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Service Information

First Name of Deceased

Last Name of Deceased

Date of Death

Billing Information

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email *

Notes

Payment Information

Payment Code *

Payment code provided to you by Fluehr Funeral Home. If you do not have a payment code please request one.*

Payment Amount (USD) *

•••• •••• •••• ••••

YOUR NAME HERE

valid thru

••/••

Summary

Subtotal

$0.00

Fee (3%) on Credit Cards

$0.00

Total

$0.00

Customer Pricing Notice

For those choosing to pay with CREDIT CARD, a 3% Convenience Fee is applied to all sales. Different forms of payment carry different costs for merchants. With the increasing expense of credit card acceptance fees, a 3% Convenience Fee will be applied to all credit card transactions that is not greater than our acceptance fee.

There is NO Convenience Fee for debit cards. Thank you for your understanding.