Statement of Funeral Goods and Services 

FTC Disclosure

Authorization for Embalming

 Lakeshore Memorial Services, Inc

11939 James Street

Holland, MI 49424

616-395-3630

Michael P. Dozeman -- Owner & Manager

Charges are only for those items that you selected or that are required.  If we are required by law or by a cemetery or crematory to use any items, we will explain the reason in writing below.  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 you did not approve if you selected arrangements such as direct cremation or immediate burial.  If we charged for embalming, we will explain why below.

 

Services for:

_______________________________________________

(Name of Deceased)

This is a cash transaction. The undersigned jointly and severally agree to pay Lakeshore Memorial Services Inc the balance due on this account, plus the agreed value of such additional services, materials and cash advances as may be furnished by Lakeshore Memorial Services, Inc. 

Such payment shall be made at the time of arrangements.

A late penalty of 1.25% per month (15% per year) will be assessed on the unpaid balance for material and services.   Lakeshore Memorial Services Inc makes no warranties or representations concerning the products sold herein.  The only warranties, expressed or implied, granted in connection with the products sold with this funeral service, are the expressed written warranties, if any, extended by the manufacturers thereof.  Lakeshore Memorial Services Inc hereby expressly disclaims all warranties, expressed or implied, relating to all such products, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose.  

 Reason for embalming:                   ____ Family requested      ____ No Embalming  

Reason for outer burial container:   ____ Family requested      ____ Required by cemetery                                                                  

FUNERAL RULE DISCLOSURE/ DISCLAIMER FORM

The Federal Trade Commission’s Funeral Rule requires certain disclosures and prohibits misrepresentations.  This disclosure/disclaimer form is a checklist we ask those we serve to read and sign if during the funeral arrangements our funeral home complied with the following:  

1.   The undersigned received the General Price List effective on October 1, 2008 prior to  discussing prices, services, merchandise or arrangements.

2.   The undersigned were shown a Casket Price List effective on October 1, 2008 prior to viewing or discussing prices of caskets.

3.   The undersigned were shown an Outer Burial Container Price List effective on October 1, 2008 prior to viewing or discussing prices of our outer burial containers.

4.   The undersigned were informed that embalming is not required by law (except in certain cases). If embalming was provided, it was done with the permission of the undersigned.

5.   The undersigned were informed that the law does not require embalming for direct cremation, immediate burial or if refrigeration is available and the funeral is without viewing or visitation.

6.   The undersigned were informed that the law does not require a casket for direct cremation.

7.   The undersigned were informed that the law does not require the purchase of an outer burial container.

8.   The funeral home made no representations to the undersigned that embalming or the use of any merchandise available from the funeral home would delay the decomposition of the remains for a long time or indefinite time.

9.   The undersigned understands that Lakeshore Memorial Services has disclaimed all warranties with regards to caskets, outer burial containers and other merchandise sold by the funeral home. The undersigned further understands that the only warranties, express or implied, granted in connection with the goods sold by the funeral home are the express written warranties, if any, which are extended by the manufacturers of the goods. No other warranties, including the implied warranties of merchantability or fitness for a particular purpose, are extended by the funeral home.

The undersigned, being the nearest degree of relationship to the above named, individual hereby authorize Lakeshore Memorial Services, Inc. or its agents to care for, transport, embalm and otherwise prepare said body for burial or other legal disposition.   I/We, the undersigned, acknowledge that the foregoing statement has been read to me/us and I/we hereby acknowledge receipt of completed copy.    

 

X_____________________________________       ________________________________                             Signature                                                                Phone Number

___________________________________________________________________________                                                                                                              Complete Address