New York > Workers Compensation
Proof Of Burial And Funeral Expenses By Undertaker C-65 - New York
| Proof Of Burial And Funeral Expenses By Undertaker Form. This is a New York form and can be used in Workers Compensation . |
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DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC(800)877-1373 HEMP(866)805-3630 HAUP(866)681-5354 PEEK(866)746-0552 100 Broadway Menands ALBANY 12241 (866) 750-5157 State Office Building 44 Hawley Street BINGHAMTON 13901 (866) 802-3604 295 Main Street Suite 400 BUFFALO 14203 (866) 211-0645 130 Main Street W. 935 James St. ROCHESTER 14614 SYRACUSE 13203 (866) 211-0644 (866) 802-3730 WORKERS' COMPENSATION BOARD STATE OF NEW YORK PROOF OF BURIAL AND FUNERAL EXPENSES-BY UNDERTAKER W. C. B. Case No. Carrier Case No. Social Security No. STATE OF NEW YORK ............................................... COUNTY OF.............................................................. } SS.: ...........................................................................................................being duly sworn, says, that (s)he is a duly licensed undertaker of ............................................................................at..................................................... (city or town) (street and number) that on the .............day of................................,............,(s)he prepared the body of .............................................. ..................................................................................................... (grave, vault, express car) for burial; that (s)he placed a coffin, containing the said body in a ........................................................................................................................................ in ..................................................................cemetery; that (s)he shipped said body via ..................................... to ......................................................................................... at ............................................................... (relative, friend, etc.) that (s)he was directed to conduct such burial by ................................................................................................... (name) ................................................................... who authorized the following itemized bill: (address) ................................................................................................................................................................$...................... ........................................................................................................................................................................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................ Total $ That (s)he was informed said bill would be paid by ................................................................................................ (name) .............................................................................................................., (address) that no part of said bill of expenses so authorized for said burial has been paid, except, $ ......................................... by ............................................................................................................... (name) (address) 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. (Signed) .................................................. Subscribed and sworn to before me, this ............................. day of ...................................................., .................. ................................................................ C-65 Notary Public (1-11) Statewide Fax Line: 877-533-0337 www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com
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