MCCOMB & WAGNER Selections Form

FAMILY CONTACT INFO

Name of Decedent*:

Name of Person Making Arrangements*:

Phone Number*:

Email*:

WHEN DO YOU NEED OUR SERVICES?

Select Timing of Need*:

Immediately (My loved one has passed) ($0.00) Soon (My loved one's passing is imminent- 6mo or less) ($0.00) Future (I'm planning ahead ($0.00)

GENERAL PRICE LIST

GENERAL PRICE LIST

Acknowledgment*:

 I have received the Price List

REMOVAL & TRANSPORT

What county are we picking up the decedent?*:

Thurston County ($0.00) Pierce County ($0.00) Lewis County ($0.00) Mason County ($0.00) Grays Harbor County ($0.00) Kitsap County ($0.00) King County ($0.00) Pacific County ($0.00) Jefferson County ($0.00) None of these

Location where we'll be picking up the decedent?*:

Coroner or Medical Examiner Facility ($0.00) Hospital Morgue ($0.00) Other Funeral Home ($0.00) Nursing Facility or Hospital Bedroom (1 Staff - Immediate Response) ($200.00) Residence House or Apartment (2 Staff - Immediate Response) ($300.00)

Name & Address of Location (If Know):

Transport (Outside Primary Service Area):

Clallam ($1,000.00) Wahkiakum/Cowlitz ($800.00) Kittitas/Yakima ($1,000.00) Clark/Skamania ($1,000.00) Snohomish ($800.00) Skagit ($1,000.00) Whatcom ($1,200.00) Other WA County ($1,500.00) Portland, OR Metro ($1,000.00)

INCLUDES:

• Services of Funeral Director and Staff
• Removal of Decedent (<300lbs) from a Morgue at a Hospital, Coroner, Medical Examiner, or other Funeral Home
• Refrigeration/Sheltering
• Cremation Process
• Alternative Container
• Memorial Webpage
• Black Plastic Urn with Logo Receiving Bag
• Order and Obtain Death Certificates from Health Department

CREMATION PACKAGE

Select Cremation Type*:

Standard Cremation ($2,695.00) Standard Cremation with Stones ($4,650.00) Water Cremation ($3,745.00) Water Cremation with Stones ($4,950.00)

Select Decedent Weight*:

Less than 300lbs ($0.00) 300-349lbs ($350.00) 350-399lbs ($400.00) 400-499lbs ($650.00) 500-599 ($1,000.00)

Minimum Preparation of an unembalmed body is required for any viewing (whether paying your respects for 5 minutes or an hour) in order to ensure a safe, clean, and peaceful experience for all. The Min. Preparation charge includes the minimum preparations and use of facility and staff for a one hour ID viewing at the Shelton facility during the week M-F before 4pm. Overtime is anytime after 5pm or Saturday-Sunday. Some families prefer to upgrade to Embalming preparation for viewing even though it is not required for an ID viewing. If you choose "No Viewing" then you acknowledge that no one will need to view the decedent prior to the cremation. Autopsy Restoration is required for viewing if the decedent has had an autopsy. Dressing is optional and if not selected, then we will use the clothing that was on the decedent when they came into our care or a clean gown as needed.

WILL THERE BE ANY VIEWING?

Select Preparation For Viewing*:

No Viewing ($0.00) Min. Prep. & Facility for 1hr Family Viewing ($1,295.00) Min. Prep. & Facilty for Family Dressing ($1,295.00) Embalming & Facility for 1hr Public Viewing ($1,795.00) Autopsy/Tissue Restoration & Facility for 1 hr Family Viewing ($2,395.00)

Select Dressing:

No Dressing ($0.00) Add Use of Facility for Dressing by Family ($175.00) Add Dressing by Staff ($195.00)

Select Overtime for Viewing:

No Overtime for Viewing ($0.00) Overtime for Viewing (M-F after 4pm ($195.00) Overtime for Viewing (Saturday) ($395.00) Overtime for Viewing (Sunday) ($595.00)

Direct cremation normally takes 1-2 weeks. Would you like to "cut-in-line" and expedite the process? Rush Cremation takes place 1-2 days after the permit is obtained and authorizations are secured.

EXPEDITE "RUSH" CREMATION

Select Rush Cremation*:

No RUSH needed ($0.00) Add RUSH Cremation ($195.00)

ADDITIONAL SELECTIONS

Take Fingerprint for Jewelry*:

No Fingerprinting ($0.00) Add Fingerprinting ($25.00)

Take Locket of Hair*:

No Locket ($0.00) Add Take Locket of Hair ($25.00)

Witness Laying in Chamber*:

No Witness Cremation ($0.00) Witness Laying in Chamber ($900.00)

If you plan to bring in a family provided urn or any urn or jewelry not purchased from our firm, then there is a charge added for our service in transferring and placing Cremated Remains into your provided item or items (per 10 items). This charge also covers requests to split the Cremated Remains into multiple sections or portions in order to be given to multiple people. Please provide any instruction for us here.

URN FILLING/SPLITTING

Select Filling/Splitting*:

No Filling/Splitting ($0.00) Fill Family Provided Urn ($75.00) Split Cremated Remains ($75.00) Fill & Split ($75.00)

Additional Instructions for Filling/Splitting:

. 

URNS, JEWELRY & KEEPSAKES (Optional)

________

Simple Engraving = Full Name and Dates

Premium Engraving = Custom Text, Photo, etc. as available on the item to be personalized

URN ENGRAVING

Add Urn Engraving:

No Engraving ($0.00) Add Simple Engraving ($198.00) Add Premium Engraving ($330.00)

What would you like us to do with the Cremated Remains when they are ready to be returned to the family? If Shipping or Delivery, please provide the address.

HOW WOULD YOU LIKE TO RECEIVE THE CREMATED REMAINS?

Instructions for returning the cremated remains*:

Hold for Pick-up in Shelton ($0.00) Unattended Water Scattering Unspecified ($0.00) Scheduled Pick-up at Other Service Location ($100.00) Hand-Delivery to Home or Office (in service area) ($100.00) Mail Plastic Urn (in WA in service area) ($75.00) Mail Pastic Urn in US ($195.00) Mail Other Urn ($275.00)

Name & Address for Shipping Ashes:

Many families need one or more official certified copies of the death certificate to take care of certain estate, probate, or other business following a death. Certified Death Certificates are ordered and obtained from the local health department. If you have been informed by the ME or Coroner that the Cause of Death is PENDING- we recommend that you only order ONE death certificate at this time. Once the cause of death has been updated in the system then you can order more at that time. You can have our firm order and obtain official certified copies of the death certificate from the health department for you to pickup at our office or for mailing. You may also order and obtain them directly.

DEATH CERTIFICATES

How many Death Certificates?*:

No Death Certificates ($0.00) 1 Death Certificate ($25.00) 2 Death Certificates ($50.00) 3 Death Certificates ($75.00) 4 Death Certificates ($100.00) 5 Death Certificates ($125.00) 10 Death Certificates ($250.00)

Instructions for returning Death Certificates*:

No DCs Ordered ($0.00) Hold DCs for Pick-up ($0.00) Mail DCs No Tracking ($0.00) Mail DCs with Tracking ($25.00)

Name & Address for Mailing DCs:

OTHER GOVERNMENT ITEMS

Required WA State Fee*:

 WA State Cremation Fee ($10.80)

Select County of Death Permit Fee*:

Thurston County Permit Fee ($0.00) Mason County Permit Fee ($0.00) Lewis County Permit Fee ($0.00) Grays Harbor Permit Fee ($0.00) Kitsap Permit Fee ($0.00) Pacific County Permit Fee ($0.00) Jefferson County Permit Fee ($0.00) Pierce County Permit Fee ($10.00) King County Permit Fee ($100.00) Clark County Permit Fee ($70.00) Snohomish County Permit Fee ($15.00)

VETERAN OPTIONS

Complete Flag App & Retrieve US Flag:

Not a Veteran Do not want a Flag Retrieve Flag at Post Office ($45.00)

Select Flag Case:

No Flag Case ($0.00) Add Flag Case ($150.00)

Schedule National Cemetery:

No National Cemetery ($0.00) Add National Cemetery Scheduling ($295.00)

Upload Discharge Paperwork (DD214):

Would you like to help a less fortunate family by contributing funds to help cover their funeral or cremation expenses?

PAY-IT-FORWARD

Select Amount*:

No donation $25 donation $50 donation $100 donation $250 donation $500 donation $1000 donation