Form 08-4391 - Application For Mortuary Permit
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1MOR
State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Mortuary Science Section
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2695
E-mail: license@dced.state.ak.us
APPLICATION FOR MORTUARY PERMIT UNDER AS 08.42.020(c)
(disposition of dead human bodies not requiring embalming)
Nonrefundable application fee - $50 (make check or money order payable to State of Alaska)
AS 08.42.020(c) states, “in the event the dead body is to be disposed of in a manner not requiring embalming,
the department may issue a permit to an unlicensed person for the care and disposition of dead human bodies
for compensation. This permit otherwise in no way licenses the holder to practice mortuary science.”
Name of Applicant:
Social Security Number:
Birthdate:
Sex:
Complete Mailing Address:
Complete Physical Address:
City
State
ZIP Code
City
State
ZIP Code
Business Telephone:
PROFESSIONAL RESPONSIBILITY – By this application, I certify that I
YES
NO
1. will embalm dead human bodies ............................................................................................................
2. will care and dispose of dead human bodies for compensation.............................................................
Give the location and description of the method of disposal of the remains or cremains, or other mortuary service(s) to be
provided:
I certify the above information is true and correct to the best of my knowledge. I understand that any false or misleading
information may result in denial of the permit or subsequent revocation of the permit.
SUBSCRIBED AND SWORN TO before me on
Signature
(date).
Title
Notary Public, State of
My commission expires:
(NOTARY SEAL)
FOR OFFICE USE ONLY
Alt. Permit #:
Date Issued:
Date Expires:
12/31/
Disapproved:
Comments:
08-4391 (Rev. 1/00)
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