10 CRR-NY 78.2NY-CRR

STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
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
10 CRR-NY 78.2
10 CRR-NY 78.2
78.2 Format for statement of goods and services selected.
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.)
A. Alternative Services
1. Direct Cremation
 
$ __
2. Direct Burial
 
$ __
B. Transfer of remains to the funeral establishment, including
 
personnel, equipment and vehicle.
 
$ __
C. Preparation of Remains
1. Embalming (including use of preparation room)
 
$ __
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.
2. Other preparation (including use of preparation room but excluding embalming)
a. Topical Disinfection
 
$ __
b. Custodial Care
 
$ __
c. Dressing/Casketing
 
$ __
d. Cosmetology
 
$ __
e. Restoration
 
$ __
f. Other (specify)
_________
 
$ __
______________
D. Arrangements
 
$ __
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.
E. Supervision (funeral director and staff)
1. Supervision for visitation
 
$ __
2. Supervision for funeral service
 
$ __
3. Other supervision (specify)
_________
 
$ __
_________________
F. Use of the Facilities
1. Use of the facilities for visitation
 
$ __
2. Use of facilities for funeral service
 
$ __
3. Other use of facilities (specify)
_________
 
$ __
___________________
G. Livery
1. a. Hearse or
 
$ __
b. Alternative vehicle
 
$ __
(Specify type:
_________
)
 
2. Flower vehicle
 
$ __
3. Limousine(s)
 
$ __
(Specify number: __@ $__/limousine)
4. Passenger car(s)
 
$ __
(Specify number: __@$__/car)
H. Merchandise
 
$ __
1. Casket or Alternative Container
 
$ __
a. Supplier
 
b. Model name or number
 
c. Material: Species of wood
 
or kind of metal
 
weight or
 
gauge
__
or alternative container (describe)
 
d. Interior
 
2. Outer Interment Receptacle
 
$ __
 
Supplier
 
 
Model name or number
 
 
Material
 
I. Additional Services and Merchandise Selected
(Describe and show price)
1.
______________
 
$ __
2.
______________
 
$ __
3.
______________
 
$ __
4.
______________
 
$ __
J. Limited Services
1. Forwarding remains to
__________
 
$ __
2. Receiving remains from
_________
 
$ __
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.)
1.
______________
 
$ __
2.
______________
 
$ __
3.
______________
 
$ __
4.
______________
 
$ __
ESTIMATED TOTAL OF CASH ADVANCES
 
$ __
III. SUMMARY OF CHARGES
1. Funeral Home Charges
 
$ __
2. Cash Advances
 
$ __
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
10 CRR-NY 78.2
Current through August 15, 2021
End of Document