Contract #BAS-20260628-0001 — test name ← Back to Contract

Caribe Funeral Home

323 Avenue U, Brooklyn NY 11223
Tel: 718-755-0400  |  Fax: 718-228-4324
Email: Bigapplefuneral@gmail.com  |  www.bigapplefuneral.com

Statement of Goods and Services Selected
Number:
BAS-20260628-0001
Date:
06/28/2026
Name of Deceased:
test name
Date of Death:
07/02/1988
Place of Death:
Brooklyn NY

The undersigned hereby authorizes the above funeral establishment to obtain custody of the remains of test name

Initial:
Relation to Deceased:

The undersigned hereby authorizes the above funeral establishment ☑ to embalm   ☐ not to embalm the remains of test name

Initial:
nb
Relation to Deceased:
test
Other Authorization By:
test
I. FUNERAL HOME CHARGES
Description Amount N/A
A. Alternative Services
1 Direct Cremation $5,000.00
2 Direct Burial N/A
B. Transfer of Remains to the Funeral Establishment
Transfer of remains to the funeral establishment N/A
C. Preparation of Remains
1 Embalming (including use of preparation room) N/A
2a Topical Disinfection N/A
2b Custodial Care N/A
2c Dressing / Casketing N/A
2d Cosmetology N/A
2e Restoration N/A
2f Hairdressing N/A
2g Other Preparation (specify) N/A
2h Burial Suit N/A
D. Arrangements
Basic Arrangements (funeral director, staff, conference) N/A
E. Supervision (Funeral Director and Staff)
1 Supervision for Visitation N/A
2 Supervision for Funeral Services N/A
3 Supervision for Memorial Services N/A
4 Supervision for Graveside Services N/A
5 Other Supervision N/A
F. Use of Facilities
1 Use of facilities for visitation N/A
2 Use of facilities for the funeral N/A
3 Other use of facilities (specify) N/A
G. Livery
1a Hearse $300.00
1b Alternative vehicle (specify) N/A
2 Flower vehicle N/A
3 Limousine(s) N/A
4 Pallbearer car N/A
5 Passenger car(s) N/A
6 Lead / Clergy car(s) N/A
H. Merchandise
1 Casket N/A
1d Alternative container / Cremation Container N/A
2 Outer Interment Receptacle N/A
3 Urn
Supplier: test | Model: 123 | glay
$50.00
I. Additional Service and Merchandise Selected
1 Register Book N/A
10 Spreading Ashes At Sea N/A
11 Mileage and Tolls N/A
12 Mail Ashes N/A
13 Life Insurance N/A
2 Memorial Cards N/A
3 Acknowledgment Cards N/A
4 Crucifix / Cross N/A
5 Flowers N/A
6 Clothing or Burial Garments N/A
7 Vault Company Equipment N/A
8 Temporary Grave Marker N/A
9 Programs N/A
J. Limited Services
1 Forwarding remains $10.00
2 Receiving remains from another funeral home N/A
TOTAL OF FUNERAL HOME CHARGES $5,360.00
II. CASH ADVANCES (Estimated)
# Description Amount N/A
1 Crematory $200.00
2 Clergy N/A
3 Burial Permit $40.00
4 Death Certificates $75.00
5 Other N/A
6 Other N/A
7 Other N/A
8 Other N/A
9 Other N/A
10 Other N/A
11 Other N/A
12 Other N/A
ESTIMATED TOTAL CASH ADVANCES $315.00
III. SUMMARY OF CHARGES
1. Funeral Home Charges $5,360.00
2. Cash Advances $315.00
TOTAL FUNERAL CHARGES $5,675.00
Deposit $0.00
Credit / Paid $0.00
BALANCE OF FUNERAL CHARGES $5,675.00
Alexander Kurbatsky
Printed or Typed Name of Funeral Director
Lic# 14248
Signature of Licensed Funeral Director
06/28/2026
Date
Acknowledgment — Signature of Recipient
06/28/2026
Date
PURCHASER(S) / CO-PURCHASER(S)
MR test
Signature of Purchaser
1922 untica ave
Address
Brooklyn 11229
City, State, Zip
7183318888
Phone Number
888888888
Social Security Number
 
Signature of Co-Purchaser
 
Address
 
City, State, Zip
 
Phone Number
 
Social Security Number
 
Signature of Co-Purchaser
 
Address
 
City, State, Zip
 
Phone Number
 
Social Security Number
Total: $5,675.00
Deposit: $0.00
Balance: $5,675.00
Paid in Full: ☐

PUBLIC NOTICE: The New York State Department of Health is responsible for licensing and regulating New York State funeral directing under the Public Health Law. You may contact the Department at: Bureau of Funeral Directing, New York State Department of Health, 433 River Street, Suite 303, Troy, New York 12180-2299.


EXCLUSION OF WARRANTY. The only warranties, express or implied, granted in connection with the goods sold with this funeral service are the express written warranties, if any, extended by the manufacturers thereof. No other warranties and no warranties of merchantability or fitness for a particular purpose are extended by the funeral director.