WORKERS' COMPENSATION COMMISSION
Certification of Funeral Expenses
Instructions: The form must be completed in its entirety and be signed by all required persons. This form must include an itemized statement of the charges submitted as an attachment.
Name of Deceased:
WCC Claim Number
Deceased's Social Security Number
and am competent to make this certification. 2. 3. I am a duly licensed mortician or
am over eighteen years of age
funeral director in the State of Maryland. (check applicable)
(name of establishment), (mailing address) City, State, and ZIP Code.
I perform mortuary services at
At the request of I prepared the body of
(deceased) for burial, cremation or donation.
I performed the funeral services and provided the goods set forth in the itemized list attached to this certification. The costs associated with those goods and services, e.g., embalming, casket, facilities, vehicles, grave, vault or liner, direct cremation, are also set forth in the itemized list. I have I received $ and $ from have not from received compensation for these services. , .
I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents of the foregoing paper are true. DATE SIGNATURE
State of City or County of
I hereby certify that on this day of ,2 , the subscriber personally appeared before me and affirmed upon personal knowledge that the contents of the foregoing statements are true.
My Commission expires
Certification of Person Authorizing Burial
I hereby certify that I authorized the services set forth in the attached itemized list of goods and services totaling $ as the of the deceased employee.
10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us
MD WCC C-18 (10/19/07)
Clear This Page
Print This Form