Fillable CREMATED REMAINS DISPOSER ANNUAL REPORT (California)

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CREMATED REMAINS DISPOSER ANNUAL REPORT (California)

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CREMATED REMAINS DISPOSER ANNUAL REPORT
Pursuant to Business and Professions Code Sections 7672.7, 7672.8
For the period from July 1, __________ to June 30, __________
Name of Cremated Remains Disposer:
CRD Registration No:
Name of Deceased
Date
Remains
Received
Date of
Disposal
Location of Disposal
Name of Person Authorizing
Disposal
Address of Person Authorizing
Disposal
Means &
Manner of
Disposal
Page _____ of _____ total pages.
Name of Deceased
Date
Remains
Received
Date of
Disposal
Location of Disposal
Name of Person Authorizing
Disposal
Address of Person Authorizing
Disposal
Means &
Manner of
Disposal
Page _____ of _____ total pages.
Name of Deceased
Date
Remains
Received
Date of
Disposal
Location of Disposal
Name of Person Authorizing
Disposal
Address of Person Authorizing
Disposal
Means &
Manner of
Disposal
The total number of cremated remains scattered during the reporting period covered by this report is _____________. I certify under penalty of
perjury, under the laws of the State of California that the information presented above in this report is complete, true and correct to the best of my
knowledge and belief.
Signature: Date: Phone Number:
Name (Print): CRD No.:
• If additional pages are needed, please make copies of the second page of • Any cremated remains disposer that makes a willful and material false
the blank report. statement regarding the disposal of cremated remains in the annual report
shall be subject to disciplinary action and is guilty of a misdemeanor
• This report must be kept current throughout the year and available for
(Business and Professions Code § 7672.7(b) and (c)).
inspection by the Bureau. The annual report must be submitted to the
Bureau with the request for renewal of your cremated remains disposer • For more information, contact: Cemetery and Funeral Bureau (916)
registration. The report must be filed with the Bureau no later than
574-7870, 1625 North Market Blvd., Suite S-208, Sacramento, CA
September 30th of each year. 95834. www.cfb.ca.gov/.
(Rev. 8/05)
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DEPARTMENT
OF
CONSUMER
AFFAIRS
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
NOTICE ON COLLECTION OF PERSONAL INFORMATION
Collection and Use of Personal Information
The Cemetery and Funeral Bureau (Bureau) of the Department of Consumer Affairs
collects the personal information requested on this form in accordance with Business and
Professions Code (BPC) sections 30, 35, 114.3, 114.5, 115.4, 115.5, 144, 480, Cemetery
and Funeral Act (BPC section 7600 et. seq.), and the Information Practices Act. The
Bureau uses this information principally to identify and evaluate applicants for licensure,
issue and renew licenses, and enforce licensing and reporting standards set by law and
regulation.
Mandatory Submission
Submission of the requested information is mandatory unless otherwise noted on the
application and/or form. The Bureau cannot consider your application for licensure or
renewal unless you provide all of the requested information.
Access to Personal Information
You may review the records maintained by the Bureau that contain your personal
information, as permitted by the Information Practices Act. See below for contact
information.
Possible Disclosure of Personal Information
We make every effort to protect the personal information you provide us. The information
you provide, however, may be disclosed in the following circumstances:
• In response to a Public Records Act request (Government Code Section 6250 and
following), as allowed by the Information Practices Act (Civil Code Section 1798 and
following);
• To another government agency as required by State or Federal law; or,
• In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information
For questions about this notice or access to your records, you may contact the Custodian
of Records, Cemetery and Funeral Bureau at 1625 North Market Boulevard, Suite S-208,
Sacramento, CA 95834, by phone at (916) 574-7870, or by e-mail at
emailcfb@dca.ca.gov. For questions about the Department’s Privacy Policy, you may
contact the Department of Consumer Affairs at 1625 North Market Boulevard,
Sacramento, CA 95834, by phone at (800) 952-5210, or by e-mail at dca@dca.ca.gov.
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CREMATED REMAINS DISPOSER ANNUAL REPORT (California)

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Completed 16 June 2021

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