M OR TU A RY S CI EN C E PR O GR AM
P.O. Box 64882, St. Paul, MN 55164-0882
Telephone: (651) 201-3829
Fax: (651) 201-3839
Email: [email protected]
Change of Ownership: Crematory
The undersigned hereby submits this application to operate a funeral crematory subject to the provisions of Minnesota Statutes, section 149A.50
and 149A.65. Include an application fee of $425 payable to: Commissioner of Finance.
CURRENT CREMATORY OWNER INFORMATION
Name of Crematory
Current Crematory License Number
Crematory Address
City
County
Mailing Address ☐ Same as Crematory address.
City
Email Address
State
Zip Code
State
Zip Code
Phone Number
NEW CREMATORY OWNERSHIP INFORMATION
New Name of Crematory
Date of Ownership Change
Crematory Address (If different from above)
City
County
State
Zip Code
Type of Business (check one):
☐ Individual/Sole Proprietorship
☐ Partnership
☐ Private/LLC
Corporation
☐ Public Corporation
Federal IRS Tax I. D.
Minnesota Tax I.D.
Name of Owner(s)/Percentage of owners
Email Address
Name of Corporation
Place and date of corporation
Corporation Address ☐ Same as business address above.
Name of President
☐ Cooperative
Phone Number
Name of Licensed Morticians and Mortician’s License Number Working at this Establishment
INSURANCE INFORMATION
All applicants must provide proof of liability insurance coverage.
Name of Insurance Provider
Insurance Policy Number
Insurance Agent’s Name
Insurance Agent’s Phone Number
I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that misstatement of facts may result in denial of this
application.
Printed Name of Applicant
Signature of Applicant
Date
Include copies of the following documents with this application: ☐ 1) Liability insurance coverage; ☐ 2) Filing with the Minnesota Secretary of
State; and ☐ 3) Occupancy permit or, if not available, proof of zoning from city ordinance.
To obtain this information in a different format, call: 651-201-3829. Printed on recycled paper.
Document1
REV 7/18/2016