New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter II - Administrative Rules and Regulations
Subchapter J - Funeral Directing, Undertaking And Embalming
Part 78 - Statement To Be Furnished By Every Person Licensed Pursuant To Article 34 Of The Public Health Law
Section 78.2 - Format for statement of goods and services selected
Current through Register Vol. 46, No. 12, March 20, 2024
The statement of goods and services selected shall be in the following format:
ITEMIZATION OF FUNERAL SERVICES AND MERCHANDISE SELECTED
The following are the charges for the services, merchandise and livery you have selected. You will not be charged for any item you do not choose unless it is necessary because of other selections you have made. Any such charges are explained below.
I. FUNERAL HOME CHARGES (Indicate N/A for items of service and/or merchandise that are not provided.)
If you select a funeral for which this firm requires embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you do not approve if you select arrangements such as direct cremation or direct burial. If we charge for embalming, we will explain why below.
$ __
Basic arrangements: including funeral director, other staff, equipment and facilities to respond to initial request for service, the arrangement conference, securing of necessary authorizations and coordination of service plans with parties involved in the final disposition of the deceased.
(Specify type: _________.......................................................
)
(Specify number: __@ $__/limousine)
(Specify number: __@$__/car)
or kind of metal
weight or
_gauge __ or alternative container (describe)____________________________
Supplier
_______________________________________________________
...................................................................................................................
Model name or number
_______________________________________________________
...................................................................................................................
Material
_______________________________________________________
(Describe and show price)
TOTAL OF FUNERAL HOME CHARGES $ ___.................................................
II. CASH ADVANCES
These are estimated charges for items to be paid to others. We will charge you no more for these items than is actually paid the third parties. (Describe and show estimated charges.)
ESTIMATED TOTAL OF CASH ADVANCES $ ___.................................................
III. SUMMARY OF CHARGES
TOTAL FUNERAL CHARGES $ ___.................................................
IV. EXPLANATION OF CHARGES
Explain charges for embalming and for any items that are not required by law but may be necessary because of cemetery requirements, crematory requirements or other selections made.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Signature of Licensed Funeral Director Date......................................................
Printed or Typed Name of Funeral Director
ACKNOWLEDGMENT OF RECEIPT
I have received this itemization of funeral services
and merchandise selected.
Signature of Licensed Funeral Director Date....................................................
PUBLIC NOTICE
The New York State Department of Health is responsible for licensing and regulating New York State funeral directing under the Public Health Law.
You may contact the Department at:
Bureau of Funeral Directing
New York State Department of Health
Corning Tower, Empire State Plaza
Albany, NY 12237
