We love penguins. We make blockbuster movies about them–Happy Feet, March of the Penguins, Madagascar Penguins, Mr Popper’s Penguins. And the penguin related merchandise…wow. But vultures? Not so much. When a vulture makes an appearance in a movie, they add a sense of foreboding…something bad’s looming about.
Grant it, vultures might not have the cutest face among the birds of the world–put a turkey vulture up beside a barn owl and it’s not a fair match—but I suggest that like so many things in life, you can’t judge a book by its cover. Today is International Vulture Awareness Day (oh yes, there IS such a thing!) So indulge me and let me hit you with a few tidbits about these often misunderstood creatures who are an essential part of our ecosystem.
Vultures prevent the spread of disease.
King Vulture..how can you not love this face?
Vultures eat dead stuff. It’s one reason they get a bad reputation–people find disgusting the notion of eating rotten flesh. Yet, this act provides a valuable service. Nature is full of dead animals who succumb to sickness, diseases, accidents, cars, starvation or are the leftover remains of predators. Vultures are great at sniffing out these dead animals. And, they get rid of these health hazards for us!
I will not get into a stomach-turning detail of how carcasses rot and attract nasty bacteria and how that makes it way to human populations–just trust me that if you leave enough dead flesh outside long enough, it becomes a catalyst for disease spread.
Vultures excel at gobbling up putrid flesh that would kill any other creature. Their stomach acid is incredibly corrosive which allows them to safely consume some truly deadly disease-causing organisms like botulism, anthrax, and cholera.
Endangered and essential: a lesson in what happens without them
Consider a real-life example of what happens when vultures disappear from an ecosystem. Among the Hindu culture of India, cattle are considered sacred. Of an estimated 500 million cows in India, only 4% are consumed by people.(Ref 1) That means there’s a whole lot of cow carcasses to deal with, around 12 million tons annually. When cow dies, it is not consumed by people, but rather by the vultures. They are the waste-disposal system.
The problem for vultures began in the 1990’s when cattle in India began to be widely treated with an anti-inflammatory drug called diclofenac. (This drug is an NSAID and is also used in humans to treat inflammation such as with arthritis) The drug effectively poisoned the vultures who ate the cow’s flesh, causing them to die of kidney failure within hours (Ref 2). Between 1992 and 2007, the population of one vulture species–the oriental white-rumped vulture–is estimated to have declined by 99.9%. (Ref 3). Where there were once over 80 million of these vultures, the numbers are now only several thousand–the fastest population collapse of any wild bird in history, including the Dodo.(Ref 4)
What happened when the vultures disappeared and were no longer consuming dead cattle?
There was a build-up of carcasses which both contaminated water supplies and harbored diseases like anthrax (3)
The disappearance of vultures allowed other scavenger animals to take their place–namely rats and feral dogs. which carried pathogens and therefore spread diseases throughout human populations such as rabies, anthrax and plague.(1)
Today in India, there are an estimated 18 million feral dogs, the largest population in the world. 30,000 people die from rabies each year, more than half the world’s total.(1) 70% are children under age 15.
In response to the ‘vulture crisis’, India officially removed the drug diclofenac from market in 2006, but it continues to be available illegally in some areas. Unfortunately, the damage has been done and it will take some time for the vulture population to rebound, if at all, to levels which will improve public health.
Note that diclofenac continues to be available in the EU and US, however it has not been linked to significant declines in vulture populations in these areas.
Take-away: we are interconnected
While the lessons of what happened in India with the vulture population has many implications for other countries, the biggest is that it illustrates just how interconnected our ecosystems truly are. What on first glance appears to be an ugly, disgusting, ‘useless’ bird turned out to be an absolutely essential element in public health..and in ways no one would have ever predicted. So next time you see a vulture by the side of the road enjoying some roadkill, don’t be repulsed. Rather, rejoice in the great service nature has provided–that ugly, bald bird is actually in a very real way out there improving your health!
Tidbits:
There are 23 species of vultures worldwide (14 are considered endangered or threatened). They are found on every continent except Australia & Antarctica.
Vultures are among the longest living birds in the wild–around 30 years.
Vultures mate for life.
They reproduce very slowly–they don’t reach sexual maturity until 5-7 years old and produce 1 chick every 1-2 years.
What’s a group of vultures called? A committee, venue or volt. In flight, a flock of vultures is a kettle, and when the birds are feeding together at a carcass, the group is called a wake. So many names!
Spooky warning? Nah, they’re just enjoying sunning themselves.
How do you turn a profit off a cemetery? That is the question now facing a financially troubled international firm owning what were once community-run cemeteries across the country. The answer has far reaching implications for grieving families seeking comfort in the new ‘death care industry’ where there are few regulations.
StoneMor Partners L.P., a Trevose, Pennsylvania headquartered company, owns 322 cemeteries and 90 funeral homes in 27 states and Puerto Rico. Its stock is traded on the New York Stock Exchange under the ticker $STON.
The company has struggled financially over the past 3 years. In a Securities and Exchange Commission (SEC) filing dated July 28, 2017 the StoneMor Partners LLC admitted they have technically defaulted under the terms of their credit agreements–agreements which allow for creditors to call due $151 million in outstanding loans, immediately if they so choose.
StoneMor Partners stock history
While the company sought relief from its creditors, industry analysts remained skeptical, saying the company is unlikely to meet it’s credit obligations because “the company has no history of generating cash flow and had only $15 million of cash the last time it filed audited financials, yet it has continued to pay dividends and even expanded its sales force.” Required financial reports are often filed past-due.
Why is cash flow difficult to obtain from a cemetery? According to StoneMor’s 2019 First Quarter earnings report, revenue declines were driven primarily by “a decrease in interment revenues” and “lower sales of funeral related merchandise and services.” Keep these revenue sources in mind for later–it becomes important in appreciating how StoneMor employees interact with grieving families.
In February 2019, StoneMor announced “a bank waiver and amendment of certain loan covenants, as well at $35 million in financing from Axar Capital along with an agreement for Axar to buy up to 27.5% of the partnership units.” In May 2019, the investment bank Houlihan Lokey was hired by StoneMor to help it refinance its credit lines of nearly $200 million. (Source)
The multi-year financial struggles come on the heels of a class action lawsuit filed in federal court in November 2016, in which investors accused the company of providing misleading and falsified earnings numbers designed to make the company appear profitable. The complaint said StoneMor promoted the false figures while ramping-up dividend payments to investors each year, yet never actually generating sufficient cash flow to make these distributions. Instead of issuing cash distributions, the company simply kept issuing new securities and used those funds to pay off old investors in what has been called a ponzi-like scheme.
The class action complaint says StoneMor financial statements were “premised on a financial shell game that involved raising fresh capital from investors just in time to distribute a portion of it back to investors”
As a result, the company’s stock has taken a nose-dive, down 60% since August 2016, further increasing pressures for the company to demonstrate results.
What does this mean for StoneMor owned cemeteries and the grieving families which utilize their properties? Already, the struggling company has been accused by customers at multiple cemeteries of property neglect and squeezing grieving families for cash by utilizing harsh sales-driven policies. (sources below)
My investigation has found a pattern of questionable business practices and low to non-existent regulatory oversight.
Here’s how it manifests for consumers:
Sales Representatives misrepresented as Counselors
StoneMor is currently recruiting 128 sales representatives nationwide, according to their corporate website. Below is the job advertisement as it appears on the StoneMor website, each position is identical in wording with only the location and name of the cemetery changed. The positions are commission-based and promise high income.
However, the persons hired into these sales positions provide grieving families conducting business at the cemeteries with business cards identifying their position as that of a “Family Service Counselor“.
Business card from StoneMor employee
No mention of their role in sales is provided to consumers nor are families told they are working on a commission basis. No counseling services are provided. A search for ‘family service counselor’ on the StoneMor ‘careers’ website returns zero results and redirects to the ‘sales representative’ positions.
How do the Family Service Counselors/Sales Representatives from 20 different StoneMor owned cemeteries describe their work–is it counseling or is it sales?
In their own words:
“You’re not a counselor, this is a sales role in the death care industry.”
“you don’t get paid unless you make a sale“
“You are made tolie, and cheat customers and in their own words “prey on the emotions” when someone just died. Create the urgency!! is the motto.”
“the atmosphere was predatory“
“Unstable, hostile, and aggressive work environment. High employee turn over rate. Huge financial issues, thousands of dollars and months of overdue payments to their vendors”
“Forget the legal aspects of customer service, forget actually caring for families who have lost loved ones and are grieving, they need stuff and you had better sell it to them.”
“concern is only for “the sale” and how to manipulate any and all into a purchase“
“They want you to bring up past death experiences with families to make them feel guilty about not pre-planning for their families. It’s all about the money.“
“The company is less about the families we are servicing and more about meeting numbers.”
“business model is based on outdated vacuum sales tactics that are to be expected on a car lotand not in a cemetery.”
“Tells you to put family first but only cares about profit unless there is the chance of lawsuit!”
“Commission only!…The “leads” were going through family members of people buried in the cemetery”
“Money hungry! And will say and do whatever necessary to get it out of families!”
“Unethical means of generating leads.”
“Vultures….Let us circle the dead and pick the families wallets clean..If you do not do this you are not considered worth their time.”
“location manager don’t care about families, all they want is the sales… even if the families are having money problems.“
“They mark the memorials up 350%. You heard that right. Ripping people off at a time of desperate need.“
“The operating Officials should spend a day in an office. They should also experience a death. This industry has to change. I feel very sad for the communities that have to deal with the steady rule changes and never having a steady friendly face.”
“Issues needing to be resolved are put on the back burner as selling pre-need is “more important” – according to management.”
“If you’re gullible, you may even trick yourself into thinking you are helping people”
“I have heard more complaints from families than praise“
“they are drowning in debt. 3-4 mths behind in payments to vendor”
-former full-time StoneMor Family Service Counselors Source: Glassdoor, Inc. and Indeed, job recruitment company reviews
What happens at the community level when distant profit motives intersect with grieving families & low regulatory oversight? A case study
When you have a financially troubled distant corporation striving to meet shareholder expectations and commission-earning staff incentivized to sell products, the outcome for families utilizing a cemetery is almost inevitable. To better illustrate the local impact, here’s how this corporate profit squeeze has played out in one North Carolina cemetery:
Wayne Memorial Park, Dudley NC
Wayne Memorial Park is a 40-acre perpetual care cemetery located in Dudley, North Carolina–a rural farming community in Wayne County where the average income is $34,598. The property is an ideal spot to watch military jets fly low overhead as it lies directly at the end of a runway for Seymour Johnson Air Force Base in nearby Goldsboro, NC. Due to the proximity to a large military base, the cemetery is a popular final resting place for Veterans and their families as well as the community’s predominantly farming and blue-collar residents.
Founded in 1948, the cemetery underwent many changes in ownership over the years, but it was not until 1996 that non-local management took control of the property when Wayne Memorial Park, Inc merged with Townson-Rose Funeral Home and Forsyth Memorial Park and became SCI North Carolina Funeral Services.
During StoneMor’s tenure as owner of Wayne Memorial Park, notable changes have occurred:
High property staff turnover. A 17 year employee and former manager confirmed the 2017 revenue quota for the Dudley cemetery is $1.7 million, with each month having a specific income target….a target difficult for local staff to meet in a small community cemetery. As a result of demotions and penalties for failure to meet monthly sales quotes, there were three managers of the cemetery in 2017 alone.
The overall appearance of the property declined dramatically as reinvestment in upkeep diminished. The grass covering the graves slowly turned to weeds and bare ground appeared.
This is what Wayne Memorial Park looked like in July 2012
This is what Wayne Memorial Park looked like in July 2017 taken by the same sidewalk. A May 2019 photo of same area, different angle from the farther sidewalk showing continued decline. Little grass left, nearly all weeds and bare soil.
This is what the ‘Garden of the Good Shepard’ looked like in June 2010
This is what the ‘Garden of the Good Shepard’ looked like in June 2017, same place.
Garden of the Good Shepard, May 2019 (above statue is visible to the upper left of frame)
Temporary grave markers–historically provided free by funeral homes as part of their comprehensive services–were banned to encourage the purchase of ‘keepsake’ temporary markers–available only from 1 supplier (the cemetery) and at 1 price pointSole source in the funeral industry is a practice not permitted under regulations, yet there is little oversight which will be detailed later in this article.
The perpetual care cemetery currently neither places nor allows placement of temporary markers on the day of burial to designate where human remains are interred. The temporary markers, designed of a laminated paper material to last only until a permanent bronze and granite marker can be in place, were traditionally placed after the grave was covered at the conclusion of burial by local funeral homes as part of their services.
A grave with a temporary ‘keepsake marker’ installed. (look for the black rectangle just in front of the yellow flowers)
Families who wish to avoid an unmarked grave must purchase the ‘keepsake marker’ as the only alternative. The ‘keepsake marker’ is a small stone plaque measuring 10 inches by 6 inches etched with the decedent’s name & year of their birth & death (not full date) and no other personal information. It is available for purchase only from the cemetery at a cost of $176.14. Since it takes approximately 2 weeks to be installed, in the time between the burial & placement of the temporary keepsake marker there is nothing marking a grave.
The sales pitch on the temporary ‘keepsake marker’ is that this cost will be deducted from the permanent granite and bronze marker if it is purchased from the cemetery rather than from an outside vendor. The permanent granite marker is not currently required to be purchased from the cemetery, a consumer protection under NC law. The starting costs are $4,550 for what was described to me by the sales representative as a ‘basic’ marker going up to $8,000+ range–significantly higher than prices charged by outside vendors I surveyed.
If a family chooses not to purchase the permanent marker from the cemetery, then they are out the $176.14 temporary ‘keepsake marker’ fee plus the cemetery will then charge an additional ~$200 ‘installation fee’ for the permanent marker, even though they are not actually installing the marker (the outside marker vendor does that). It is unclear why an install fee is charged if the marker is not purchased from the cemetery and no install work is therefore done by them. I say the cost is ‘around $200’ because I was unable to get an exact fee from the Family Service Counselor/Sale Representative I met with, who said a printed price list was not available due to the ‘variable nature of their products’.
I asked what happens to people who do not purchase the temporary ‘keepsake marker’—how do they locate their loved one’s grave in the future once the grass grows and it isn’t possible to tell a fresh grave had been dug. I was told ‘the family just has to know’ but that they could also pay the cemetery a ‘location fee’ to survey the lot again. The cemetery keeps paper records of where burials occur, but does not physically/visually mark specific grave locations.
Because some families can neither afford the ‘keepsake’ nor immediately outlay the $4,000-$8,000 for permanent marker (recall this is a community where the average income is $35K), many graves now go unmarked for extended periods of time, sometimes indefinitely. Consequently, exactly where bodies are interred has been questioned. Reports have emerged of family members with valid deeds attempting to bury a loved on what they thought was ‘their family plot’, only to discover someone else was already buried in the same location….the same plot had been sold twice.
Why this matters: One unmarked grave’s evolution…..
A fresh grave of a presumed Veteran…but who? No name marks the grave.5 months later: Note the change in texture/color to the right of the existing marker…graves, but whose?
8 months later: The sod has died and the grave has now caved in. Still no marker indicates who is buried here or that a burial is even at this location.
Grave tents are banned out of liability concerns.
Customary practice among the area funeral homes I surveyed is to leave the funeral tent up for approximately 5 days to both mark and protect the fresh grave from the elements. Additionally, it serves to shield the flowers from the wilting sun. However, Wayne Memorial Park now bans this practice. I have confirmed reports that tents are erected the day of the funeral and before the last of the mourners leave a service, cemetery staff begin taking down the tent and closing the grave.
I was told by the Family Services Counselor/Sales Representative that tent use after a service’s conclusion is banned out of ‘liability concerns‘. Yet oddly, tents are permitted to be in place during the service when the greatest number of people are around it. I was unable to obtain a reason for the disconnect except that it was ‘corporate policy’ of which I was unable to obtain a written copy of the corporate policy.
Flowers placed by mourners are aggressively removed and the company’s own silk flower arrangements pitched to families as tasteful alternatives.
If you’ve never had to purchase funeral flowers…they can be expensive, with a single casket spray running $300-800 and individual wreaths from $150-300, among florists I surveyed. In one confirmed instance at Wayne Memorial Park from May 2017, fresh flowers valued over $1,500 were removed from a grave less than 48 hours after burial. With no temporary marker allowed and the flowers removed, there was nothing indicating a body had been interred at that location.
The scheduling of burial services in the cemetery is more tightly controlled under StoneMor, with hard limits on the number of services occurring on the property per day and their times with no graves permitted to be opened on weekends or holidays. A Monday burial is possible only if the management receives notification in writing by 1pm on Friday.
In one confirmed case, a death occurred on a Friday afternoon at 3pm and the family preferred to schedule the funeral for the following Monday or Tuesday. However, the cemetery said that if they weren’t notified by 1pm on Friday, they could not ‘open a grave’ on Monday. The family was then unable to bury their loved one on Tuesday because the cemetery also limits the number of services which can take place each day and they were ‘already booked’ for Tuesday with other persons ‘backed up’ who died after the 1pm Friday notification deadline. So that left Wednesday as the family’s only alternative. The day/time of the funeral was entirely driven by when corporate policy said it could be done and not when the funeral home, minister, musician, florists were available or when the family wanted. The family of the deceased had to meet the cemetery’s needs, not the other way around.
Consumers and deed holders are unable to obtain a written copyof the current cemetery policies and prices upon request.
I asked via written email, phone call and in-person visit for a copy of the cemetery’s current policies and prices. After 5 days of inquiry, I finally received a 47-page document detailing the cemetery’s policies. However, it was dated 2002—five years before the company was licensed to do business in NC and when the cemetery was under different ownership. The 2002 document has no mention of current polices pertaining to temporary markers, ‘keepsake makers’, tents or funeral flower removal. I have been unable to get such current policies or pricing in writing. State statues indicate consumers must be able to easily obtain a copy of prices and policies upon request.
Families are pressured to return after burial for additional sales opportunities. Consumers receive multiple phone calls following burial from the Family Services Counselor/Sales Representative asking for an in-person “after-care appointment“.
No counseling or support services are provided and no additional business conducted. A ‘counselor’ confirmed to me this meeting serves as an opportunity for the cemetery to market their permanent markers, silk flower arrangements and pre-planning services.
I have also confirmed cases of long-time plot deed holders being contacted by phone and told they need to come in to ‘confirm their deed‘. At such confirmation appointments, pre-planning services and products are pitched.
What is the law governing cemeteries?
Current rules and regulations were passed during a time when cemeteries were locally-owned enterprises and not owned by New York Stock Exchange trading level international conglomerates–regulation has not kept up with changes in the industry.
The Federal Trade Commission (FTC) regulates funeral homes to protect consumers, but not cemeteries except in limited situations. The Funeral Rule, enforced by FTC, makes it possible for families to choose only those goods and services needed and to pay only for those selected, whether making arrangements when a death occurs or in advance. The Rule allows for easy price comparison among funeral homes, and makes it possible to better select the funeral arrangements wanted. However, the Funeral Rule does NOT apply to third-party sellers, such as casket and monument dealers, or to cemeteries that lack an on-site funeral home. In recent years, the FTC has expressed a desire to extend the Rule to cemeteries, but so far this has not happened and it is unclear the current administration’s view expanding federal authority.
At the state level, cemeteries operate under a myriad of rules. In North Carolina, perpetual care cemeteries, including those owned by StoneMor, are overseen by the NC Cemetery Commission, created under the main legislation governing cemeteries, The NC Cemetery Act aka Article 9, Chapter 65. The 9 member Cemetery Commission is appointed by the Governor and the General Assembly; 7 of the members represent the cemetery industry and hold financial interests in cemetery and funeral related businesses, 2 appointees represent the public.
There are no ‘consumer guides’ published by the Commission to put the law in simple terms for consumers. The statues themselves are not an easy read. In the NC Cemetery Act, there are named provisions that a cemetery cannot force a family to purchase vaults and caskets from the cemetery, but there is nothing specific to temporary markers or other products which may be deemed as ‘required’ under individual cemetery policy. The intent of the NC Cemetery Act appears clear–the General Assembly was trying to prevent families from being preyed upon during times of grief–however, the Act was written in an era before for-profit corporations began purchasing nonprofit and community cemeteries. All forms of current burial practices, which many run counter to custom and tradition, were not foreseen and therefore are unaddressed.
From ancient times, a defining moment of civilization was when humans began to honor the dead. Marking graves is simply what generations have intuitively done as the first act of grief to demonstrate dignity and respect for the deceased.
Not isolated problems
My research finds that the issues detailed above are not limited to Wayne Memorial Park nor North Carolina, but rather are being reported at multiple StoneMor properties. From news reports, the consensus appears that consumers have little recourse under current (or non-existent in some states) regulations. Scenarios are arising which are not addressed under current consumer protection laws.
“We had a horrific burial, it was unbelievable,” Smelcer said. “Yes, I just want to get my husband out of here. But I pray that everybody else’s issues here get solved because this cemetery is just nothing but a joke.” Avon, Ohio
From newspaper and TV accounts:
Pinelawn Memorial Park in Kinston, NC: families report tall grass, fire ants, and weeds covering graves. Reported by the Kinston Free Press 7/14/2017
Anniston, Alabama: No grass, soil erosion, trucks driving over graves, downed limbs. Families call the condition of their loved one’s grave ‘heartbreaking’. ABC news 33 8-8-2017
Philadelphia, Pennsylvania: “allegations of high pressure sales tactics”, “In two dozen interviews with families and funeral directors, similar themes emerged: Complaints that StoneMor had harassed and misled mourners and customers, upsetting or bewildering some when they may be most fragile.” Philadelphia Inquirer 10/26/2015
Philadelphia, Pennsylvania: Family “pushed to buy” additional plots following death of son, rules prohibiting chosen monument. “It’s all about money to them,” say the parents “Losing Matthew broke our hearts,” he says. “Dealing with All Saints (cemetery) broke them all over again.” Philadelphia Inquirer 2-12-2017
Delaware: lack of price lists, pressure to pre-arrange services, handing out sales material to people leaving burial services. “In a 48-hour period, we had six clients calling about being harassed on the telephone by StoneMor sales people,” Delaware County Daily Times
West Virginia: “Families outraged over condition of burial plots” reports of ‘rude employees’, flooding, broken stones, disrepair, history of complaints regarding condition of cemetery, Register-Herald 5-31-2016
Allentown, Pennsylvania: Graves sold twice. Only discovered when marker stone was to be installed. ” The plots that we had purchased were previously sold to another couple” The Morning Call 10-6-2016
Annville, Pennsylvania: “Complaints pile up against cemetery” reports of disrepair, lack of upkeep ABC TV 27 June 8, 2016
Avon, Ohio: May 18, 2019 ABC Cleveland News Cemetery issues trigger more complaints, community meeting “We had a horrific burial, it was unbelievable,” Smelcer said. “Yes, I just want to get my husband out of here. But I pray that everybody else’s issues here get solved because this cemetery is just nothing but a joke.”
And there are many more.
Needed actions
I don’t like to present a problem without offering a possible solution. With that in mind:
In North Carolina, the General Assembly needs to:
Revise statue to clearly include consumer protections for all customary burial products and services such as temporary markers, tents, flowers.
Sole-source purchase ban should be expanded to cover all cemetery goods and services, not only caskets and vaults as current law dictates.
Price lists and policies should be written, clear, current and available upon request.
Minimum property upkeep standards for perpetual care cemeteries should be defined.
Closer monitoring and enforcement of existing regulations is also needed.
The regulatory body should be diversified to include more non-industry representatives.
Consumer education guides should be created to spell out clearly the rights of families.
An easier complaint process should be implemented with independent investigation and the ability to provide anonymous tips. Currently complaints received by the NC Cemetery Commission are forwarded to the cemetery in question for comment and resolution. I was unable with repeated attempts to get anyone to answer the phone at the number provided for the NC Cemetery Commission..number goes straight to voicemail..so anonymous tips from consumers or employees of unethical or illegal practices is not possible.
At the national level, the Federal Trade Commission needs to expand the Funeral Rule to include cemeteries. Currently they only regulate cemeteries who also own a funeral home on the cemetery property. There needs to be greater consumer protections via regulation of the cemetery industry, similar to that which already exists in the funeral home industry.
Importantly, consumers need to be aware that their local cemetery may be a for-profit corporation. I suspect few people realize that cemeteries are now stock market traded corporations and the person counseling them on burial arrangements earns a commission-only income. While every business must make a profit, the death industry is unique because it catches consumers at a vulnerable time immediately following the death of a loved one. Protections are needed to ensure ethical conduct. Greater transparency is needed so consumers can be fully aware.
Disclosure
I was compelled to research StoneMor because my family is buried in Wayne Memorial Park and one day, I may be as well. My grandparent’s and extended family’s graves are there and most recently, my father was buried there. My parents pre-planned their burial, purchasing plots in 1990 at a time before the cemetery was owned by StoneMor. When Dad died, we did not know the cemetery had changed hands, yet the difference in the experience was striking. Red flags of things which ‘didn’t seem quite right’ I encountered during our burial experience prompted me to research the company. I therefore make no claim of un-bias, rather I have tried here to present what I found as factually as possible. I encourage news outlets to conduct their own independent research to verify and expand upon what I have presented. I am happy to share sources and collaborate with verified members of the news media.
My Dad’s Grave, May 2019. He–and all who are buried here–deserve a more dignified and respectful burial.
I’ve always been a color-inside-the-lines type person. I’ve never had a speeding ticket nor even a parking ticket…which is kind of amazing since I’ve spent 30 years in a university town with tight parking and overzealous towing!
I’m so rule obsessive that I was once dismissed from a jury because, after questioning, the defense didn’t think I could identify with the accused because I was the only one of the jurors who had NEVER been in trouble with the law! I wasn’t a ‘jury of peers’…which I’ll take that as a divine compliment any day when the potential peer is a repeat offender drug dealer who resisted arrest!
Still, is it possible to play it too safe? Not in the law and order sense, but in life-in-general. Career advancement, public recognition, even some relationships seem to go to those who take risks rather than sit back. Risk-taking often means pushing the boundaries of what’s deemed the status quo…to push the line of perceived acceptability out just a bit as we strive to stay within it. Stasis stagnates us. Yet, none of us likes to find ourselves hanging out alone on the outside of the line–a hard line to navigate when society inconsistently both criticizes and rewards nonconformity.
Going where you ‘shouldn’t go’ in life is a gamble…sometimes you succeed beyond your wildest expectations and other times you fall flat on your face. But you don’t know which outcome until you push that boundary, go beyond the restricted zone in your life. And the only way to do that is by holding firm to your integrity. Follow your inner moral compass reflecting honesty and genuineness. If something intuitively feels ‘right’ or ‘wrong’ there’s probably a good reason those feelings crop up..that’s the only restricted zone you really need to heed. You simply cannot go wrong being yourself.
Dear reader: Getting back into the publishing groove after a long, necessary hiatus. Expect more frequent posts on a wide range of topics. (gotta push past my own restricted zone!)
The modern marker of disenfranchisement has become…littering by nature lovers?
Jordan Lake Reservoir, Bell’s Church Public Fishing Area
I take wildlife photos, so I do quite a bit of hiking around local rivers and lakes. I’ve always packed a trash bag in my photo bag to wrap gear in case of rain. At some point, I found myself starting to use the bag to pick up litter along the way. Nothing spoils a great shot of a natural vista or potentially harms the wildlife living there more than garbage.
Time was, I gathered a half-bag of trash on my photo walks. Then, a full bag. Now, I pack two bags–the most weight I can carry with my gear–and fill both to overflowing, leaving behind many, MANY, bags worth more of trash. I don’t have hard data to show that littering has become worse, just personal observation that at least in my neck of the woods, littering is habitual.
The photos posted here are what I found on just one day visiting 4 locations in the Haw River and Jordan Lake area of North Carolina. Notable is that this particular watershed (which supplies drinking water to ~300,000 people) is located in the heart of what is known as the Research Triangle–dubbed so for it’s high-tech companies and higher-education research universities.
It is an affluent area–with a median income 25% higher than the rest of North Carolina and a significantly higher percentage of persons with advance education. (Census data source) The quality of life gained from our many natural resources and outdoor recreation opportunities figures prominently in the economic development recruitment pitches for the Triangle region, which leads among the mid-Atlantic states in population growth. It is also an area with strong environment awareness markers–there’s a robust local market for hybrid vehicles, organic food, farm-to-table, and the state is home to a nearly 100 environmental groups
Why are the demographics relevant?
A computer hard drive, Cell phone, Battery…all oddities found at the bottom of the Haw River dam
Let’s consider why someone would litter a natural area. These litterers are obviously people who appreciate the recreational benefits of nature enough that they chose to go out into it to enjoy what it has to offer…fishing, hiking, swimming, boating, etc. So if you like being in nature, why then trash it? People don’t go to sit by a lake to view the garbage…if you trash it, it destroys the very thing you went there to enjoy…so why do it?
Researchers of litter (yes there is such a thing) postulate that people litter because they feel disenfranchised and powerless. In other words, they don’t feel connected to society or the land, and hence why it is considered acceptable behavior to trash the landscape. Yet, does the high-income, high-education Triangle fit that resident profile? No really. So what else could be going on.
Jordan Lake area near both Adopt a Shoreline & No littering signS
Sense of personal responsibility lacking?
Haw River where I found worms still alive in a plastic bag.
Another theory of why people litter is that they lack a sense of personal responsibility. These folks litter because they believe others will pick up after them. That theory might have some traction if you couple it with a dose of down-right laziness. Think of it: Do we have a population of people motivated and intelligent enough to plan an outing, go buy beverages, drive to a lovely natural setting to enjoy what the outdoors offers, yet also lazy and stupid enough to then throw the empty containers on the ground rather than make the effort to take it with them? If so, that’s pretty darn lazy as it takes less physical effort to take an empty bottle out of the woods than it does to acquire and bring the full bottle into the woods to begin with.
Failure of anti-litter messages?
“Ugliness is so grim. A little beauty, something that is lovely, I think, can help create harmony, which will lessen tensions.” Lady Bird Johnson
Where do people learn that when you are done with something, you simply throw it down? Well, it wasn’t because we don’t hear the ‘littering is bad’ public messages.
1964, Keep America Beautiful
While there had been anti-litter campaigns before, it was in the 1960’s that Lady Bird Johnson made anti-littering mainstream by making highway beautification her cause as First Lady. The ‘don’t be a litterbug’ message took off, sparking a societal stigmatization of littering. Take a look at the ads from that time and you’ll notice peer pressure and shame were key motivators to not litter. Children were even encouraged to call down their parents when they saw them litter!
The ‘Keep America Beautiful’ campaign was born out of this new mindset. Who can forget in the 1970’s their iconic public service announcement featuring Iron Eyes Cody, with a single tear falling down his cheek at the sight of litter. We’ve had generations now growing up exposed to not only the anti-littering message but also the environmental movements educational emphasize on the importance of clean air and water along with preserving wildlife habitat.
Yet the educational plea hasn’t worked and neither has the threat of legal action. In the places, I go ‘litter is against the law’ signs are everywhere, so when someone litters, they clearly know that it is against the law. Legal action isn’t a deterrent because state and local municipalities impose fines for littering when a law enforcement officer spots a litterer in action…and therein is the rub, it must be witnessed which is very hard to do as most of these areas are, understandably, not patrolled. In the bigger picture, littering isn’t considered a serious offence especially when there is violent crime to target with limited funding and staff.
So really, people litter because they can. Even when told it’s illegal and it’s bad for the environment, people still do it.
Just shut up & pick it up?
piles of trash are within view of the UNC ALPHA PHI OMEGA ‘Adopt a shoreline’ sign
Because the prevention and enforcement sides are lacking, volunteers try to meet the need by picking up litter. Nonprofit organized Adopt-a-highway and Adopt-a-stream/shoreline programs exist. Yet the volume of trash is so high, not even these noble efforts can keep pace. In the Triangle area, formal lake and river clean-ups are typically organized 2-3 times per year, depending on the program, location and sponsor. A shocking amount of trash is collected during these organized clean-ups.
Unfortunately, the accumulation of trash is continual and happens on far more miles of waterways than these events can possibly cover. The Clean Jordan Lake nonprofit over the past 8 years has organized removal of over 128 tons of trash along 15 miles of shore…that’s nearly 13,000 bags worth of trash!! The lake boast 180 miles of shoreline…so simple math shows 1) the potential volume of uncollected trash which may be out there along the waterways and 2) how being able to pick it all up is logistically and economically impractical. Keep in mind, this data is just from one of the regions many lakes and rivers.
What to do?
Bucket of dead fish: caught & neither released nor eaten but left with the rest of the trash
While I don’t have a magic answer, I also don’t like to present a problem without offering possible solutions. Volunteers can’t possibility pick up all the trash…there must also be deterrence to prevent the litter in the first place. It’s not realistic to expect increased funding for anti-litter efforts. And, it’s not realistic to change the mindset of a ‘don’t give a damn’ litterer overnight. The quickest short term fix is to bring back the shame associated with littering to get people to modify their behavior.
Here’s my brainstorm idea: While there the many miles of lake shores and rivers banks can’t all be monitored, there are certain ‘hot spots’ of dense litter activity centered near recreation areas. Mount some trail cameras in these areas and post the photos of litterers on the internet. Invite the public to tag people they recognize. In our social media image conscious society, the negative peer-pressure of public shaming is greater punishment than the threat of a $250 fine IF a law enforcement officer actually sees you in the act. A basic wildlife camera, like the ones used by hunters, costs less than $100 each…as good of an investment for volunteers, donors and nonprofits as the cost of buying trash bags and ‘adopt’ signs.
Additionally, I highly encourage all visitors to our parks, lakes and rivers to bring a trash bag…for your own garbage but also, be kind and pick up what you see around you too.
What ideas do you have? Why do you think that here in the Research Triangle, a community in which we are supposed to be well-educated and know better than to litter, it’s still done to such a degree? Is there so little pride in our home area that we don’t think twice about trashing it? Surely in a region like ours, we can do better…we at least should try. Let’s discuss below.
We’re not the only ones depending on these waterways: I took this photo of a fishing bald eagle from the same spot where I took photos of computer electronics, beer cans/bottles, fast food containers, dirty diapers, discarded fishing lines & hooks, a grill, two shoes (not matching), a cell phone and oh yes…a scratch-off lottery ticket.
How one man was buried in an unmarked grave despite preplanning his burial in 1990 and having a $20,000 funeral. How this surprising indignity can occur–to ANY of us–is rooted in the growing national trend of out-of-state publicly-traded for-profit holding companies buying historically non-profit community cemeteries. Regulations, meant to protect consumers during their most vulnerable time after the death of a loved one, have not kept up with the rapid changes of the death-care industry.
Are you “financially ambitious” with a “competitive spirit” and want “unlimited earning potential”?
A job working with grieving families is for you!
Wayne Memorial Park is a perpetual care cemetery located in the rural farming community of Dudley, North Carolina. The property is an ideal spot to watch military jets fly low overhead as the property lies directly at the end of the runway for Seymour Johnson Air Force Base in Goldsboro, NC. Due to the proximity to a large military base, the cemetery is a popular final resting place for Veterans and their families as well as the community’s predominant farming and blue-collar residents.
May 11, 2017 dated job recruitment for “sales representative” position at Wayne Memorial Park reflects an aggressive profit emphasis. Employees hired into “sales representative” positions provide consumers with business cards indicating their position is as a “Family Service Counselor” No mention of sales. Click to enlarge (source: https://careers-stonemor.icims.com/jobs/3812/sales-representative/job )
Founded in 1948, the cemetery underwent many changes in ownership over the years, but it was not until 1996 that non-local management took control of the property when Wayne Memorial Park, Inc merged with Townson-Rose Funeral Home and Forsyth Memorial Park and became SCI North Carolina Funeral Services.
StoneMor Partners L.P. has grown quickly by acquiring properties—today they own 316 cemeteries and 105 funeral homes in 28 states and Puerto Rico. The company’s stock is traded on the New York Stock Exchange under the ticker id STON. Securities and Exchange Commission filings (FORM 10-K/A) for the last fiscal year available online, 2015, show $319 million in annual revenue, $202 million of which was earned in the sale of cemetery merchandise and services.
Nineteen of StoneMor’s cemeteries are located in North Carolina including the large historic Montlawn Memorial Park in Raleigh, purchased in 2014 for $8 million. NC properties include:
Alamance Memorial Park, Burlington, NC
Carolina Biblical Gardens of Guilford, Jamestown, NC
Chatham Memorial Park, Siler City, NC
Crestview Memorial Park, Rural Hall, NC
Floral Garden Park Cemetery, High Point, NC
Lakeview Memorial Park, Greensboro, NC
Martin Memorial Gardens, Williamston, NC
Montlawn Memorial Park, Raleigh, NC
Mountlawn Memorial Park, North Wilkesboro, NC
Oakhill Memorial Park, Kinston, NC
Oaklawn Memorial Gardens, Winston-Salem, NC
Pinelawn Memorial Park, Kinston, NC
Randolph Memorial Park, Asheboro, NC
Rowan Memorial Park, Salisbury, NC
Skyline Memory Garden, Mount Airy, NC
Wayne Memorial Park, Dudley, NC
West Lawn Memorial Park, China Grove, NC
Woodlawn Memorial Park, Durham, NC
York Memorial Park, Charlotte, NC
Managing visitor’s grief experience
Wayne Memorial Park, Dudley NC
Wayne Memorial Park in Dudley, NC contains 40 acres of grounds with graves going back to 1948. After StoneMor’s purchase in 2005 for $1,013,500, small changes began to be noticed by visitors to the cemetery.
Temporary grave markers are banned. The perpetual care cemetery neither places nor allows placement of temporary markers on the day of burial to designate where human remains are interred. The markers, designed of a material to last only 60-90 days until a permanent marker could be in place, were traditionally placed after the grave was covered at the conclusion of burial by local funeral homes as part of their funeral services. This practice is no longer permitted. A ‘keepsake marker’ is now pitched to families as an alternative to an unmarked grave; it can only be purchased from 1 source–the cemetery–at 1 price point and takes 2 weeks to install. Because some families cannot afford a permanent marker nor choose not to purchase the ‘keepsake’, many graves now go unmarked forever.
Tents over graves, which had previously been kept up for 5 days, are removed even before the last mourner leaves the graveside service. Tent use after a service’s conclusion were banned out of ‘liability concerns’.
Flowers placed by mourners are aggressively removed and the company’s own silk flower arrangements pitched to families as more tasteful alternatives.
The scheduling of burial services in the cemetery are more tightly controlled, with hard limits on the number of services occurring on the property per day and their times with no graves permitted to be opened on weekends or holidays. A Monday burial is possible only if the management receives notification in writing by 1pm on Friday.
The overall appearance of the property has diminished: The grass covering the graves slowly turned to weeds and bare ground appeared.
Consumers and deed holders are not able to obtain a written copy of the current cemetery policies and prices upon request.
Family Service Counselors or Sales Representatives?
Most disturbing of the changes were in the interactions between grieving consumers and cemetery staff, now motivated by commission-only income and sales quotas. (see job ad). Although the company, for all it’s cemeteries nationwide, posts job recruitment ads for “sales representative”, the persons employed in these sales positions provide families with business cards identifying their position as “Family Service Counselor”. No mention of their role in sales is provided to consumers nor are families told they are not salaried employees and earn commission-only. A search for ‘family service counselor’ on the StoneMor ‘careers’ website returns no results and redirects to the ‘sales representative’ positions, of which there are currently 93 vacancies nationwide.
What do full-time Family Service Counselors from 20 different StoneMor owned cemeteries say about their work? In their own words:
“You’re not a counselor, this is a sales role in the death care industry.”
“You are made to lie, and cheat customers and in their own words “prey on the emotions” when someone just died. Create the urgency!! is the motto.”
“Forget the legal aspects of customer service, forget actually caring for families who have lost loved ones and are grieving, they need stuff and you had better sell it to them.”
“They want you to bring up past death experiences with families to make them feel guilty about not pre-planning for their families. It’s all about the money.”
“The company is less about the families we are servicing and more about meeting numbers.”
“Tells you to put family first but only cares about profit unless there is the chance of lawsuit!”
“concern is only for “the sale” and how to manipulate any and all into a purchase”
“you don’t get paid unless you make a sale”
“Commission only!…The “leads” were going through family members of people buried in the cemetery”
“Money hungry! And will say and do whatever necessary to get it out of families!”
“Unethical means of generating leads.”
“the atmosphere was predatory”
“Vultures….Let us circle the dead and pick the families wallets clean..If you do not do this you are not considered worth their time.”
“location manager don’t care about families, all they want is the sales… even if the families are having money problems.”
“They mark the memorials up 350%. You heard that right. Ripping people off at a time of desperate need.”
“The operating Officials should spend a day in an office. They should also experience a death. This industry has to change. I feel very sad for the communities that have to deal with the steady rule changes and never having a steady friendly face.”
“Issues needing to be resolved are put on the back burner as selling pre-need is “more important” – according to management.”
“business model is based on outdated vacuum sales tactics that are to be expected on a car lot and not in a cemetery.”
“If you’re gullible, you may even trick yourself into thinking you are helping people”
“I have heard more complaints from families than praise”
-former full-time StoneMor Family Service Counselors Source: Glassdoor, Inc. job recruitment company reviews Source link
A family’s experience: death is only the beginning
My Dad passed away suddenly on May 12, 2017. While he had fought lung cancer for 2 ½ years, he did not die following a long-goodbye from the cancer itself. He unexpectedly developed a pulmonary hemorrhage (bleeding in the lung). It was sudden. It was traumatic. Just moments before his passing, Dad was well enough that doctors were planning a transfer for later in the day out of UNC Hospital’s ICU to a ‘step-down’ room with preparations already underway for eventual discharge home. So as a family, we were totally unprepared to say goodbye when he passed away unexpectedly in ICU at 3pm on a Friday afternoon.
When a loved one dies, there is little time to grieve before having to jump into making funeral arrangement decisions. We fortunately contacted a wonderful funeral director who provided truly outstanding care to my family during this difficult time. The funeral home was professional, compassionate and flawless in the services they provided.
I understand that the funeral business is indeed a business—every business must make a profit. Dad was a businessman too, so he would have understood that also. The compassionate manner in which the funeral home conducted necessary business was in such a way that it did not feel like ‘just business’—we were never pressured and the pricing of products and services werefully transparent in writing, with multiple options and price-points to choose from. My mother and I were empowered by the funeral home to be in control of all decisions. It is the way a business which touches consumers at the saddest and weakest moment of their lives should operate.
To make things easiest on us so we’d only need to write one check afterwards, we asked the funeral home to pay all outside vendors on our behalf and we’d reimburse—such as the cemetery’s fees for digging the grave, newspaper ad costs for the obituary, Register of Deeds fee for obtaining certified copies of the death certificate, etc. No fees were added on to provide this convenience for us. When we left the funeral home meeting after making Dad’s arrangements, we anticipated no additional monies to be paid.
Burial plot: Where raw grief met corporate greed
Mom and Dad were married 55 years
Since Dad died on a Friday afternoon, my mother and I had originally hoped for a Monday or Tuesday funeral at the latest, but it became clear this would not be possible. While we met with the funeral director on Saturday less than 24 hours after Dad died, the cemetery was unavailable to meet with us until Monday at 11 AM.
My parents paid $2,070 in April 1990 for 6 connecting burial plots in Wayne Memorial Park. The deed was issued at a time before StoneMor Partners L.P. owned the cemetery, when the cemetery was owned by Wayne Memorial Park, Inc. At the time of Dad’s passing, we were unaware the cemetery had changed ownership.
Flags mark the burial plot at the pre-burial meeting.
Our ‘pre-burial meeting’ was with StoneMor’s Family Services Counselor. The purpose of the meeting, we thought, was to go out to the gravesite and indicate which of the 6 plots my family owns we wished to use for Dad’s interment. It was at this meeting, my mother and I learned that this perpetual care cemetery neither places nor allows placement of temporary markers on the day of burial to designate where human remains are interred.
We were shocked. The very idea of Dad being in an unmarked grave broke my heart in that moment. My mother was equally emotional. We knew we would eventually be purchasing a permanent granite and bronze marker for the grave—a double one large enough to cover both my mother & father’s plots. But such markers take 6-8 weeks to be made and installed from the time of order; and it is typically not an immediate decision at the time of a loved one’s death as families like to put some thought into the memorial and with costs ranging from $4,000-$8,000, it is an expense which must be budgeted.
My Dad and I…the thought of his life being reduced to an unmarked grave broke my heart and in that moment I felt we had no choice but to pay whatever it took to prevent him from being forgotten so quickly.
But there was an interim alternative the cemetery offered. In the same meeting after my mom and I learned that Dad would be buried without any identification, we were given a sales pitch to purchase a ‘keepsake marker’ to be ordered and installed in an estimated 1-2 weeks after burial. The ‘keepsake marker’ is a small stone plaque measuring 10 inches by 6 inches with the decedent’s name & year of their birth & death (not full date) and no other personal information. It was available for purchase from the cemetery and to comply with their policy it could ONLY be purchased from the cemetery, at a cost of $176.14. Since it takes approximately 2 weeks to be installed, in the time between the burial & placement of the temporary keepsake marker there is nothing marking the grave. We were presented with 1 choice for a temporary marker…no other price points, styles or options to mark the grave until the permanent granite/bronze marker was installed months later.
The pitch on the temporary ‘keepsake marker’ was that this cost would be deducted from the permanent marker if it was purchased from them. The expensive permanent granite marker is not currently required to be purchased from the cemetery. Their starting costs are $4550 for what was described to us by the representative as a ‘basic’ marker going up to $8000+ range. If we choose not to purchase the permanent marker from them, then we are out the $176.14 plus they will then charge ~$200 ‘installation fee’ of the permanent marker, even though they do not actually install the marker themselves (our outside marker vendor would do that); the fee is merely to review the drawing, permit & manage the process. I say the cost is ‘around $200’ because I was unable to get an exact fee from the Family Service Counselor, who said a printed price list was not available due to the ‘variable nature of their products’.
Keepsake marker…the only temporary marker permitted, only available for purchase from the cemetery and not able to be installed at time of burial
I asked what happens to people who do not purchase the temporary ‘keepsake marker’—how do they locate their loved one’s grave in the future once the grass grows and it isn’t possible to tell a fresh grave had been dug. I was told ‘the family just has to know’ but that they could also pay the cemetery a ‘location fee’ to survey the lot again. They keep paper records of where burials occur, but do not physically/visually mark the location in any way.
On that day of the pre-burial meeting, still raw with grief my mother and I felt we had no choice but to purchase this temporary ‘keepsake marker’ because we couldn’t stand the thought of nothing at all marking Dad’s grave, even if only for a few weeks or months. Cost was not the issue, respect was.
From ancient times, a defining moment of civilization was when humans began to honor the dead. Marking graves is simply what generations have intuitively done as the first act of grief to demonstrate dignity and respect for the deceased.
Scheduling
My son and my Dad. My son is a pilot…it was one of the proudest, happiest day’s of my Dad’s life when his grandson took him flying.
We were limited by the cemetery on when we could bury Dad. He died on a Friday afternoon at 3pm at UNC Hospitals, located 2 hours away. The family preferred to schedule the funeral for the following Monday or Tuesday, but the cemetery said that if they weren’t notified by 1pm on Friday, they could not ‘open a grave’ on Monday. When I expressed our desire to not delay the burial, the Family Service Counselor twice indicated that we should have notified them before 1pm on Friday per policy if that was truly what we wanted and I kept replying…’but he didn’t die until 3pm!’
So due to their notification policy, we were unable to bury Dad on Monday. We were then unable to bury him on Tuesday because they limit the number of services which can take place each day and they were ‘already booked’ for Tuesday. So that left Wednesday as the only alternative. The day/time of Dad’s funeral was entirely driven by when the cemetery said it could be done and not when the funeral home, minister, musician, florists were available or when the family wanted. The family of the deceased had to meet the cemetery’s needs, not the other way around.
Burial day
Dad working in his garden. He loved yellow flowers.
My Dad was buried on Wednesday, May 17. My mother and I planned for Dad a lovely graveside service. He loved flowers–yellow was his favorite color so we ordered a casket spray filled with beautiful yellow flowers. Dad knew many people having been in the refrigeration and electrical business for over 40 years and was active in a large antique tractor club. Many of his long-time customers and tractor-club friends also sent arrangements. Over $1,500 in fresh flowers from the family alone covered his grave.
One of the 3 arrangements my mother and I ordered.
A tent over the grave was erected the day of the funeral—it was the first 90-degree day of the year and the shade protected not only the mourners but also the flowers. The funeral home’s practice is to leave the tent up for 5 days to both mark and protect the fresh grave and it serves to shield the flowers from the wilting sun. However, the cemetery bans this practice. Before the last of the mourners left the service, cemetery staff began taking down the tent and closing the grave.
I was told the restriction was for liability reasons, in case someone got hurt. Yet I couldn’t square this logic since the tent was in place during the service when the greatest number of people were around it. Over 200 people signed the register at Dad’s funeral with most standing around the tent for the burial and with 30 family members seated in chairs directly under the tent. The time of greatest liability was during the service, not in the days afterward when there would be only the occasional family visitor to the grave.
A clean, unmarked grave
When my family returned 2 hours after the conclusion of the funeral, following interment, the tent was gone and there was nothing marking the grave except the mound of beautiful flowers.
Family at the grave hours after burial. The flowers were gone and the grave raked clean when visited 36 hours later.
The ‘keepsake marker’ would not be installed for 1-2 weeks we were told. It felt wrong there was nothing with Dad’s name, but at least the flowers were there to indicate where his grave was.
Yet, that also was not to be for long. When family visited the cemetery on Friday late morning, less than 48 hours after burial, all flowers had been removed. The grave had been raked clean. No flowers. No marker. No name. Nothing at all to indicate whose grave it was or that a burial had taken place. It broke our hearts yet again. We were unable to take any clippings from the flowers or ribbons to preserve as mementos. All that money, all that love invested in choosing the perfect way to honor my dad…gone in less than 48 hours after the service. What a waste. And for what reason I cannot imagine to know. The flowers would not have died that quickly.
Some of the flower arrangements later placed on the grave
Unknown to me at the time, one of my Dad’s sisters was so moved that she called the cemetery to complain when she saw the unmarked grave. She spoke with a manager who confirmed the removal of the tent was policy and indicated she would speak with ‘higher-ups’ about changing the timing of flower removals.
On the Tuesday following burial, my Dad’s temporary ‘keepsake marker’ was installed. It was chipped during installation, but I did not mention it because I did not dare risk removal. So my Dad’s grave now at least has a name, albeit the feeling I’m left with is hollow. He deserved so much more respect in death than he was shown…any one does. He was a husband, father, grandfather, and brother….he was loved. And it is the people who loved him who visit the cemetery. It is the people who loved him on both sides of my family tree who also have grave plots purchased in this same cemetery…it has over the years become the final resting spot for all the people I hold near and dear. But it can now never feel the same and there is no reason for this change of heart other than simple corporate greed.
What are the rules and regulations governing the for-profit cemetery industry? Read on.
The grave with the $176.14 temporary ‘keepsake marker’ installed. I placed the silk flowers behind it.
Written policies and prices lacking
At our ‘pre-burial meeting’ and in subsequent emails, I asked for written cemetery policies and price lists. I was told I could get a copy of the policies at our ‘after-care appointment’. The purpose of such a meeting was puzzling to my family since after burial, there should be no further need for the consumer to sit down and meet with a cemetery representative. Consumers are pressured to return for an in-person ‘after care’ appointment which can have no role after burial except to serve as an opportunity to market their permanent markers, which currently can be purchased from any vendor, not just the cemetery.
Indeed at my family’s after-care meeting, we were pitched markers starting with a ‘basic model’ at $4,550 going up to $8,000 for more elaborate markers which we were told were of better quality and durability.
I was provided—6 days after the burial and 11 after he died and we began making arrangements–a 47-page document detailing the cemetery’s policies. However, it was dated 2002—five years before the company was licensed to do business in NC and when the cemetery was under different ownership. The 2002 document has no mention of current polices pertaining to temporary markers, ‘keepsake makers’, tents or funeral flower removal. I have been unable to get such current policies or pricing in writing. I have begun to suspect such written policies do not exist—if so, then as a consumer, I have not been able to obtain a copy easily and upon request, as (my understanding) state statues require.
Laws and regulations
What does the law require of perpetual care cemeteries? Current rules and regulations were drafted during a time prior to the for-profit corporate transition of the cemetery industry and therefore do not fully address today’s practices.
The Federal Trade Commission (FTC) regulates funeral homes to protect consumers. The Funeral Rule, enforced by FTC, makes it possible for families to choose only those goods and services needed and to pay only for those selected, whether making arrangements when a death occurs or in advance. The Rule allows for easy price comparison among funeral homes, and makes it possible to better select the funeral arrangements wanted. However, the Funeral Rule does NOT apply to third-party sellers, such as casket and monument dealers, or to cemeteries that lack an on-site funeral home. In recent years, the FTC has expressed a desire to extend the Rule to cemeteries, but so far this has not happened and it is unclear the current administration’s view expanding federal authority.
At the state level, cemeteries operate under a myriad of rules. In North Carolina, perpetual care cemeteries, including Wayne Memorial Park, are overseen by the NC Cemetery Commission, created under the main legislation governing cemeteries, The NC Cemetery Act aka Article 9, Chapter 65. The 9 member Cemetery Commission is appointed by the Governor and the General Assembly; 7 of the members represent the cemetery industry and hold financial interests in cemetery and funeral related businesses, 2 appointees represent the public.
In the Act, there are provisions that a cemetery cannot force a family to purchase vaults and caskets from the cemetery, but there is nothing about temporary markers. (At least none which I could find in the regulations, but keep in mind I am not a lawyer and there are no ‘consumer guides’ published by the Commission to interpret the law in simple terms for consumers) The omission of temporary markers may be an oversight as it seems with the Act, the General Assembly was trying to prevent families from being preyed upon during times of grief with the casket, vault and permanent marker provisions, and if this is the case, it should also be extended to temporary markers. The statutes were likely written in an era before for-profit corporations began purchasing nonprofit and community cemeteries. Plus, I suspect it was understood to be simple common sense that it was desirable to mark a grave temporarily.
Needed changes to cemetery industry regulations
Since my Dad’s funeral, people in the community have shared stories with me of graves being sold twice and family members going to bury a loved one only to find the plot long held already occupied. As I have no first-hand experience with this, I cannot comment on its accuracy, although I have 100% faith in the integrity of the people who shared those stories. What I can comment on is my first-hand experience, as detailed above. That alone should be cause for alarm.
My grandparents are buried near my Dad…many relatives on both sides of my family tree have burial plots in the 69 year old cemetery.
To be clear: While my mother and I were obviously disturbed when we encountered the cemetery’s practices, we at no time acted irate, irrational or even raised our voices. Rather, we cried. The days after my Dad’s unexpected death were ones of overwhelming sadness and this experience added to that feeling of being overwhelmed by events beyond our control. Our interactions with cemetery staff have all been respectful and professional as we’ve expressed our concerns and unhappiness…this is in part, because that’s the sort of professional minded business people we are, and in part, because we do fear being banned by the cemetery from visiting our family’s graves. I don’t know if they have the power to do this, but I suspect this fear is what keeps many in the community from speaking out. In addition to my Dad, my grandparents are also buried there and aunts and uncles on both sides of my family have plots there—this cemetery years ago became our family’s choice of a final resting spot. I try to always be polite to people and separate the policy from the person…I appreciate that perhaps the staff at the cemetery are simply doing their jobs enforcing corporate policy passed down from elsewhere. I have no way to know who, or where, policy decisions are made. I just know they are bad ones. With that in mind….
As a consumer, my concerns are:
That human remains are not marked. This is standard practice at this cemetery. Temporary markers are banned and if a family does not choose to purchase the one-option ‘keepsake marker’ or a permanent granite marker, the grave will forever go unmarked. This goes against the very philosophy behind a perpetual care cemetery and against the societal custom of marking a grave out of respect for the deceased as as part of the grieving process for the family. I can’t imagine persons who purchase plots years in advance would assume they would be in an unmarked grave…even if only for a few days. They likely assumed this was part of the price they paid or if not, that such a basic thing certainly wouldn’t be banned. Respect and comfort to the family requires at least a name on a grave. Many plots are also current and retired Veteran’s burials due to the proximity to a major Air Force base.
The temporary ‘keepsake marker’ could only be purchased from the cemetery and there was only one option and price point.
That this came up only immediately after a death during a time of great emotional upheaval for the family who thought all had been arranged with no decisions to make or money to pay. Deed holders should be kept apprised of changes in policies, changes in ownership and given opportunity for public comment.
That consumers and deed holders are not able to easily obtain a written copy of the cemetery policies and prices—I asked for copies multiple times, in writing also, in advance of the burial. I was only able to obtain an outdated copy from a time before the company even owned the cemetery and then that was provided 11 days after the death.
Whose policies govern whether graves must be marked & limit temporary markers to a sole source? In our meetings, the representative for the cemetery kept referring to the need to adhere to ‘the policies’ and I cannot get clarified WHOSE policies so I know who to appeal or complain to—is this state law, Cemetery Commission, FTC, corporate rules etc. I was told I could complain about the policies in an after-care survey…which when I received it, the return address for the survey goes to the cemetery office in Dudley to the very people whose work I have concerns about, so I’m confident that survey will never be passed higher up the chain of corporate leaders. I don’t know what recourse I as a consumer have to question or help change the practices.
The State of NC statues need to be revised to clearly include temporary markers in the code.
The Federal Trade Commission needs to expand the Funeral Rule to include cemeteries. Currently they only regulate cemeteries who also own a funeral home on the cemetery property.
There needs to be greater consumer protections via regulation of the cemetery industry, similar to that which already exists in the funeral home industry.
A plea for common sense decency
My Dad and I on my wedding day
I am unclear if the practices and policies of this particular cemetery and its corporate parent are legal or not…I do hope someone more legally savvy than myself will know. If the practice and policy I’ve described are indeed legal, then it certainly isn’t ethical.
This is a farming, blue-collar community with many military and retired military residents. Many citizens are on fixed incomes. Hitting up grieving widows, widowers and families at the time of bereavement for an overpriced temporary marker which can only be purchased from a single source or else the loved one’s grave will go un-marked is wrong. Quickly removing the tent and the flowers placed by mourners on the grave is wrong. The intent behind a family choosing a perpetual care cemetery is that they want a grave to be properly recorded and cared for long into the future. They desire it to look nice and honor the memory of their loved one. That today there can exist unmarked graves in our state’s perpetual care cemeteries is an abomination and an affront to the hardworking consumers who chose this product as their final resting place.
While bringing to light what happened to my family will not change the hurt inflicted upon us, it is my hope it may prevent it from continuing to happen in the future. I call upon the NC General Assembly, the NC Cemetery Commission and the Federal Trade Commission to more closely regulate perpetual care cemeteries and protect consumers. I stand ready to testify what I have detailed above to be true. This I do to honor my Dad.
Knowledge empowers. Action transforms.
Bad things continue to happen when good people do nothing.
Examples of unmarked graves:
Veteran’s grave…but who? No identifying information.Note the change in texture/color to the right of the existing marker…graves, but whose? As time goes by and a fresh burial is no longer obvious, a used grave plot is unrecognizable
On April 6, 2017, the FDA approved marketing of 23andMe Personal Genome Service Genetic Health Risk tests for 10 diseases or conditions.(FDA Press Release 4-6-17) No prescription or physician needed. These are the first direct-to-consumer tests authorized by the FDA that provide information on an individual’s genetic predisposition to certain medical conditions. Among them, hereditary thrombophilia.
The “hereditary thrombophilia” wording used in the FDA release is a very broad term. There are multiple genetic variants which have been shown to correlate with increased clot risk including heterozygous & homozygous Factor V Leiden, prothrombin 20210 and deficiencies of antithrombin, protein C and protein S.
So a question I posed to both the FDA and the company 23andMe was 1) Which specific thrombophilias does the panel test for and 2) to what specificity—ie do results only indicate the presence of a gene mutation or does it report whether the mutation is heterozygous or homozygous.
Two most common thrombophilias included
The company replied with the following information:
“The 23andMe PGS Genetic Health Risk Report for Hereditary Thrombophilia is indicated for reporting of the Factor V Leiden variant in the F5 gene, and the Prothrombin G20210A variant in the F2 gene. This report describes if a person has variants associated with a higher risk of developing harmful blood clots, but it does not describe a person’s overall risk of developing harmful blood clots. This report is most relevant for people of European descent.”
The FDA responded with identical wording and indicated more details may be in the de novo pathway Decision Summary for the product, which may not be publicly posted for some time due to the need for review by the Freedom of Information staff.
What does this mean? 23andMe’s genetic test will include the 2 most common thrombophilias–Factor V Leiden and Prothrombin 20210 mutations.
Factor V Leiden thrombophilia is the most common thrombophilia in the United States. “Between 3 and 8 percent of people with European ancestry carry one copy of the factor V Leiden mutation in each cell (heterozygous mutation), and about 1 in 5,000 people have two copies of the mutation (homozygous mutation). The mutation is less common in other populations.” (Source: NIH Genetics Home Reference, US National Library of Medicine) The heterozygous mutation increases clot risk 5 fold, the homozygous mutation increases clot risk 18 fold. (see chart source below)
Prothrombin thrombophilia is the second most common inherited form of thrombophilia after factor V Leiden. “Approximately 1 in 50 people in the white population in the United States and Europe has prothrombin thrombophilia. This condition is less common in other ethnic groups, occurring in less than one percent of African American, Native American, or Asian populations.” (Source: NIH Genetics Home Reference) The heterozygous form of the mutation increases clot risk 4 fold; no data was available on homozygous risk.(See source chart below)
Why testing may (or may not) be helpful.
First, to be clear, when we are talking about a genetic thrombophilia, what we’re truly talking about is not a disease but rather a specific gene mutation that results in an increased tendency to form abnormal blood clots known as deep venous thrombosis (DVT). DVTs are fairly common–impacting ~900,000 Americans annually–and occur most often in the legs, although they can also occur in other parts of the body such as the arm, brain or abdomen. DVTs which travel to the lungs result in pulmonary embolism (PE), which is a potentially life-threatening condition. In the US, pulmonary embolism deaths outnumber those from breast cancer, AIDS and car accidents combined.
Inherited thrombophilias are found in around half of all DVT/PE patients.
Inherited thrombophilias are found in around half of all DVT/PE patients.(Source) So what a thrombophilia test does is look for a gene mutation which is correlated with an increased risk for developing these types of deadly clots. Sounds desirable, yes? The rub is that not everyone with the genetic mutation will develop a blood clot. In the most common thrombophilia, Factor V Leiden, only about 10 percent of individuals with the factor V Leiden mutation ever develop abnormal clots. (Source) Blood clots are often the result of a combination of risk factors–such as hospitalization, cancer, long-duration travel, surgery, pregnancy, estrogen containing oral contraceptives in addition to thrombophilia.(Source)
With that said, there is a subpopulation of thrombophilia patients at very high risk for developing a blood clot. These are the patients for whom access to thrombophilia testing would potentially be life-altering. The following chart (Source ) is helpful to illustrate:
Lim, Moll,Thrombophilia Vasular Medicine, 2015
Put into perspective
I have publicly disclosed previously that I have a high-risk thrombophilia–homozygous Factor V Leiden. You will notice in the chart above, that means my risk for developing a blood clot is 18 times greater than someone without the mutation. Indeed, the statistics bore out and I developed both DVT and PE in 2003 for which I was hospitalized 9 days and, without exaggeration, nearly died from my clot. I am now on life-long treatment to prevent a recurrence. Most folks would agree that’s something pretty bad to avoid if possible.
The question then is: If I’d known I carried this high-risk mutation years earlier, could I have taken steps to reduce my risk and avoid the clot? Absolutely. Effective prevention strategies exist. For one, I would not have chosen to take an estrogen based oral contraceptive (which further increased my clot risk) and when I suffered from pregnancy complications, my physician and I would have better understood the potential cause and managed it better as a high risk pregnancy. (pregnancy and c-section both increase clot risk). So, in theory, if I’d known earlier I had a high-risk thrombophilia, it would have altered my lifestyle and medical decisions in such a way that, perhaps, my eventual DVT/PE episode as well as pregnancy complications could have been avoided. There is of course no way to know for certain since for some people, despite best prevention efforts, clots and complications still happen.
Views from the medical community
For the past 2 years, I have served as a patient representative and voting member of a thrombophilia evidenced-based guideline panel of the American Society of Hematology. And while I cannot disclose the group’s findings until publication, I can make some general observations.
The medical community is conflicted about when and why to do thrombophilia testing. There is inconsistency in daily practice from clinician to clinician and hospital to hospital as to when tests are orders, for what patients and how those are used to inform decisions. Research studies tend to be few, with small study size and therefore of limited quality. Decisions based on such weak data translates into a diversity of opinions and practices. Thrombophilia testing as it correlates to outcomes is an area in which further clinical research is sorely needed.
What is clear, is that we are at a crossroads for thrombophilia testing and the FDA approval of a direct-to-consumer test reflects this change in thinking. A decade ago, thrombophilia testing was considered rather routine following a DVT/PE. More recently, the pendulum swung to an opposite extreme to where few clinicians routinely test for thrombophilia. (See the ACCP guideline for current recommendations & evidence)
Based upon recent data, I suspect we will eventually end up somewhere in the middle of these two extremes—to where there will be a certain patient population in which thrombophilia testing is warranted and helpful in informing decisions, patients such as myself for example. The challenge will be in how to screen and find those persons at high-risk for clotting, without over-testing and creating undue worry in those patients who are lower-risk for clotting. It is the shared challenge of every screening test really–from breast cancer to PSA–how to maximize helping the most numbers of patients and minimize potential harms. In my view, this is where education of both patient and provider is essential.
Patient & provider education gaps
Unfortunately, patient education is an area of great concern and where we fail badly. Very badly. Ideally, every person who receives a genetic test would receive counseling before and after. As this doesn’t always happen with diagnostic thrombophilia tests, it is unrealistic to expect it will happen with direct-to-consumer tests either. I, myself, received no genetic counseling before or after my thrombophilia test–it was never offered. In fact I never even knew my clinician had ordered a genetic test until the results were given to me by a different provider who really, in hindsight, didn’t articulate accurately what the results meant. My understanding of the impact of the test was very much a process of self-education and searching for a knowledgeable clinician, in my case a thrombosis-specialized hematologist.
A 2008 Surgeon General report found clinical gaps in thrombosis knowledge and the inconsistent application of evidence based interventions. My personal experience is that little has changed since the report’s release. While any provider in any specialty can order a thrombophilia panel, not every provider is skilled in interpreting them. Thrombophilia specialists are few. With direct-to-consumer testing, there is the potential for patients to have a difficult time finding a professional well-versed in thrombophilia and its implications for thrombosis risk management.
Why are there still gaps in thrombosis knowledge? There is no line-item funding in the federal budget for venous blood clot education…without it and engagement of federal public health agencies, the dissemination of patient and provider education is severely hampered. So whether a patient is able to access accurate information in interpreting a positive thrombophilia test is going to be entirely dependent upon how knowledgeable their individual provider is with interpreting such tests and his/her willingness to refer a patient with no prior thrombosis, but a positive thrombophilia home test, to a specialist for a more thorough thrombophilia evaluation and discussion. It will also reflect the patient’s ability to pay–and insurance company’s willingness to reimburse—for such specialized consultation and additional testing in the absence of an acute clotting event.
My recommendation
To put the finding of a positive thrombophilia test into perspective, patients need solid information and my concern is that they won’t easily get it. Yet despite this limitation, at the moment, I would recommend the 23andMe service and here’s why:
Knowledge empowers. Everyone should know their clot risk. I am a strong advocate that the public needs greater awareness and education of their blood clot risk. This test will serve that goal. Is it diagnostic? No. It is not meant to replace diagnostic testing. Perfect solution? No. But it is a start in the right direction and if it informs and empowers 1 person to take steps to reduce their clot risk such that a future clotting event is avoided…it is well worth it.
Cost considerations. A typical ‘thrombophilia panel’, consisting of 5-8 diagnostic tests, ordered by a physician costs around $3,000 in the US and would include tests for all the 5 mutations discussed above plus a few others which are considered ‘acquired’ thrombophilias. Currently, 23andMe markets a genetic test panel of 65 genetic reports for $199 US. That’s an incredible cost difference. While the 23andMe is not meant to be a diagnostic test–it won’t replace the $3000 panel—it holds potential as a first line screening tool to allow for greater public screening of lower risk individuals. Cost is one of the biggest drawbacks as to why we don’t see more public health screenings of all types of conditions, thrombophilia is no exception.
Privacy and genetic discrimination. Direct-to-consumer thrombophilia testing may provide a way for people to learn more about their thrombophilia status without it becoming part of their formal medical record. This may be most helpful to 2nd or 3rd degree relatives of those already diagnosed with thrombophilia or a DVT/PE event to where there is curiosity if they share a trait but don’t wish to, for whatever reason, undergo diagnostic thrombophilia testing. The degree of privacy of both forms of testing is still unclear. In the US, when a patient goes to a physician and a thrombophilia test is ordered, those results become part of the patients permanent medical record. A positive thrombophilia test has implications far beyond clinical decisions. The Genetic Information Nondiscrimination Act (GINA) protects individuals from discrimination based upon a genetic test result. However, it’s protections are limited. While a person with a positive thrombophilia result cannot be denied health insurance or employment, it is still legal for a person with inherited thrombophilia to be denied life or disability insurance based upon the positive test and if they do get insurance, it is allowable to pay higher life, disability, or long-term care insurance premiums. Existing GINA protections with respect to health insurance and employment are also under threat…several recent Congressional proposals call into question the long-term protections of one’s genetic results. Laws can always be changed. Protections provided today may not be in place tomorrow. For that reason, patients should not treat genetic testing as a light decision, but rather be aware that both traditional clinic based testing and direct-to-consumer testing carries potential discrimination risks and these risks should be weighed with the benefits of testing.
Peace of mind. I can foresee a negative result from a direct-to-consumer test providing peace of mind without the cost and potential hassles of diagnostic testing. Any positive test will need to be followed up with a clinician and perhaps a confirmatory diagnostic test to confirm herto- or homozygous status….but this should be a smaller number of people as even the most common thrombophilia is found in less than 10 percent of the population. In other words, the 23andMe could be used as an inexpensive, personal first step screen test for the most common thrombophilias, because statistically the majority of people will have a negative result. Only those positive need to move on to the more expensive, diagnostic panel.
There is no 100% right or wrong answer when it comes to testing for genetic thrombophilia. In the end, it comes down to individualized patient decisions..decisions hopefully made with full information in hand. It will be interesting to see how this new era of consumer driven thrombophilia testing evolves.
Today is International Women’s Day. One way to honor women is to share life-saving knowledge. So let’s talk about venous blood clots because far too many women do not realize they are uniquely at risk for developing this common, potentially life-threatening condition.
What is it?
Venous thromboembolism (VTE) is a blood clot which forms in a deep vein of the body. It may go by several names depending on the physical location of the clot: deep vein thrombosis (DVT), pulmonary embolism (PE), sinus vein thrombosis (SVT), cerebral vein thrombosis(CVT), portal vein thrombosis (PVT), mesenteric vein thrombosis (MVT)
Each year, 10 million people worldwide experience venous thromboembolism (VTE). It is a leading cause of death and disability in both low-income and high-income countries. (7)
In the United State alone, deaths from venous thromboembolism (VTE) are greater than those of AIDS, breast cancer, and crashes combined.
In Europe, VTE causes half a million deaths annually.
Effective prevention strategies exist. Yet studies show few people worldwide even know what VTE is or how it can be prevented.
How do they impact women?
While venous blood clots affect both men and women, there are unique considerations for women:
Blood clots can be life-threatening during pregnancy and are the leading cause of maternal death in the United States. (1)
A woman is at increased risk for developing blood clots during pregnancy and that risk remains elevated for up to six-weeks following childbirth. Pregnancy increases the risk of a blood clot fivefold, with the risk even higher in the postpartum time period. (2)
Post-menopausal women undergoing hormone replacement therapy have a two to four fold increase in the risk for clots. (3)
Women with a clotting disorder (thrombophilia) have increased clot risk. About 8% of the US population is estimated to have a clotting disorder and a clotting disorder is found in upwards of 50% of women who have a blood clot during pregnancy.
Women with a clotting disorder experience a higher rate of pregnancy complications including repeated miscarriage or stillbirth.(4)
Estrogen containing oral contraceptives increase clot risk. Some contraceptives significantly increased risk more than others, 2-3x more. More information on specific contraceptives and clot risk. (5)
Cancer patients are at increased venous clot risk. Cancer, chemotherapy and surgery can each increase clot risk. Women treated with tamoxifen to prevent or treat breast cancer are also at increased risk. (6)
What can you do?
Educate yourself and then pass along what you’ve learned to those persons closest to you. If you’ve been impacted by blood clots, share your story. Silence about venous blood clot risk helps no one. If we wish to save lives, we first must talk openly about it.
ACCP: VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Bates et al Chest. 2012;141(2_suppl):e691S-e736S
ACOG:Practice Bulletin 123: Thromboembolism in Pregnancy Guidelines from the American College of Obstetricians and Gynecologists regarding the prevention, management and treatment of blood clots during pregnancy. Obstetrics & Gynecology. 118(3):718-729, September 2011. Note: journal license required to view full article
ACOG: Practice Bulletin 124: Inherited thrombophilias in Pregnancy Review of common thrombophilias and their association with maternal venous thromboembolism risk, adverse pregnancy outcomes, indications for screening to detect these conditions and management options during pregnancy. Obstetrics & Gynecology. 118(3):730-740, September 2011. Note: journal license required to view full article.
REFERENCES
1. Berg CJ, Atrash HK, Koonin LM, Tucker M. “Pregnancy-related mortality in the United States 1987-1990”. Obstet Gynecol 1996;88(2):161-7 Also see Marik. P.E. and Plante, L.A. “Venous Thromboembolic Disease and Pregnancy”. New England Journal of Medicine, volume 359, number 19, November 6, 2008, pages 2025-2033.
2.Heit JA, Kobbervig CE, James AH, Petterson TM,Bailey KR, Melton LJ, 3rd. Trends in the incidenceof venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005;143(10):697-706
3. Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism US Department of Health and Human Services 2008
