Pre-Need Online Arrangement – Section 3

Name of Decedent*
Date*
Month
Day
Year
Contact Email*
Your Name*
Simple Cremation Plan*

A pre-planned cremation is for those individuals who are looking to plan for the future to alleviate the burden experienced by a family member or close friend at the time of passing.
- Pre-Planned Cremation Plan - $999.00
(*) Qualification required.
Does the client have a pacemaker?*
- Has a pacemaker (Additional $75)
- No pacemaker
Please select if said client has a pacemaker or does not have a pacemaker or other explosive implant. If said client has such a device at time of death, Simple Cremation has been advised of same and authorized to remove and dispose of all such devices.
Do you want your remains shipped?*
- Yes, ship remains, in an urn of my choice
  (Additional $150)
- Yes, ship remains, in a Simple Urn
  (Additional $150 + Simple Urn $40 + tax)
- I will pick up remains
Person(s) authorized to pick up remains*
Multiple names may be entered separated by a comma (,)
Simple Urn*
Price:
Shipping Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Current Total
$0.00

Death Certificates
Southern Nevada Death Certificates are $38 for the first and $25 for each additional with a $30 ordering fee. Northern Nevada and Washoe County Death certificates are always $25 each with a $30 ordering fee.
Death Certificates*

Order one Southern Nevada Death Certificate

Order one Northern Nevada or Washoe County Death Certificate

No Death Certificates
Additional Death Certificates Quantity
Price: $25.00
Additional Death Certificates Quantity
Price: $25.00
Choose your delivery method
Do you need to purchase an urn?*

Yes I will purchase an Urn

No, I will provide by own urn
Please select an urn choice below*

Simple Urn ($40.00)

Harbor Cherry Urn

Somerset White Urn

Mountainside Scattering Urn

Tree of Life Aria Style Brass Urn

Grecian Rustic Pewter Urn

Mother of Pearl Artisan Style Urn
Simple Urn
Harbor Cherry Urn
Somerset White Urn
Mountainside Scattering Urn
Tree of Life - Aria Style Brass Urn
Grecian Rustic Pewter Urn
Mother of Pearl Artisan Style Urn
The undersigned have elected to provide their own container (the “Provided Container”) for purposes of holding the cremated remains of the Decedent. Therefore, the undersigned acknowledge and agree to the following items: Container Requirements • Provided Container must have a minimum volume capacity of two hundred (200) cubic inches to accommodate the adult cremated remains. If the Provided Container does not have sufficient capacity to hold the entire amount of the cremated human remains, the undersigned authorizes La Paloma Funeral Services (the “Company”) to return the excess cremated human remains in a sealed plastic bag.
Initials*

• Provided Container should be constructed of a permanent, durable material which will not break, crack, crumble, dissolve or shatter if dropped, bumped or jostled during transfer, storage or handling or exposed to the natural elements such as heat, water or moisture and if Provided Container is not so constructed, the undersigned agree to indemnify and hold the Company harmless if the Provided Container should break, crack, crumble, dissolve or shatter while in the Company’s possession. • Provided Container must have a lid or top to its opening, which can be securely fastened in order to prevent spillage during transfers, storage, or handling. Transfer of Provided Container • The undersigned acknowledges that the Company can return the Provided Container only to the undersigned (or other authorized representative) or deliver it to a local cemetery or to be mailed via USPS (for a fee). Indemnification of the Company • The undersigned assume all liability arising out of the use of the Provided Container and agree to indemnify and hold the Company, it’s officers, employees and agents harmless from any an all claims, suits or causes of action, including attorney’s fees for the defense thereof, arising out of the use of the Provided Container. Furthermore, the Company, by taking possession of the Provided Container, does not make any implicit or explicit guaranty or warranty as to the suitability of the Provided Container for its intended use or satisfaction of any cemetery regulations.
Date*
MM slash DD slash YYYY

Signature*
First Last
Relation to Decedent*

Signature
First Last
Relation to Decedent

Nevada State Funeral Board Fee*
Price:
Regional Tax*

Northern Nevada

Southern Nevada
Northern Nevada: Reno, Sparks, Carson City Southern Nevada: Las Vegas, Henderson, Boulder City
Merchandise Tax
Price: $0.00
Current Total
$0.00

Review Order, then click NEXT to proceed to checkout.
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Total
$0.00

Checkout

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Cash
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Supported Credit Cards: Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*
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