2. Service Date*
   Service Date

   Please provide the date services were provided. i.e. burial date or purchase date if just buying a plot.

3. Submitter's Full Name*
5. Bill To:*

   Enter name of Funeral Home or name of party to receive the billing invoice.

7. Burial Site
9. Services provided for:

   Provide name of individual.

11. Bill For:
    -- Select One --Burial Site Regular $500Burial Site Infant Babyland $100
12. Plot Number:
14. Services Provided for:

    Provide name of individual.

16. Bill For:
    -- Select One --Burial Site Regular $500Burial Site Infant Babyland $100
17. Plot Number:
19. Openings & Closings
21. Services provided for:

    Provide name services were provided for.

23. Bill For:
    -- Select One --Opening & Closing Regular $531.00Opening & Closing Cremation $265.50Opening & Closing Infant $212.40
25. Services Provided for:

    Provide name of individual.

27. Bill For:
    -- Select One --Opening & Closing Regular $531.00Opening & Closing Cremation $265.50Opening & Closing Infant $212.40
29. Weekend Fee Amount:*
31. Disinterment
33. Services Provided for:

    Provide name of individual.

35. Bill For:
    -- Select One --Disinterment Regular $849.60Disinterment Cremation $424.80Disinterment Infant $424.80
37. Services Provided for:

    Provide name of individual.

39. Bill For:
    -- Select One --Disinterment Regular $849.60Disinterment Cremation $424.80Disinterment Infant $424.80
41. Special Instructions:*

    Include any additional instructions regarding this billing. 

Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field