DISCLOSURE/DISCLAIMER
Name of Deceased ______
Date of Death ______
Date of Final Disposition of Body ______Tri-State
The Federal Trade Regulation Rule for “Funeral Industry Practices” requires certain disclosures and prohibits misrepresentations. This Disclosure/Disclaimer Form is a check list we ask those we Funeral Services, Inc. serve to read and sign if during the arrangements for the funeral of the aforementioned decedent our funeral home did or did not do the following.
I/We who made the arrangements for the funeral and final disposition of the remains of the afore- mentioned decedent do hereby attest to the following: Worthy Of Your Trust I/We hereby acknowledge that I/we have the legal right to arrange the funeral services for the deceased and authorize the Tri-State Funeral Services, Inc., to perform the ser- vices, provide funeral goods and incur outside charges. I/We were given a General Price List effective January 1, 2013 prior to discussing prices, service and merchandise. I/We were shown a Casket Price List effective January 1, 2013 prior discussing prices of caskets. I/We were shown an Outer Burial Container Price List effective January 1, 2013 prior to discussing prices of outer burial containers. 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 was provided, this was done with my/our permission. I/We were not told that any law requires embalming for direct cremations, immediate burial or a funeral using a sealed casket or if refrigeration is available and the funeral is without viewing or visitation with a closed casket. I/We were not told that any law requires a casket for direct cremation. I/We were told that state law does not require the purchase of an outer burial container or any of the funeral goods or services. I/We have selected except as set forth on the statement of funeral goods and services selected. No claims were made to me/us as to the merchandise or other offerings of this funeral firm (embalming, casket, outer burial container) that embalming or use of any merchan- dise available from this firm would delay the decomposition of the remains for a long term or indefinite time or would protect the body from graveside substances. No repre- sentations or warranties were made to us 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 manufacturer thereof. No other warranties or merchandising fitness for a particular purpose were extended to us. I/We were told that the amount of each of the cash advance items was the actual cost to 814 Upshur St., N.W. the funeral home. Washington, D.C. 20011 Reviewed this day of ___ 20______202-882-1202 Person(s) Making Final Arrangements
______eFax: 443-378-7354
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______Funeral Home Representative GENERAL INFORMATION Vaults used by
The goods and services shown below are those we can provide to our customers. You may choose only the items you desire. However, any funeral arrangements you select will include a charge for our basic ser- Tri-State vices and overhead. If legal or other requirements mean you must buy any items you did not specifically ask for, we will explain the reason in writing on the statement we provide describing the funeral goods and Funeral Services, Inc. services you selected.
PROFESSIONAL SERVICES (Washington Wilbert Vault Works, Inc.)
BASIC SERVICES of FUNERAL DIRECTOR & STAFF $1,800.00 Burial Vault Prices Our basic service charge includes, but is not limited to initial request for service; arrangement conference with family or responsible party; ar- rangement of funeral or other disposition; preparation and filing of nec- essary authorization and permits; recording vital statistics; preparation and placement of obituary notices; coordination with third parties pro- viding other portions of the funeral; e.g. cemetery, crematory, and oth- ers. Also included in this charge are the overhead expenses relative to our facility such as insurance, maintenance, and utility expenses, secre- Outer Burial Container tarial and administrative costs, and equipment and inventory expenses.
This fee for our basic service anderhead ov will be added to the total cost Cameo Rose 30 x 86 $1675.00 of the funeral arrangements you select. (This fee is already included in our charges for direct cremations,immediate burials and forwarding or Venetian - receiving remains.) 30 x 86 $1025.00 Cream & Gold
EMBALMING $ 800.00 Continental 30 x 86 $950.00
Except in certain special cases, embalming is not required by law. Em- balming may be necessary, however, if you select certain funeral ar- Monticello 30 x 86 $850.00 rangements, such as a funeral with a viewing. If you do not want em- balming, you usually have the right to choose an arrangement that does Capitol Concrete not require you to pay for it, such as direct cremation or immediate bur- 30 x 86 $850.00 ial.
1. Reconstructive restoration when necessary (per hour) …..$75.00 Salute 30 x 86 $800.00 2. Special care of autopsied remains ……………….………..$125.00 3. Washing and disinfecting of unembalmed body…….……$200.00 4. Cosmetology, dressing, and placement of deceased in casket……….…………………………………………...... $225.00 Special ITEMIZED SELECTIONS Needs Youth 20 Gauge Steel Gasketed Cas I. USE OF FACILITIES AND STAFF kets
A. Viewing 20 GA Gas- White Shaded Ivory Visitation/Wake (Per Day) Child 2-6 $1,400.00 keted Gold Crepe Our service includes set-up of viewing area, placement of encased de- 20 GA Gas- Blue Shaded ceased, display of floral arrangements, supervision and attendance dur- ing the viewing………………………………………………….$450.00 Child 3-6 $1,400.00 keted Silver Blue Crepe
B. Funeral Service 20 GA Gas- White Shaded Child 3-6 $1,400.00 keted Pink Pink Crepe 1. Funeral service at the Funeral Home – Our service includes coordina- tion and supervision of the funeral service, staff to attend the funeral 20 GA Gas- Blue Shaded service……………………………………………………...……$450.00
Child 4-6 $1,400.00 keted Silver Blue Crepe 2. Funeral service at another facility – Our service includes coordina- tion and supervision of that funeral service, and additional staff neces- 20 GA Gas- Blue Shaded sary to conduct funeral service at another facil- Child 5-6 $1,600.00 keted Silver Blue Crepe ity……………………….$450. 00
C. Memorial Service
Over- 1. Memorial services at the funeral home - Our service includes coordi- nation and supervision of the memorial service, set-up and use of facili- sized ties ... ……………………………………………………………$350.00 18 Gauge Non 2. Memorial service at another facility - Our service includes coordina- Gasketed Tall & Wides tion and supervision of that memorial service and additional staff neces- Silver Shaded Ivory sary to conduct the memorial service at another facility.……….$350.00 Moreland 32" $2,900.00 18 Gauge Ebony Crepe Silver Shaded 3. Graveside Funeral Service – Our service includes coordination and supervision of funeral service, staff to attend the funeral service and Moreland 36" $3,000.00 18 Gauge Ebony Blue Crepe recessing equipment……………………...……………………..$250.00 Silver Shaded Ivory
Moreland 40" $4,580.00 18 Gauge Ebony Crepe Silver Shaded Ivory D. Refrigeration Charge for Unembalmed Remains Moreland 44" $4,780.00 18 Gauge Ebony Crepe Per day in addition to charge referred to in Basic Service of Funeral Director and Staff (This charge begins 24 hours after the time of death) ……….. …………..$100.00
II. TRANSPORTATION Special A. Transfer of Remains to Funeral Home Needs 1. Within 25 mile local service radius ……………………….…$275.00 Cloth Covered & 2. Additional miles outside local 25 mile service radius (per mile) ……………………………………….…………………………$0.95 Cremation Caskets Particle Ivory B. Automotive Equipment Eden $540.00 Board Gray Doeskin Crepe Ivory 1. Hearse ...... $450.00 Kraft $650.00 Fiberboard Gray Doeskin Crepe 2. Hearse at another location ………………………………...….$_____ Particle Cherry 3. Family Car ……………………………………..………….….$_____ Rosemont $1,020.00 Board Laminated Blue Crepe 4. Limousine.,(Five Hour use-additional @ $90.00/h)…….……$450.00 5. Clergy Care …………………………………………..………$150.00 Particle Cherry Rosetan 6. Other automotive transportation ………………..……………$250.00 Shellbrook $1,420.00 Board Laminated Crepe 7. Additional miles outside local 25 mile service radius (per mile) ……………………………………………………….…………$0.95 Youth Vault Combination Caskets III. MERCHANDISE Ivory McCord 18" $540.00 Polystyrene Golden Frost Crepe A. Casket Price Range Ivory From $600.00 to $7,000.00 McCord 24" $620.00 Polystyrene Golden Frost Crepe (A complete price list will be provided at funeral home.) Ivory McCord 30" $720.00 Polystyrene Golden Frost Crepe B. Outer Burial Containers Range Ivory
From $995.00 to $3,000.00 McCord 36" $820.00 Polystyrene Golden Frost Crepe (A complete price list will be provided at funeral home.) Ivory McCord 48" $1,220.00 Polystyrene Golden Frost Crepe C. Urn Price Range
Selection of ten urns, each priced at $250.00 Youth Cloth (A complete price list will be provided at funeral home.) Caskets Particle Ivory D. Burial Clothing Little Angel $540.00 Board Pink, or Blue Crepe From $85.00 to $300.00 Particle Ivory Little Angel $600.00 Board Pink, or Blue Crepe
IV. PACKAGED SERVICES The caskets in this section can be used to build a package 20 Gauge suitable to your needs. 1. Package 1~Includes Basic Services of Director and Staff, embalming, one hour viewing before funeral service in the funeral home. Casket Viking Blue or provided by the funeral home …………………………...…….$3500.00 Triumph Mirror $1,680.00 20 Gauge Rose Crepe 2. Package 2~Includes Basic Services of Director and Staff, embalming, Blue, Blue Slate, Silver one hour viewing before funeral, service use of limousine. Casket pro- Varina $1,440.00 20 Gauge Gunmetal Crepe vided by the funeral home……………………..………………$4500.00
3. Package 3~Includes Basic Services of Director and Staff, embalming, 20 Gauge one hour viewing before funeral service, use of limousine. Casket pro- vided by the funeral home…..……………………...……………… $5500.00 Non
Gasketed V. SPECIAL SERVICES 20 GA Non- Atlantic $920.00 Gasketed Basic Colors Crepe A. Forwarding Remains to Another Funeral Home 20 GA Non- This charge includes temporary shelter of the remains, the embalming, Atlantic Select $920.00 Gasketed Select Colors Crepe shipping receptacle for body, necessary authorization for and basic ser- 20 GA Non- vices of staff and local transportation to airport or rail head. It does not Bentley $1,000.00 Gasketed Stock Colors Crepe include visitation, rites, or ceremonies prior to forwarding of the body. 20 GA Non- Viking Blue With minimum shipping container. ……………$1895.00
Birds $1,460.00 Gasketed Shaded Silver Blue Crepe 20 GA Non- White Shaded B. Receiving Remains form Another Funeral Home Garland $1,260.00 Gasketed Pink Pink Crepe 20 GA Non- P. Blue Shaded This charge includes temporary shelter of the remains, the transporta- tion of the remains to cemetery or crematory, and the basic services of In God's Care $1,460.00 Gasketed Silver Blue Crepe staff. It does not include visitation, funeral rites, or ceremo- nies...... $1500.00 20 GA Non- White/Pink or Lumber River $1,750.00 Gasketed White/Blue Crepe 20 GA Non- C. Immediate Burials……..$1050.00 to $1750.00
Pace $1,200.00 Gasketed Silver or Copper Crepe Our charge for immediate burial, without any attendant rites or ceremo- 20 GA Non- White Shaded nies, includes removal and shelter of remains, local transportation to Rose $1,450.00 Gasketed Pink Pink Crepe the ceremony, necessary service of staff, and authorizations.
1. Immediate burials with cloth covered casket ..$1750.00 2. Immediate burials with merchandise provided by purchaser…………………………………… …$1050.00 Special
Needs DIRECT CREMATION………………………………………$850.00 Cloth Covered & (Not including D.C. Medical Examiner fee for approval of crema- Cremation Caskets tion)……………………………………………..………………. $75.00 Blue Tabor Our charge includes removal and shelter of remains, basic services of staff, authorization and local transportation to cemetery. Fair $600.00 Fiberboard Wood Handles Blue Crepe The caskets in this section can be used to build a package 20 Gauge suitable to your needs. DIRECT CREMATION WITH CONTAINER PROVIDED BY PURCHASER……………………………...…………………..$650.00 Ivory Bogue $2,225.00 20 Gauge Silver or Blue Crepe DIRECT CREMATION WITH CONTAINER PURCHASED Ivory FROM FUNERAL HOME…………….…………………….. $850.00 Butner $2,220.00 20 Gauge Silver or Bronze Crepe
Carnation $1,800.00 20 Gauge White/Pink Pink Crepe If you want to arrange a direct cremation, you can use an alternative Silver w/Gold Ivory container. Alternative containers encase the body and can be made of Clarksville $1,795.00 20 Gauge Pinstripe Crepe materials like fiberboard or composition materials (with or without an P. Blue Sh Sil- outside covering). The containers we provide are cardboard. Devotion $1,795.00 20 Gauge ver Blue Crepe
CREMATION WITH FUNERAL VIEWING, RENTAL CASKET Silver Shaded Ivory ………………………………………………………………....$2895.00 Dove $1,795.00 20 Gauge Ebony Crepe Edenton $1,660.00 20 Gauge Stocked Colors Crepe VI. OUR PAYMENT POLICY White/Pink w/ Forget Me Not $2,225.00 20 Gauge Silver Mirrors Pink Crepe 1. Cash advances (monies paid to third parties on your behalf to help White Shaded facilitate the funeral) represents an interest-free cash outlay on the Garland $1,460.00 20 Gauge Pink Pink Crepe part of the funeral home; therefore all cash advances must be paid at V. Blue/Silver the time of the arrangements. 2. Payment policy - Total Funeral Bill- We are a small business provid Going Home $1,640.00 20 Gauge Pinstripes Blue Crepe ing services and merchandise and are totally dependent upon our P. Blue Shaded clients for prompt payment. Our payment terms are: In God's Care $1,460.00 20 Gauge Silver Blue Crepe Heartland $1,760.00 20 Gauge All Colors Crepe a. Payment via valid insurance claims is accepted Ebony w/Silver Ivory along with a standard processing fee.
Knight $2,200.00 20 Gauge Mirrors Crepe b. All other payments for funeral expenses must be Ivory paid 48 hours prior to the funeral date by certified Lighthouse $1,800.00 20 Gauge Gunmetal Crepe check, cashier's check, money order, bank or Blue Shaded credit card, or cash. Longleaf $1,600.00 20 Gauge Silver Blue Crepe White/Pink or DISCLOSURES Lumber River $1,600.00 20 Gauge White/Blue Crepe White Shaded This list does not include prices for certain items that you may ask Rose $1,600.00 20 Gauge Pink Pink Crepe us to buy for you such as cemetery and crematory supplies, flowers and newspaper notices. The prices for these items will be shown on Whited Shaded your bill or the statement describing the funeral goods and ser- Spring Rose $1,600.00 20 Gauge Pink Pink Crepe vices you have selected. White Shaded Ivory St. John $1,600.00 20 Gauge Gold Crepe All legal requirements for preparation and shipping of remains will Silver, Copper, be provided to you in writing, as well as the additional costs. Treemont $1,540.00 20 Gauge Blue, White/Pink Crepe Silver w/Gold Ivory Triumph $1,560.00 20 Gauge Stripe Crepe
Precious Metals 18 Gauge Gasketed Going Home/ Viking Blue Caskets used by Pearl Rose $1,940.00 18 Gauge Shaded Silver Blue Crepe Hamilton Ebony Brushed Ivory Brushed $2,380.00 18 Gauge Natural Crepe Ivory Tri-State Harmony $1,940.00 18 Gauge Silver Crepe Viking Blue Hatteras $1,940.00 18 Gauge Shaded Silver Blue Crepe Funeral Services, Inc. Hero $2,780.00 18 Gauge Platinum Silver Blue Crepe
Blue Brushed Blue Lexington $2,980.00 18 Gauge Natural Velvet Lexington Oval 18 Gauge Gold Brushed Ivory Glass $5,780.00 w/Glass Gold Velvet Lord's Supper/ Silver Brushed Ivory West Minister $3,380.00 18 Gauge Natural Velvet White Shaded Meadow $1,940.00 18 Gauge Pink Pink Crepe Mother $2,220.00 18 Gauge Orchid Blend Pink Crepe Powder Blue Neuse $1,820.00 18 Gauge Shaded Silver Blue Crepe Wallace/Rose Silver Hill $1,940.00 18 Gauge Silver/Ebony Crepe
20 Gauge The caskets in this section can be used to build a package Gasketed suitable to your needs. Anchor $1,220.00 20 Gauge All Colors Crepe
All Colors w/ Ivory Bayside $1,850.00 20 Gauge Custom Script Crepe Worthy Of Your Trust Ivory Bennett $1,450.00 20 Gauge Silver or Bronze Crepe Viking Blue Birds $1,450.00 20 Gauge Shaded Silver Blue Crepe
Solid Cedar Hardwoods Eggshell Name Price Material Finish Interior Lane $380.00 Solid Cedar Polished Finish Crepe Solid Walnut Poplar Ivory Ivory Clifton - Boots $5,700.00 Solid Walnut Rubbed Finish Velvet Alston $2,480.00 Poplar Cherry Finish Crepe Solid Pine Mahogany Eggshell Solid Ivory American $2,780.00 Pine Polished Finish Crepe Capitol $6,880.00 Mahogany Rubbed Finish Velvet Pine Ivory Solid Ivory Levi Flat Top $1,580.00 Orthodox Clear Finish Crepe Chatham $5,300.00 Mahogany Rubbed Finish Velvet Ivory Pinetown $2,180.00 Pine Dark Pine Crepe Solid Cherry Rosetan Oregon $3,980.00 Solid Cherry Rubbed Finish Crepe Precious Ivory 18 Gauge Victoria $4,660.00 Solid Cherry Polished Finish Velvet Eggshell Gasketed Washington $4,660.00 Solid Cherry Rubbed Finish Velvet Alamance $3,260.00 18 Gauge Brushed Crepe Viking Blue Bl. Oak Calvary $1,820.00 18 Gauge Blue Blue Crepe Ivory White Shaded Memory $3,980.00 Solid Oak Satin Finish Velvet Carnation $2,580.00 18 Gauge Pink Pink Velvet Ivory Ivory Oak Ridge $1,240.00 Oak Light Oak Crepe Catawba $1,940.00 18 Gauge Platinum Silver Crepe Rosetan Blue, Bronze, Oakboro $1,240.00 Oak Dark Oak Crepe Corinthian $1,940.00 18 Gauge White, M. Blue Crepe Ivory Solid Maple Faithful $1,940.00 18 Gauge White or Ebony Crepe Pink or Gaston $3,680.00 Solid Maple Satin Finish Rosetan Father $2,220.00 18 Gauge Neo Blue Blend Blue Crepe Fleming V. Bronze Rosetan Solid Pecan Brushed $2,380.00 18 Gauge Brushed Gold Crepe Beige White Shaded Woodsdale $3,580.00 Pecan Satin Finish Velvet Floral Basket $2,180.00 18 Gauge Pink Pink Crepe