Low cost cremation Mid States Cremation Arrangement Form Kansas

Deceased First Name*

Deceased Middle Name

Deceased Last Name*

Social Security Number of Deceased*

Date of Death*

Name 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

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

Merchandise

Urns

Basic Urn

0.00

Select

Walnut Scattering

109.00

Select

Purity Urn

438.00

Select

Blue Roman

252.00

Select

Merchandise Urns:

Transferring Cremated Remains to Provided Urn - $40.00

Sales Tax 9.35% :

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 Phone Number:

Shipping Address 1:

Shipping Address 2:

Shipping City:

State:

Shipping Zip Code:

Your Contact Information

First Name*:

Last Name*:

Billing Address 1*:

Billing Address 2:

City*:

State*:

5-Digit Zip*:

Your Email*:

Confirm Email*:

Phone Number*:

Do not Accept

Acknowledge receipt and review of General Price List*:

Yes

I understand that to complete the cremation process ALL LEGAL NEXT OF KIN must sign the Authorization Form in front of a Notary Public

(Step 3)*:

Yes

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

Total $0.00

kansas

Additional Mileage (County where death occurred): *

Custom Option:

Additional Options:

Custom Option:

Merchandise

Urns

Custom Option:

Death Certificates:

Final Disposition

Total $0.00

Your Contact Information