shown an Outer Burial Container Price List effective January 1, credit card, or cash. 2019 prior to discussing prices of outer burial containers. Death Certificates – Maryland, District of Columbia, Virginia ...... $25.00 • I/We were not told that embalming is required by law and were told that the law does not require embalming except in certain special cases. If embalming DISCLOSURES was provided, this was done with my/our permission.

This list does not include prices for certain items that you may ask us to buy for • I/We were not told that any law requires embalming for direct cremations, you such as cemetery and crematory supplies, flowers and newspaper notices. immediate burial or a funeral using a sealed casket or if refrigeration is The prices for these items will be shown on your bill or the statement available and the funeral is without viewing or visitation with a closed casket. describing the funeral goods and services you have selected. • I/We were told that state law does not require the purchase of an outer burial container or any of the funeral goods and services. I/We have selected except All legal requirements for preparation and shipping of remains will be provided as set forth on the statement of funeral goods and services selected. to you in writing, as well as the additional costs. • No claims were made to me/us as to the merchandise or other offerings of this 1505 Kenilworth Avenue, N.E. funeral firm (embalming, casket, outer burial container) that embalming or Vaults used by Tri-State Funeral Services, Inc. use of any merchandise available from this firm would delay the Washington, DC 20019 (Washington Wilbert Vault Works, Inc.) decomposition of the remains for a long term or indefinite time or would protect the body from graveside substances. No representations or warranties Burial Vault Prices were made to us about the protective features of caskets or outer burial Outer Burial Container containers other than those made by the manufacturer. The only warranties (202) 882-1202 (phone) expressed or implied, granted in connection with goods sold with the funeral Cameo Rose 30 x 86 $1675.00 service we arranged were the expressed written warranties, if any, extended 443-378-7354 (fax) Venetian – Cream & Gold 30 x 86 $1025.00 by the manufacturer therefore. No other warranties or merchandising fitness for a particular purpose were extended to us. Continental 30 x 86 $950.00 Monticello 30 x 86 $850.00 • I/We were told that the amount of each of the cash advance items was the actual cost to the funeral home. Capitol Concrete 30 x 86 $850.00 Salute 30 x 86 $800.00 Prices are good through Reviewed this ______day of ______20 ______

Person(s) Making Final Arrangements 01/01/2019 – 01/01/2020 ______Price is subject to change under certain circumstances ______Funeral Home Representative

GENERAL INFORMATION B. Funeral Service B. Outer Burial Containers Range

The goods and services shown below are those we can provide to our customers. 1. Funeral service at the Funeral Home – Our service includes coordination and From $995.00 to $3,000.00 You may choose only the items you desire. However, any funeral arrangements supervision of the funeral service, staff to attend the funeral service. .$600.00 (A complete price list will be provided at funeral home) you select will include a charge for our basic services and overhead. If legal or other requirements mean you must buy any item you did not specifically ask for, 2. Funeral service at another facility – Our service includes coordination and C. Urn Price Range we will explain the reason in writing on the statement we provide describing the supervision of that funeral service, and additional staff necessary to conduct funeral goods and services you selected. funeral service at another facility ...... $600.00 Selection of ten urns, each priced at $250.00 (A complete price list will be provided at funeral home) PROFESSIONAL SERVICES C. Memorial Service D. Burial Clothing BASIC SERVICES OF FUNERAL DIRECTOR/STAFF. . $2,000.00 1. Memorial services at the funeral home – Our service includes coordination From $85.00 to $300.00 and supervision of the memorial service, set-up and use of facilities..$350.00 Our basic service charge includes, but is not limited to, initial request for IV. PACKAGED SERVICES service; arrangement conference with family or responsible party; arrangement 2. Memorial service at another facility – Our service includes coordination and of funeral or other disposition; preparation and filing of necessary authorization supervision of that memorial service and additional staff necessary to 1. Package I – Includes Basic Services of Director and Staff, embalming, one and permits; recording vital statistics; preparation and placement of obituary conduct the memorial service at another facility...... $350.00 hour viewing before funeral service in the funeral home. Casket provided notices; coordination with third parties providing other portions of the funeral; by the funeral home ...... $3,500.00 e.g. cemetery, crematory, and others. Also included in this charge are the 3. Graveside Funeral Service – Our service includes coordination and overhead expenses relative to our facility such as insurance, maintenance, and supervision of funeral service, staff to attend the funeral service and 2. Package 2 – Includes Basic Services of Director and Staff, embalming, utility expenses, secretarial and administrative costs, and equipment and recessing equipment ...... $350.00 one-hour viewing before funeral, service use of limousine. Casket inventory expenses. provided by the funeral home ...... $4,600.00 D. Refrigeration Charge for Unembalmed Remains This fee for our basic services and overhead will be added to the total cost of the 3. Package 3 – Includes Basic Services of Director and Staff, embalming, funeral arrangements you select. (This fee is already included in our charges for (Storage Fees) one hour viewing before funeral service, use of limousine. Casket direct cremations, immediate burials and forwarding or receiving remains). provided by the funeral home ...... $5, 500.00 Storage fee will be applied after five days at $25.00 a day. EMBALMING $1,250.00 V. SPECIAL SERVICES II. TRANSPORTATION A. Forwarding Remains to Another Funeral Home Expect in certain special cases, embalming is not required by law. Embalming A. Transfer of Remains to Funeral Home may be necessary, however, if you select certain funeral arrangements, such as a This charge includes temporary shelter of the remains, the embalming, funeral with a viewing. If you do not want embalming, you usually have the 1. Within 25 mile local service radius ...... $300.00 shipping receptacle for body, necessary authorization for and basic right to choose an arrangement that does not require you to pay for it, such as 2. Additional miles outside local 25 mile service radius (per mile) . . . . $0.95 direct cremation or immediate burial. services of staff and local transportation to airport or rail head. It does B. Automotive Equipment not include visitation, rites, or ceremonies prior to forwarding of the 1. Reconstructive restoration when necessary (per hour) ...... $75.00 body. With minimum shipping container ...... $1,895.00 2. Special care of autopsied remains ...... $125.00 1. Hearse ...... $600.00 3. Washing and disinfecting of unembalmed body ...... $200.00 2. Limousine (five hour use – additional @$90.00/h)...... $600.00 B. Receiving Remains From Another Funeral Home 4. Cosmetology, dressing and placement of deceased in casket ...... $225.00 3. Clergy Care ...... $150.00 4. Other automotive transportation ...... $250.00 This charge includes temporary shelter of the remains, the transportation of ITEMIZED SELECTIONS 5. Additional miles outside local 25 mile service radius (per mile) . . . . $0.95 the remains to cemetery or crematory, and the basic services of staff. It does not include visitation, funeral rites, or ceremonies ...... $1,500.00 I. USE OF FACILITIES AND STAFF III. MERCHANDISE C. Immediate Burials ...... $1050.00 to $1750.00 A. Viewing A. Casket Price Range Our charge for immediate burial, without any attendant rites or ceremonies, Visitation/Wake (Per Day) includes removal and shelter of remains, local transportation to the ceremony,

From $600.00 to $7,000.00 necessary service of staff, and authorizations. Our service includes set-up of viewing area, placement of encased deceased, (A complete price list will be provided at funeral home) display of floral arrangements, supervision and attendance during the 1. Immediate burials with cloth covered casket ...... $1,750.00 viewing ...... $450.00 2. Immediate burials with merchandise provided by purchaser . . . $1050.00

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Price is subject to change under certain circumstances Price is subject to change under certain circumstances Price is subject to change under certain circumstances