Date: Service # Name of Deceased:

Place of death:

Charges are only those items that you selected or that are required. If we are required by law or by a Cemetery or a crematory to use any items, we will explain the reasons 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 a direct cremation or immediate burial. If we charge for embalming, we will explain why below. For more information on funeral & cemetery matters, contact: State of CA Dept. of Consumer Affairs: Cemetery & Funeral Bureau, 1625 N Market Blvd Ste 208, Sacramento, CA 95834.

A. CHARGES FOR SERVICES D. CASH ADVANCE

Professional Services

Funeral Director & Staff $

Embalming $

Reconstruction / Autopsy repair $

Dressing / Others: $

Others: $

Facilities, Services & Equipment

Chapel Use $

Equipment for Church Services $

Others: $

Automotive Equipment

Transfer of Remains to Mortuary $

Hearse / Transportation $

Limousine $

Service / Utility Vehicle $

Emergency Service $

Obtaining Apostille $

Others: $

Certificates:

Permit of Disposition

County Recorder Authentication

Secretary of State Apostille

Public Health Letter

Clergy

Musician

Florist:

Cemetery:

Crematory:

Flight Tickets:

County Coroner:

Airlines:

Escorts:

Consulate:

Dove Release:

Outside Mortuary:

Receiving Funeral:

Scattering Ashes:

Witness Cremation:

Rush Cremation:

Video:

Inman:

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$ TOTAL CHARGES FOR SERVICES $

TOTAL CASH ADVANCE $ B. CHARGES FOR MERCHANDISE

Casket* (name): $ We are charging you for our services in obtaining:

Rental Casket $

Vault $ E. SALES TAX

Head Plate $ Write Taxable Sales amount (if apply) $

Burial Clothing $ From total charges for merchandise (local service) $

Urn $ Local Service Out of State

Prayer Cards $

Register Book $ SUMMARY OF CHARGES

Photo $ A. Charges for Services $

Gloves (pairs): $ B. Charges for Merchandise $

Crucifix: $ C. Special Charges $

Other: ( ) $ D. Cash Advance $

Air Tray $ E. Sales Tax (If applicable) $

Other: $ TOTAL MORTUARY CHARGES $

Other: $

TOTAL CHARGES FOR MERCHANDISE $ LESS CREDIT & PREPAYMENTS

Discounts $

C. SPECIAL CHARGES Check and Deposit Date $

Forwarding of Remains to $ Cash and Deposit Date $

Receiving of Remains to $ Insurance $

Immediate Burial $ Other: $

Direct Cremation $ TOTAL CREDIT & PREPAYMENT $

Other: $

TOTAL SPECIAL CHARGES $ BALANCE DUE $

Funeraria Latino-Americana FD 1412 3827 E. Whittier Blvd Los Angeles, CA 90023

Ph: (323) 265-7016 Fax: (323) 262-2941

Service # _______________

*The only warranty on the casket and/or outer burial vault sold connection with this service is the express written warranty if any, granted by the mfg. This Mortuary makes no warranty, express or implied, with respect to the casket and/or outer burial container.

If any law, cemetery or crematory requirements have required the purchase of any of the item listed above, the law or requirements is explained below by Cemetery.

BURIAL PERMIT PER STATE LAW

Reason for Embalming:

Billing to:

Address:

City, State, Zip:

I hereby agree that I have examined the above stated items and found them to be correct and according to the arrangements requested and I hereby

acknowledge receipt of a copy of this memorandum and agreement. I hereby represent that I have sufficient funds and assets legally available for

payment of cash price and hereby agree and covenant jointly and severally to make payments of:

Within 10 days.

A late charge of 1.5% per month amounting to 18% per year is applied to the unpaid balance beginning days from the date of this agreement. Any

additional services or merchandise ordered or requested after the date of this agreement will be considered part of this agreement and the cost thereof

will be reflected on the final statement. I acknowledge that I have received the general price list and have been offered for review the casket price list

and the outer burial container price list.

Viewing:

Date: __________________________________Time: __________________________________ Place: __________________________________

Mass:

Date: __________________________________Time: __________________________________ Place: __________________________________

Burial:

Date: __________________________________Time: __________________________________ Place: __________________________________

Casket: _____________________ Company: _____________________ Color: ____________________ Panel: _____________________

Type of Service : ____________________________

Signed: Dated: Relationship to Deceased:

Signed: Dated: Relationship to Deceased:

Name of Funeral Home Representative: Initials: Dated: