8120 Sawyer Brown Road, Suite 108 Nashville, Tennessee 37221 (615) 678-4832 www.NashvilleCremationCenter.Com Deceased*Date of Death* Date Format: DD slash MM slash YYYY Date of Statement Date Format: MM slash DD slash YYYY STATEMENT OF FUNERAL GOODS AND SERVICES SELECTEDCharges 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 you did not approve if you selected arrangements such as direct cremation or immediate cremation or immediate burial. If we charged for embalming, we will explain why below.Reason for EmbalmingIf any Law, cemetery or crematory requirements have required the purchaseof any items listed, the law or requirement is explained below.ACKNOWLEDGEMENT AND AGREEMENTI (we) authorized this funeral home to perform services, furnish goods and incur outside charges specified on this Statement. I (we) acknowledge that I (we) received a General Price List and a Outer Burial Container Price List.TERMSFull payment is due to no later thanIf 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 (we) have read (or been read) the above, accepted and approve same, and jointly and severally promise to make full payment. Receipt of a copy of this Statement is acknowledge.Signed*Name* First Last Social Security No.Address Street Address City / State ZIP / Postal Code Email* PhoneCo-SignedCo-Signed NameCo-SignedCo-signed NameNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.