New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Mortuary Science of New Jersey
124 Halsey Street, 6th Floor, P.O. Box 45009
Newark, New Jersey 07101
(973) 504-6425
Application for Reinstatement of a Funeral Home’s Registration
Complete the following information. Please print clearly.
Funeral Home name: __________________________________________________________
Address: ____________________________________________________________________
Street
____________________________________________________________________________
City State ZIP code
Work telephone number:_____________________ Fax number: ______________________
(include area code) (include area code)
Ownership/Corporation status: ___________________________________________________
Date of last renewal: _______________________ N.J. License No.: ___________________
Month Day Year
The manager or licensee-in-charge must answer the following questions regarding the time
period since the establishment was last licensed in New Jersey. For all “Yes” answers,
provide sufcient details on a separate sheet of paper.
1. Has there been a change in the manager or licensee-in-charge of this funeral home since the
facility last held an “active” registration? (If “Yes,” please provide a copy of the corporate
resolution designating the licensed practitioner of mortuary science and a letter indicating that
the individual accepted the position.)
Yes No
2. Has there been a change in the ownership of this funeral home since the facility last held an
“active” registration? (If “Yes,” please provide a copy of the certicate of incorporation or certicate
of formation, and the name, address(es) and telephone number(s) of the ofcers, general
partners, and/or members of the corporation or limited liability company, corporate charter.)
Yes No
3. Does the manager of this facility currently hold the position of “manager” or “licensee-in-
charge” of more than one registered funeral establishment? (If “Yes,” please list the name(s)
and address(es) of the other registered mortuaries.)
Yes No
4. Are you aware of any criminal or disciplinary charges that have been led against any of the
owners of the funeral establishment since the facility last held an “active” registration?
Yes No
5. Since your last renewal have you been arrested, charged or convicted of any crime or offense
that you have not already reported to your Board? (Minor trafc offenses, such as
speeding or parking need not be provided, but motor vehicle offenses such as driving while
impaired or intoxicated must be reported.)
Yes No
6. Since your last renewal has any action been taken or is any action now pending against your
professional license or have you been permitted to surrender or otherwise relinquish your
license to avoid inquiry, investigation or action by any other licensing authority that you have
not already reported to your Board?
Yes No
If you answered “Yes” to questions 5 or 6, you must describe the circumstances surrounding
the event(s) on a separate piece of paper, and provide copies of the relevant complaint(s),
indictment(s), judgment(s), order(s), and any other ofcial documents which relate to the event(s)
in question.
