Ariz. Admin. Code § tit. 4, ch. 12, art. 5, app B
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
The charges are only for those items that are used. If we are required by law to use any items, we will explain the reasons in writing.
FUNERAL OF ____________________________________________
FORWARDING OF REMAINS TO ANOTHER FUNERAL HOME $__________
This charge includes removal of body, services of staff, necessary authorizations, embalming, and local transportation (but not shipping charges.)
RECEIVING OF REMAINS FROM ANOTHER FUNERAL HOME $__________
This charge includes services of staff, care of remains, and transportation to cemetery or crematory.
DIRECT CREMATION (As selected) $__________
This charge includes removal of body, necessary authorizations, services of staff, transportation to crematory, and cremation of body.
TRANSFER OF REMAINS TO FUNERAL HOME ( ________ miles transported) $__________
IMMEDIATE BURIAL (As selected) $__________
This charge includes removal of body, services of staff, necessary authorizations, and local transportation to cemetery.
FUNERAL ARRANGEMENTS (Indicated services and facilities selected) $__________
Funeral Director and Staff Services __________
Embalming __________
Other preparation of body __________
Use of facilities for viewing __________
Use of facilities for funeral __________
Other use of facilities __________
AUTOMOTIVE EQUIPMENT (Indicated items selected) $__________
Hearse __________
Limousine __________
Other automobiles __________
ACKNOWLEDGMENT CARDS $__________
CASKET SELECTED $__________
VAULT OR LINER $__________
OTHER ITEMS (describe)_____________________________ $__________
_____________________________ $__________
CASH ADVANCE ITEMS
Organist and/or other music $__________
Hairdresser or barber $__________
Flowers $__________
Pallbearers $__________
Motorcycle escorts $__________
Clergy Honoraria $__________
Obituary Notice $__________
Death Certificate(s) $__________
Gratuities $__________
Other (describe) $__________
Total $__________
TOTAL COST FOR ARRANGEMENTS SELECTED $__________
FOR FUNERAL HOME________________________________________ Date__________________________________
___________________________________________________________
Arranged by_________________________________________________ Date__________________________________
___________________________________________________________________
NOTICE TO PURCHASER
You may choose to purchase a casket or container for the funeral services and final disposition. However, except under certain public health circumstances pursuant to A.R.S. § 36-136, state law does not require the purchase or use of caskets or containers.
METHOD OF PAYMENT AND INTEREST CHARGES [describe the method of payment required by the funeral establishment for the funeral services and any interest charges.
[Statement not used as final bill]
Ariz. Admin. Code tit. 4, ch. 12, art. 5, app B