Fillable At Need Forms Packet (City of Oakland)

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At Need Forms Packet (City of Oakland)

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BAKERSFIELD FUNERAL HOME FD 1792
FOR MORE INFORMATION ON FUNERAL, CEMETERY, AND CREMATION MATTERS,
CONTACT: THE DEPARTMENT OF CONSUMER AFFAIRS, CEMETERY AND FUNERAL
BUREAU, 1625 N. MARKET BOULEVARD, SUITE S-208, SACRAMENTO, CA 95834,
(916) 574-7870.
DECEASED ___________________________________________________ _________
DATE OF DEATH _________________________________________________ ________
PLACE OF DEATH ________________________________________________ _______
DATE OF STATEMENT ______________________________________________ ______
A. CHARGE FOR SERVICES SELECTED
1. Professional Services:
Basic Services of Funeral Director & Staff . . . . . . . . . ___________
Embalming . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .___________
___________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
_______________
2. Facilities, Equipment & Staff:
_________ __
_________ __
___________
_________ __
___________
_______________
3. Transportation:
Transfer of Remains to Funeral Home . . . . . . . . . . . _________ __
_______ __
________ __
___________
_______________
4. Other Services/ Facilities/ Equipment:
TOTAL OF SERVICES SELECTED $ _______________
B. CHARGE FOR MERCHANDISE SELECTED
Casket . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
Name/ No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
Color. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
Outer Burial Container. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
Name/ No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________
TOTAL OF MERCHANDISE SELECTED $ _______________
C. SPECIAL CHARGES
. . . . . . . . . . . . . . . . . . . . . . ___________
. . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .
TOTAL OF SPECIAL CHARGES $ _______________
TOTAL FUNERAL HOME CHARGES $ _______________
(This total does not include cash advances)
STATEMENT OF FUNERAL GOODS AND SERVICES
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 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 if you selected arrangements such as a direct cremation or
immediate burial. If we charge for embalming, we will explain why below.
CASH ADVANCES
Certified Copies of Death Certificate
County Disposition Permit
TOTAL CASH ADVANCES $ _______________
We charge you for our services in obtaining: (specify cash advance items)
SUMMARY
Total Funeral Home Charges $
Local Sales Tax (if applicable) $
State Sales Tax (if applicable)
$
Total Cash Advances $
GRAND TOTAL $ _________________
Less Credits and Payments
_____________________________________ $_____ _ ________________
_____________________________________ $_____ _ ________________
_____________________________________ $_____ _ ________________
_____________________________________ $_____ _ ________________
Total Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _ __ ___ _ __
BALANCE DUE $ __ _ ____ ___
Billing To_________________________________________________ __
_____________________________________________________________
DISCLOSURES
Reason for embalming_______ __________________ __
If any law, cemetery or crematory requires the purchase of any items listed,
the law or requirement is explained below.
____________________________________ ________________________
____________________________________ ________________________
ACKNOWLEDGEMENT AND AGREEMENT
I hereby acknowledge that I have the legal right to arrange the final services
for the deceased, and I authorize this funeral establishment to perform
services, furnish goods, and incur outside charges specified on this
Statement. I acknowledge that I have received the General Price List and the
Casket Price List and the Outer Burial Container Price List.
Terms of Payment:____ ____________________________ __
____________________________________ _________________________
Full payment is due no later than__ _____ ___.
If any payment is not paid when due, an unanticipated LATE CHARGE of
________ % per month (ANNUAL PERCENTAGE RATE ________ %) on the
unpaid balance will be due. I agree to pay the Balance Due listed on this
Statement, plus any Late Charge. In the event I default in payment to this
funeral establishment, I agree to pay reasonable attorney’s fees and court
costs in addition to any Late Charge applicable. I understand and agree that I
am assuming personal liability for the charges set forth in this Statement
and that this is in addition to the liability imposed by law upon the estate of
the deceased. By my signature below, I hereby agree to all of the above and
acknowledge receipt of a copy of this Statement.
X__________________________ __________________ ______________
Signature Date
ACCEPTANCE: This funeral establishment agrees to provide all services,
merchandise, and cash advances indicated on this statement.
By_______________________ __________________________________
. . . . . . . . . . . . . . . . . . . . . .
BAKERSFIELD FUNERAL HOME FD 1792
3125 19TH ST.
BAKERSFIELD, CA 93301
(661) 324-4446 Phone/(661) 249-6899 Fax
0
0
0
-
-
-
-
-
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
4
0
-
-
0
0
0
0
-
-
0
-
-
-
-
-
-
0
0
0
0
0
0
0
0.00
Direct Cremation
Overweight Fee
Overweight Fee
-
0
0
0
0
0
0
0
0
21
0
@
each
$
0
12
@
each
$
0
California State Cremation Fee
-
-
-
-
-
0
0
0
0
0
0
0.00
0
7.3%
0.00
0.00
0
0
0
0
0
0
0.00
Not Requested
Under 200 lb.
bet. 200~250
bet. 251~300
($200)
extra
($400)
extra
BAKERSFIELD FUNERAL HOME FD 1792
3125 19TH ST.
BAKERSFIELD, CA 93301
(661) 324-4446 Phone/(661) 249-6899 Fax
BAKERSFIELD FUNERAL HOME FD 1792
BAKERSFIELD FUNERAL HOME FD 1792
3125 19TH ST.
BAKERSFIELD, CA 93301
(661) 324-4446 Phone/(661) 249-6899 Fax
DECLARATION FOR DISPOSITION OF CREMATED REMAINS
I/We hereby declare (my remains) or (the remains of) in
Name of Person arrangements are for
the possession of , will be cremated by
Name of Funeral Establishment and Telephone Number
and shall be disposed of in the following
Name of Crematory and Telephone Number
manner
(Note 1):
Manner, Location and Other Details of Disposition
Attach additional pages if necessary
Name of person(s) with the legal right to control disposition
(Note 2):
Signed
Date
Person(s) with legal right to control disposition to Self, if pre-arranging
Signed Date
Person(s) with legal right to control disposition
Signed Date
Person(s) with legal right to control disposition
Signed Date
Person(s) with legal right to control disposition
Name of person(s) contracting for cremation services:
Signed Date
Person(s) contracting for cremation services
Signed Lic. # Date
Funeral Director, Employee, or Agent for Funeral Establishment
If a Funeral Director
Note 1: See Health & Safety Code Sections 7054, 7054.6, 7116, 7117 for legal dispositions of cremated remains.
Note 2: See Health & Safety Code Section 7100 for the list of person(s) with the legal right to control disposition of human remains.
IMPORTANT: Business and Professions Code § 7685.2(b) requires Funeral Establishments to complete this form, provided
by the Cemetery and Funeral Bureau, when making arrangements for cremation. Failure to complete this form may result in
disciplinary action by the Bureau. This declaration does not replace the written authorization to cremate required by Health
and Safety Code Sections 7110 and 7111.
NOTICE REGARDING CREMATED REMAINS
A person having the right to control disposition of cremated remains may remove the remains in a durable
container from the place of cremation or interment, pursuant to Section 7054.6 of the Health and Safety Code.
If the cremated remains container cannot accommodate all cremated remains of the deceased, the crematory
shall provide a larger cremated remains container at no additional cost, or place the excess in a second container
that cannot easily come apart from the first, pursuant to Section 8345 of the Health and Safety Code
California Department of Consumer Affairs, Cemetery and Funeral Bureau www.cfb.ca.gov (Rev. 10/2008)
BAKERSFIELD FUNERAL HOME FD 1792
1792
Rose Family Crematorium CR329 (661) 792-3866
AUTHORIZATION TO ACCEPT OR DECLINE EMBALMING
TO: ________________________________________
(Funeral Establishment Name)
RE: ________________________________________
(Decedent)
Embalming is the addition to, or the replacement of, body fluids by chemical
preservatives or the application of chemical preservatives for the temporary
preservation of the body. I understand that embalming is not required by law.
I, ____________________________, do __ do not __ (check one) request embalming.
I understand that for storage or embalming purposes the decedent may be transported
to the following location:
______________________________________________________________________
(Location Name and Address)
The undersigned hereby represents that he/she has the legal right to control disposition
of the remains of the decedent.
Signed: ____________________________, Relationship to Decedent: _____________
Executed this ____ day of _______________, _____, at ________________________.
(Month) (Year) (City and State)
This section is to be completed by the funeral establishment if authorization to accept or
decline embalming is obtained orally.
The above statement regarding embalming and storage was read and/or provided to
______________________________, Relationship to Decedent: _______________,
who did __ did not __ (check one) authorize embalming at the above named funeral
establishment. Telephone Number: _________________________
Date and time authorization granted: ______________________________
This section is to be completed by the funeral establishment representative who is
executing this authorization to accept or decline embalming.
I declare under penalty of perjury that the foregoing is true and correct.
Executed this ____ day of _______________, _____, at ________________________.
(Month) (Year) (City and State)
________________________________ ________________________________
Funeral Establishment Representative (Print Name) Funeral Establishment Representative (Signature)
12-AUTH (rev. 11/14)
BAKERSFIELD FUNERAL HOME FD 1792
McFarland Family Funeral Home FD1679 McFarland, CA 93250
Disclosure of Preneed Funeral Agreement
The funeral
establishment, ____________________________________________________________,
(funeral establishment name)
license number FD________, DOES ____, DOES NOT ____ (check one) have a preneed arrangement, as
defined below, made by or on behalf of ____________________________________________________.
(name of decedent)
If the funeral establishment does have
a preneed agreement, complete the following:
In compliance with Business and Professions Code Section 7745, the funeral establishment has
presented to the person named below a copy of any preneed agreement which has been signed and
paid for in full, or in part by, or on behalf of the deceased and is in the possession of the funeral
establishment.
____________________________________________ ______________________________
Signature of funeral establishment representative Date
“Preneed arrangement,” "preneed
agreement” or “preneed” is written instruction regarding goods or services
or both goods and services for final disposition of human remains when the goods or services are not provided
until the time of death, and may be either unfunded or paid for in advance of need.
Funeral Establishment’s Responsibility
– Business and Professions Code Section 7745 requires a funeral
establishment to present to the survivor of the decedent or the responsible party a copy of any preneed
agreement in its possession which has been signed and paid for in full, or in part by, or on behalf of the
deceased. Business and Professions Code Section 7685.6 requires a copy of any preneed arrangements to
be disclosed prior to drafting any contract for funeral goods or services. The funeral establishment may
present the copy in person, by certified mail, or by facsimile transmission, as agreed upon by the person with
the right to control disposition. A funeral establishment that knowingly fails to present a preneed agreement as
required is liable for a civil fine equal to three times the cost of the preneed agreement, or one thousand dollars
($1,000), whichever is greater.
You ma
y contact the Cemetery and Funeral Bureau for more information on funeral, cemetery or cremation
matters or to file a complaint against a licensee:
Cemetery and Funeral Bureau
1625 North Market Blvd., Suite S-208
Sacramento, CA 95834
916-574-7870
____________________________________________ ______________________________
Signature of the survivor or responsible party Date
____________________________________________
Print name of the survivor or responsible party
____________________________________________ ______________________________
Signature of funeral establishment representative Date
____________________________________________ ______________________________
Print name of funeral establishment representative Title
The funeral
establishment must:
• Give a copy
of the completed statement to the survivor or responsible par
ty.
•
Retain the original or a copy of the completed disclosure
statement on file for not less than one (
1) year
after the preneed accou
nt has been
audited by the Bureau or seven (7) years from the date the
disclo
sure statement wa
s made, whichever comes first.
21F1 (10/03)
BAKERSFIELD FUNERAL HOME FD 1792
1792
Funeral Consultant
ORDER FOR RELEASE
KERN COUNTY SHERIFF-CORONER
PUBLIC ADMINISTRATOR
1832 Flower Sstreet
Bakersfield, CA 93303
(805) 861-2606
FAX (805) 81-3714
Case No. . ________________
Case Name ________________
Date: _________________
Please read and answer all questions before signing
WAS THE DECEDENT LEGALLY MARRIED AT TIME OF DEATH...________________
DOES THE DECEDENT HAVE ANY ADULT LIVING CHILDREN.....________________
HEALTH AND SAFETY CODE * CHAPTER 3 * CUSTODY AND DUTY OF INTERMENT
7100. The right to control the disposition of the remains of a deceased person, unless other directions have been given by the decedent, vest in, and
the duty of interment and liability for reasonable cost of interment of the remains devolves upon the following: (a) The surviving spouse, (b) The sur-
viving adult child or majority of adult children, (c) The surviving parent or parents of the decedent, (d) The surviving person or persons respectively
in the next degree of kindred in the order named by the laws of California as entitled to succeed to the estate of the decedent.
WARNING: The person signing this “Order for Release” is liable for all damages caused by any untruthful statements contained in this document.
(Health & Safety Code 7110). It is also a criminal offence to knowingly file a false statement with a government agency. (Penal Code Section 115
and 470). Therefore please release the body and possesions upon completion of your investigation of the death of said decedent to:
MORTUARY:________________________________________________________________________________________
NAME OF NEXT-OF-KIN (PRINT);________________________________RELATIONSHIP:______________________
ADDRESS:_____________________________________________________________________
TELEPHONE NO. __________________________________
I hereby authorize the mortuary listed above to act as my agent and to take possession of the remains and all of the decedent personal property
under the immediate control of the Kern County Sheriff/Coroner/Public Administrator
SIGNED: x_______________________________________________________________DATED SIGNED:_______________________
If not next-of-kin, sign above and explain why next-of-kin is not handling. If the executor, attach a copy of the will.
_______________________________________________________________________________________________________________
Next-of-kin: _____________________________________________________ Relationship: ____________________________________
Adress:____________________________________City:_______________________State________________ZIP CODE:____________
DECEDENT INFORMATION - FILL IN ALL BLANKS BELOW - TYPE OR PRINT ONLY
FINAL DISPOSITION OF REMAINS
First Name
Middle Name
Last Name (Family)
Date of Birth Age Sex Date of Death Hour of Death
Race State of Birth SSN# Marital Status
Occupation Type of Business Employer
Residence-Street Address City County Zip Code:
Funeral Director
Type of Disposition Location of Disposition
No
No
BAKERSFIELD FUNERAL HOME FD 1792
M F
AUTHORIZATION/ CONSENT OF RELEASE
I, am the of
and I am authorizing to handle all cremation and/or funeral arrangements for this
decedent.
(Yes No ) I would like the above mentioned person to be authorized to handle this decedent's personal
property.
Dated Signature
Autorizacion/Consentimento
Yo/Nosotros
Soy/Somos
De
estoy/estamos autorizando a
a tramitar los arreglos de inceneracion o funeral del fallecido.
Si No me gustaria que la asignada sea autorizada para recibir las pertenencias personales
de fallecido.
Fecha
Firma Del Autorizado
BAKERSFIELD FUNERAL HOME FD 1792
3125 19TH ST.
BAKERSFIELD, CA 93301
(661) 324-4446 Phone/(661) 249-6899 Fax
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At Need Forms Packet (City of Oakland)

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Completed 28 May 2021

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