Low cost cremation Mid States Cremation Arrangement Form Kansas

Name of Deceased (First Name, Middle Name, Last Name):
* *

Social Security Number of Deceased:
*

Date of Death:
*

Name of Purchaser:
*

Drivers License Number of Purchaser:
*

Direct Cremation $1095.00: * if deceased weighs more than 300lbs additional cremation charges apply (select below under additional options) final total determined upon confirmed weight of deceased by crematory.

In Person Arrangement $400.00: By Appointment Only - Includes administration fee and meeting at facility with our director to complete the required paperwork.

Additional Mileage (County where death occurred): *
Wyandotte County - $0.00
Johnson County - $0.00 - County Cremation Permit - $50.00
Leavenworth County - $200.00
Miami County - $200.00
Douglas County - $300.00
Franklin County - $300.00
Jefferson County - $400.00
Shawnee County - $400.00 - County Cremation Permit - $50.00
Atchison County - $500.00
Coffey County - $700.00
Jackson County - $700.00
Osage County - $700.00
Chase County - $800.00
Dickinson County - $800.00
Geary County - $800.00
Lyon County - $800.00
Morris County - $800.00
Pottawatomie County - $800.00
Riley County - $800.00
Wabunsee County - $800.00
Butler County - $900.00
Marion County - $900.00
Saline County - $900.00
McPherson County - $1,000.00
Ottawa County - $1,000.00
Custom Option: Amount: $

Additional Options:
Priority Cremation (within two days of receiving the cremation permit) - $295.00

Additional removal/transfer (ie organ donation, autopsy) - $195.00

Cremation container if over 300lbs - $495.00

Cremation container if over 500lbs - $695.00

Urn Filling (for transferring cremated remains into urn or keepsake not purchased from Mid States Cremation) $35.00

Custom Option: Amount: $

Merchandise
Urns:

Custom Option: Amount: $
Sales Tax 9.35% :

Death Certificates:

Final Disposition
Pick up at our facility (By appointment only)

Shipping Cremated Remains by USPS Priority Mail Express - $105.00 (within U.S. only)

Name:
Shipping Address 1:
Shipping Address 2:
Shipping City:
State:
Shipping Zip Code:
Shipping Phone Number:

Total: $0.00

Your Contact Information:
First Name: *

Last Name: *

Billing Address 1: *

Billing Address 2:

Billing Address 3:

City: *

State: *

5-Digit Zip: *

Your Email: *

Confirm Email: *

Phone Number: *

Terms of Service : Accept Do not Accept

Acknowledge receipt and review of General Price List : Yes No

I understand that to complete the cremation process ALL LEGAL NEXT OF KIN must sign the Authorization Form (Step 3) : Yes No

I understand that all Necessary Forms must be submitted within 5 days of completed payment, and that after 5 days Refrigeration Fees of $250 per day will apply. : Yes No