Tri-State Booklet 2

DISCLOSURE/DISCLAIMER Name of Deceased ____________________________________________________ Date of Death ________________________________________________________ Tri-State Date of Final Disposition of Body ________________________________________ 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 aforementioned 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 services, 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 merchandise 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 _____________________________________________________________________________________________ _____________________________________________________________________________________________ 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; arrangement of funeral or other disposition; preparation and filing of necessary 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 and overhead 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 embalming, 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 Youth20GaugeSteelGasketedCas 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 during 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 coordination 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 coordination 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 coordination and supervision of the memorial service, set-up and use of facili- sized ties ... ……………………………………………………………$350.00 18GaugeNon 2. Memorial service at another facility - Our service includes coordina- GasketedTall&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 ClothCovered& 2. Additional miles outside local 25 mile service radius (per mile) ……………………………………….…………………………$0.95 CremationCaskets 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 YouthVault CombinationCaskets 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

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