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: First Middle WCC Claim Number 1. I, Last Deceased’s Social Security Number First Middle am over eighteen years of age Last and am competent to make this certification. 2. I am a duly licensed mortician or 3. funeral director in the State of Maryland. (check applicable) I perform mortuary services at (name of establishment), (mailing address) City, 4. At the request of I prepared the body of ZIP Code. State, and , (deceased) for burial, cremation or donation. 5. 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. 6. I have I received $ and $ have not received compensation for these services. from from , . I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents of the foregoing paper are true. DATE SIGNATURE NOTARY State of City of 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. (seal) Signature My Commission expires ,2 Certification of Person Authorizing Burial I hereby certify that I authorized the services set forth in the attached itemized list items of goods and services totaling $ as the of the deceased employee. Signature Date 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us MD WCC C-18 (10/05/07) American LegalNet, Inc. www.FormsWorkflow.com