Fillable FUNERAL AND CEMETERY SERVICES BOARD INFORMAL COMPLAINT FORM (State of Nevada, Department of Information Technology)

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FUNERAL AND CEMETERY SERVICES BOARD INFORMAL COMPLAINT FORM (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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State of Nevada
FUNERAL AND CEMETERY SERVICES BOARD
3740 Lakeside Drive, Suite 201, Reno, Nevada, 89509
Phone (775) 825-5535
INFORMAL COMPLAINT FORM
Informal Complaint Instructions and Information
Chapter 642 of the Nevada Revised Statues authorizes the Nevada Funeral and Cemetery
Services Board (Board) to investigate accusations against persons licensed or issued permits by the
Board. A notarized Informal Complaint Form must be received in the office before the Board can take
any action. Please complete the Informal Complaint Form and mail to the office with any pertinent
information and supporting documents that may substantiate any violations of under the purview of the
Board. In order for disciplinary action to be taken, an accusation must fall within the provisions set
forth in the statutes or in the regulations promulgated by the Board.
All accusations are carefully reviewed for potential violations. If potential violations are
identified, an investigation will be commenced. After all the facts have been obtained and if it is
determined that the actions may constitute a violation of law, the matter will be submitted for an
evaluation to determine whether sufficient evidence exists for the Board to file a formal complaint. If it
is determined that no potential violation exists or there is insufficient evidence to file a formal
complaint, the accusation may be dismissed. You will be notified of the outcome of this review.
If a formal complaint is filed, the matter will be set for a disciplinary hearing and you may be
asked to testify. At any time during this process, the respondent may choose to resolve the matter by
entering into a consent decree. A consent decree is a written agreement between the parties in which
the person charged admits to certain violations and agrees to a particular disciplinary action.
Person Filing Complaint (Complainant )
Your Name:
Address:
Street / P.O. Box City State Zip
Email Address:
Phone #: Fax #:
Complaint Filed Against (Respondent)
Name of Funeral Establishment,
Cemetery or Crematory:
Address:
Street / P.O. Box City State Zip
Phone #: Fax #:
Name of Funeral Director (if applicable):
Name of Embalmer (if applicable):
Informal Complaint Narrative
Please provide a narrative description of the complaint, explaining in detail the alleged activity you
witnessed or of which you have direct and personal knowledge. Do not forget to include dates, times,
places, and the names of any other people who might have witnessed the alleged activity. Use
additional sheets if necessary, and provide copies of all supporting documents.
Please list any other organization you have contacted relative to this complaint:
Company/Agency/Contact Name:
Contact Address/Phone Number:
Have you discussed this issue/problem with the funeral establishment or funeral director?
Yes _________
If yes, please detail the response:
No _____________
If no, please explain why:
Testimony
Are you willing to testify at a public administrative hearing? Yes No
(Please note that even if you are unwilling to testify, this form may still be used as evidence).
Declaration
I, ______________________, being duly sworn, hereby declare under penalty of perjury, that I have
written the foregoing complaint and that the information furnished on this document is true and
accurate to the best of my knowledge.
Signature of Complainant Date
SUBSCRIBED AND SWORN BEFORE ME
This____________________ day of _____________________, in the year____________________.
________________________________________
Notary Public Seal
For Board Use Only: Case Number___________
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FUNERAL AND CEMETERY SERVICES BOARD INFORMAL COMPLAINT FORM (State of Nevada, Department of Information Technology)

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Completed 3 November 2021

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