Statement of Funeral Goods & Services Selected / Purchase Agreement
Seller / Funeral Establishment:
Cremation Enterprises
1904 Vermillion St., Hastings, MN 55033
Date of Death: {dateOf}
Date of Arrangements / Contract Date: {date}
Name of Deceased: {lovedOnes}
Purchaser: {yourFirst} {yourLast}
Address: {deliveryAddress}
Phone: {phoneNumber8}
In this Agreement, the words “you” and “your” refer to the Purchaser, and the words “we,” “us,” and “our” refer to Cremation Enterprises. The goods and services described below are those selected by the Purchaser or required for this arrangement.
Charges are only for those items that you selected or that are required. If we are required by law, by a cemetery, or by a crematory to use any items, we will explain the reasons in writing below.
Section I — Services and Merchandise
Package Offerings
Signature Cremation Package
To provide full transparency, we list the standard price of each individual good and service included in your package. Funeral regulations require us to itemize these goods and services, even when they are purchased as part of a package.
The items highlighted in beige are included in your selected Signature Cremation Package at the package price shown below. Any green-highlighted items represent additional goods or services selected outside of the package, & only if applicable. Discounts are highlighted in blue.
Signature Cremation Package Charge: $1,895
Funeral Director and Staff Services
Basic Professional Service Fee
Professional services, arrangement coordination, administrative services, authorizations, permits/paperwork assistance, and coordination with third parties.
Charge: $1,095 (INCLUDED)
Care and Preparation of Remains
Embalming
Embalming Disclosure: If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming if you did not approve it. If you selected arrangements such as direct cremation or immediate burial, and we charged for embalming, we will explain why here:
EMBALMING NOT APPLICABLE
Charge: $____________________ / N/A
Other Preparation — Refrigeration / Sheltering / Care of Remains
Charge: $65 (INCLUDED)
Use of Facilities and Related Services
Visitation
Charge: $____________________ / N/A
Funeral Ceremony
Charge: $____________________ / N/A
Memorial Service
Charge: $____________________ / N/A
Graveside Service
Charge: $____________________ / N/A
Other Facility / Related Service
Charge: $____________________ / N/A
Transportation
Transfer / Removal of Remains into Our Care
Charge: $495 (INCLUDED)
Personal Residence / Assisted Living Transfer, if applicable
Charge: ${personalResidence}
Funeral Vehicle / Hearse
Charge: $____________________ / N/A
County Mileage / Distance Charge, if applicable
Charge: {aDistance}
Other Goods and Services
Cremation Fee / Direct Cremation / Crematory Service
Charge: $525 (INCLUDED)
Mailing / Delivery of Cremated Remains
Charge: $165 (INCLUDED)
Additional Staff / Weight Safety Fee, if applicable
Charge: ${weightFee}
Additional Death Certificates, if selected
Charge: ${wouldYou}
Additional certified copies selected beyond the 5 included with the Signature Cremation Package. This amount includes the applicable county/state certified copy fee and our service charge for obtaining and handling the additional certificates.
Other Service / Item
Charge: $____________________ / N/A
Merchandise
Casket or Alternative Container
Material: Heavy Cardboard Exterior
Interior: No interior
Basic Cardboard Cremation Container
Rigid, combustible container required by the crematory.
Charge: $165 (INCLUDED)
Outer Burial Container
Charge: $____________________ / N/A
Urn Selected
Manufacturer / Supplier: Khan Eximpo
Model Name / Number: {urnSelection}
Material: Aluminium
Taxable merchandise value, if applicable: ${salesTax}
Charge: $200 / Separated Charge in Package
Keepsake / Additional Merchandise, if selected
Description: {keepsakeSelection}
Charge: FREE
Section II — Charges to Be Incurred by Us on Your Behalf / Cash Advance Items
We charge you for our services in obtaining cash advance items listed below. Cash advance items are charges made by other agencies or third parties outside our funeral home. Some cash advance charges may be estimated.
Certified Copies of Death Certificate
Charge: $110 - 5 Copies (INCLUDED)
We charge you for our services in obtaining certified copies of the death certificate. The amount shown for death certificates includes the applicable county/state certified copy fee, which varies by county, and our service charge for ordering, obtaining, handling, and/or forwarding the certificates.
Cremation Permit / Government Fees
Charge: $125 (INCLUDED)
Includes the applicable county/government cremation permit fee and Cremation Enterprises’ service charge for preparing, coordinating, filing, obtaining, and/or handling the cremation permit. County/government permit fees vary by county.
Cemetery Charges
Charge: $____________________ / N/A
Crematory Charges
Charge: $____________________ / N/A
Obituary Notice
Charge: $55 (INCLUDED)
Flowers / Clergy / Church / Luncheon / Other Third-Party Expense
Charge: $____________________ / N/A
Total Section I and Section II Charges (Before Discounts, Package Rates)
${largeTotal}
Section III — Allowances / Discounts / Promotions
Promotional Discount / Promo Code
Description: MNCREMATION
Allowance / Discount: -$300
Allowance / Package Discount: -$805
Total Allowances / Discounts:
($1,105)
Section IV — Taxes, Fees
Taxable Items: Urn, Merchandise
Taxable amount: $200
Sales Tax on Taxable Merchandise Only
Tax Rate: 6.875%
Sales Tax: ${salesTax}
Total Charges and Payment
Total Section I & II — Services and Merchandise, Cash Advance Items:
${largeTotal}
Less Section III — Allowances / Discounts:
$1,105
Total Section IV — Taxes:
${salesTax}
Card Processing Fee:
${creditCard}
Total Charges:
${costWith}
Unpaid Balance Due:
${costWith}
Balance Due Date:
{date}
Payment Terms
You understand that no extension of credit by us, subject to federal or state credit disclosure, installment sale, or other consumer credit statutes, is contemplated by this Agreement. You have no right to defer payment of any amount due under this Agreement. You agree that you are personally liable for payment of the applicable balance due shown on this Statement of Funeral Goods and Services Selected by the due date indicated on the Statement.
Such payment will be made to us as set forth in this Agreement. If this Statement is not paid when due, we may pursue collection as allowed by law.
Identification and Description of Mandatory Items / Explanation of Embalming Charge
We have identified and described below any legal, cemetery, or crematory requirements that compel the purchase of any items listed above, and we have explained why we charged for embalming, if applicable.
Mandatory Item / Requirement:
A rigid, combustible cremation container is required by the crematory. A permit for cremation is required by the state.
Reason for Embalming Charge:
No embalming charge.
Additional Explanation, if any:
__________
You confirm that you have examined the service and merchandise items listed in this Statement and found them to be correct and according to the arrangements selected. You also confirm that prior to signing or submitting this Statement, you reviewed and approved a completed copy of this Statement. You further confirm that you have been informed of your right to select only such services and merchandise as you desire, and that you have the legal right to arrange the funeral services for the deceased named above.
An additional itemized Statement of Funeral Goods and Services Selected will be emailed to you immediately after submission.
Acknowledgement and Agreement
This funeral home is authorized to perform services, furnish goods, and incur cash advance charges specified in this Statement. It is also acknowledged that a General Price List was received.
Terms:
This is a cash transaction. Total amount is due in full and, in all events, becomes past due and delinquent upon expiration of the due date. A penalty of 18.00% per annum for unanticipated late payment will be charged 10 days after the cremation takes place. Purchaser(s) agree to pay reasonable attorney’s fees, court costs, and other costs of collection incurred in the collection of this debt.
I/We, having read the above, accept and approve same, and jointly and severally promise to make full payment thereof. Receipt of a copy of this contract is acknowledged.
Purchaser Acknowledgment / Signature
Do not sign or submit this Agreement before you read it. Do not sign or submit it if it contains any blank spaces you do not agree to or if you have not received or reviewed an exact copy of this Agreement.
By signing & submitting this Agreement below, you acknowledge that you have reviewed the full itemized Statement of Funeral Goods & Services Selected, including all selected services, merchandise, cash advance items, discounts/promotions, taxes, fees, required disclosures, agreement terms, and total charges.
Purchaser Name:
{yourFirst} {yourLast}
Purchaser Signature:
Electronically signed / submitted through Jotform
Date:
{date}