Proof Of Burial And Funeral Expenses By Undertaker {C-65}

PO Box 5205 Binghamton, NY 13902-5205 Statewide Fax Line: 877-533-0337 www.wcb.ny.gov PROOF OF EXPENSES FOR BURIALS, FUNERALS AND MEMORIAL SERVICES BY UNDERTAKER WCB Case Number: STATE OF NEW YORK COUNTY OF: of (city or town) Carrier Case Number: Social Security Number: - - } at (street and number) SS.: being duly sworn, says that (s)he is a duly licensed undertaker and on the day of , , and such direction was provided by (s)he was directed to prepare the body of: , who authorized the following itemized invoice (or attach copy of itemized invoice): $ $ $ $ $ $ $ $ $ $ TOTAL $ No part of the invoice so authorized for this burial has been paid. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. Signature Sworn to before me this day of , 20 Notary Public C-65 (6-16) American LegalNet, Inc. www.FormsWorkFlow.com