Fillable Form -25: Funeral Director's Affidavit (City of New York)

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Form -25: Funeral Director's Affidavit (City of New York)

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Office of Burial Service
s
33-28 Northern Boulevard, 3rd Floor
Long Island City, New York 11101
Tele
p
hone Number: 92
9
-25
2
-773
1
M-860n (E) 03/13/2020
Date:
Decedent:
Date of Death:
Burial Claim Number:
Funeral Director's Affidavit
Your compliance with this request will facilitate a prompt determination for your claim.
STATE OF NEW YORK )
)
S
S
COUNTY OF
)
, being duly sworn, deposes and says
(
Name
)
1.
I am the
(Insert whether Owner or Officer, if a Corporation)
of
(Name of Company)
which handled the burial of
(Name of Deceased)
on the day of 20 at the agreed price of
$ which price includes all charges and cash outlays, paid or to be paid, and incurred for the
complete burial of the deceased.
2.
That the only payment received on account thereof is $
from
(Name and Address)
on 20 .
3.
That there is still due the sum of $ for this burial.
4.
That $ has been deposited in escrow or as collateral for full or partial payment.
(If None, State "None")
5.
That no receipt has been issued for payment in connection with the above burial except as follows
:
(If None, State "No Exception")
Funeral Director
Sworn to before me on the
day of , 20
Notary Public or Commissioner of Deeds
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Form -25: Funeral Director's Affidavit (City of New York)

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Completed 7 February 2022

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